1. Is it Dilantin, Dilaudid or Diltiazem? Edward R. Sobel, D.O. Medical Director, Quality Insights of Delaware Family Practice Associates, PA

2. Objectives Reduce the rate of prescribing errors Avoid drug interactions Empower nursing into clinical decision making

3. Onymnomycin 300mg 1 qid until finished #40 0 refills

10. Transfer Errors 92-year-old male is transferred from inpatient hospital care. He has been in the hospital four times in the last three months The patient begins to decline unexpectedly He develops CHF and is readmitted for the fifth time but ultimately succumbs to the disease process What was the cause of his death?

11. Transfer Errors An elderly patient is discharged to OP care following hospitalization for CAD He is seen in the office about 10 days following DC, c/o extreme fatigue – “I feel well, doc, but I just have no energy.” What was the cause of his excessive fatigue?

13. Where Are There Errors? Scribbling of meds on the transfer form Duplicate medications in the same therapeutic class “Resume all previous medications” No discharge medication sheet or instructions Change of pill color, shape, dosage Multiple pharmacy source

18. What Can We Do to Make Administration of Medications Safer? List all the medications, prescription medications, over-the-counter drugs and any vitamin and herbal supplements they take Educate the elderly person about their medications, including the desired effects, and be familiar with the instructions on how and when to take the medication, possible side effects and drug interactions

19. What Can We Do to Make Administration of Medications Safer? Develop a medication usage sheet. A medication list should include the following: –Name of the medication, color and shape –Dosage and frequency –Reason they are taking the medication –The date they started taking the medication –The prescribing physician's name and contact information –Any special instructions and/or side effects about the medication

20. What Can We Do to Make Administration of Medications Safer? It is important to have all the medications filled at only one pharmacy. It can be very helpful to develop a relationship with one of the pharmacists where the elder picks up their medications. Pharmacists are well trained and can answer their questions about possible drug interactions, side effects and contraindications that their health care clinician may not tell them. Keep a list of all the medications the elderly are taking on the refrigerator or by the main telephone they use in a brightly colored folder clearly marked.

21. What Can We Do to Make Administration of Medications Safer? Ensure that the medications are stored properly (away from the heat or in the refrigerator), and discard any drugs that have expired or have no labels Instruct the elderly to put on a light when taking medications and never take their drugs in the dark

22. What Can We Do to Make Administration of Medications Safer? If the elderly person utilizes a pill box, always have them keep at least one pill in the original medication container for identification purposes Never have the elderly mix more than one medication in a pill container, especially when traveling Always have the elderly bring a list of all of the medications they are currently taking when going to a physician appointment

23. What Can We Do to Make Administration of Medications Safer? You may ask the pharmacist for medication labels in a larger print size, home delivery services, easy to open containers and senior citizen discounts Read more: How to Prevent Medication Errors in the Elderly, http://www.ehow.com/how_5464552_prevent-medication- errors-elderly.html#ixzz10wCOWuXQ

24. Does All This Really Work? Objective: To investigate whether a Medication Report can reduce the number of medication errors when elderly patients are discharged from hospital. Method: We conducted a prospective intervention with retrospective controls on patients at three departments at Lund University Hospital, Sweden that were transferred to primary care. The intervention group, where patients received a Medication Report at discharge, was compared with a control group with patients of the same age, who were not given a Medication Report when discharged from the same ward one year earlier. Main outcome measures: The main outcome measure was the number of medication errors when elderly patients were discharged from hospital. Results: Among 248 patients in the intervention group, 79 (32%) had at least one medication error as compared with 118 (66%) among the 179 patients in the control group. In the intervention group, 15% of the patients had errors that were considered to have moderate or high risk of clinical consequences compared with 32% in the control group. The differences were statistically significant (P < 0.001). Conclusion: Medication errors are common when elderly patients are discharged from hospital. The Medication Report is a simple tool that reduces the number of medication errors. Medication report reduces number of medication errors when elderly patients are discharged from hospital Patrik Midlov, Lydia Holmdahl, Tommy Eriksson, Anna Bergkvist, Bengt Ljungberg, Håkan Widner, Christina Nerbrand and Peter Höglund Pharmacy World & Science Volume 30, Number 1, 92-98, DOI: 10.1007/s11096-007-9149-4

25. Thank you This material was prepared by Quality Insights of Delaware, the Medicare Quality Improvement Organization for Delaware, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication number 9SOW-DE-PS-KD-102610. App. 10/10.