Medication misadventures, a quaint term. Sounds like one is going on a trip with a few unexpected twists and turns, resulting in an entertaining story. Reality is a little harsher. In 1995 the economic cost of medication misadventures was quantified at $76.5 billion annually. In 2000 the amount was adjusted to $177 billion. Neither of the studies take into account the quality changes in the lives of individuals, their friends and families.

US medicine uses a swiss cheese model of preventing medication misadventures. If each healthcare practitioner independently does their own quality control any mistakes (holes) will not overlap and an error will not reach the patient. The intent of this diary is to provide enough information to minimize misadventures by knowing when to ask for a review of drug therapy, and at minimum feel like you have the right to speak up to question a health professional. If you have no reason to question, it’s fine to trust your doctor, but when you get home, verify!

Medical visits are a high stress event and it is is easy to have trouble processing technical, highly personal (sometimes scary) information in a rational manner. Most of us in our day to day lives are not practiced in making fast medical decisions. If one makes fast decisions in a non-medical profession they may not have the base medical knowledge to make well formed medical decision within the 10 to 20 minutes of a physician visit.

Take a relative, friend or tape recorder with you. Also, a written list of your medications, supplements, allergies, diagnoses and medical history each visit. Your electronic records may have been "upgraded" or transferred to a new program and area not available to the MD. (short as possible). Most MDs process written info quickly and can then ask specific questions to identify or rule out a issues versus general info gathering.

The belief that technology will eliminate medication related problems assumes medical software primary design is quality patient care. The starting basis for most medical software has been efficient billing, maximizing revenue, reducing costs, documentation to reduce litigation and maximize staff/patient ratios. There is hope for the future, but one should not over rely on software alone to prevent problems.

For a complete evaluation of “drug” therapy all prescription medications, over the counter drugs, alcohol, illegal drugs, and dietary supplements should be considered without moral judgment. They all result in a chemical intervention of the body. Most reference material organizes these commercial categories separately and do not integrate the information for easy decision making or risk benefit analysis.

General Guidelines

• Use as few medications as possible.
• Keep a list of medications you are taking and the reason for use.
• Keep a list of allergies, drugs discontinued for adverse reactions and drug discontinued due to therapy failures.
• Know the expected goals of a medication and monitor for effectiveness.
• Use the lowest dose possible.
• Know storage and administration instructions.
• If possible try and avoid a medication new to the market for 2 years. Multiple unique chemical entities have been removed from the market or had Black Box Warnings added after use in the general public.
• When possible use single ingredient products.
• Work on lifestyle changes and diet to improve diagnosed conditions and general health.
• Review drug use annually for drugs you may no longer need. Review drugs as a potential cause when health condition changes. If you do not have a health professional able to provide a quality review I have added a few of the reference sources I use.
• If the person recommending the drug is receiving remuneration for selling it, the advice you are getting might be in their best interest, not yours.

Specific guidelines

• When starting a new medication or restarting an old medication, read the full prescribing information intended for medical professionals
• Check how the medication should be taken in relation to food. Some medications are indifferent. In other cases, consumption in proper relation to the state of your stomach is essential for effectiveness. Different formulations of the same medication can even have opposite requirements.
• Check carefully for interactions with diet, supplements, and other medications you are taking. Even specialists can miss important interactions.

When is a misadventure most likely to occur?

When a new drug is started.
For most patients it is a non-event. However, if you have a history of being sensitive with medications the likelihood of a problem is greater. Don’t be shy, you are the one who has to live with the consequences.

Case in point: A cardiologist advised his patient, with a lidocaine allergy, he would do his best to let the hospital know of her allergy, but she needed to watch and speak out at each step. She reminded the admitting nurse. She reminded the nurse putting in her IV. She told the OR nurse to remove the lidocaine bottle from the surgical tray. She reminded the recovery nurse as soon as she became conscious. She doubled checked with the floor nurse her allergy was on her medical record. She was talking to a guest and and the roaming IV tech injected her with lidocaine to change an IV. Instead being discharged the next morning, she went home 6 days later.

When a dose is changed.
A patient was taking his blood pressure medication twice a day. A new time released dosage form became available on the market. His physician changed him to the drug. Patient had a swallowing problem and crushed all his medications. He began experiencing dizziness in the morning and his bedtime blood pressure readings were high. Fortunately it was discovered before he fell and broke a bone. Moral of story: know what you are taking — do not crush time-release medications! Had the patient read and heeded the prescribing information this would not have happened.

When a new diagnosis is identified.
Current medication should be reviewed for possibly causing the problem or a drug/disease contraindication in current therapy. The patient had a script for a reduce gastric acid for stomach pain the doctor wanted him to try. He also had a large bottle of Tums (calcium carbonate) on the counter when I went to sell him his script. I asked, they were for him. He was told a year earlier to start taking calcium. Let him know calcium carbonate can cause rebound acid production. I saw him a few months later the script did not help the stomach pain, switching the calcium stopped the pain.

When medication assistance is started or stopped.
If a patient had not been taking medication exactly as written on a bottle the timing or amount of drug could be changed when medication assistance is started. Personalized dosing schedules for conditions such as Parkinson’s may be changed adversely to match a facility’s med-pass time. The patient’s caregiver should follow up to insure the patient’s needs are being met.

Any admission or discharge to a healthcare facility or level of care; including a different floor or wing in the same hospital, nursing facility, assisted living or hospice.
This is the most likely time a medication for a chronic condition, such as glaucoma or hypothyroidism, is dropped from therapy by not being included in admission orders. If there is no immediate change in the patient’s condition and the likelihood of the error being discovered is reduced.

Some hospitals will add new orders at discharge to comply with quality prescribing protocols for specific disease states or change from injectable to oral meds. The patient and other healthcare providers may assume the new drugs were started and evaluated for safety and effectiveness at the hospital. Some facilities will switch drug therapy from what the patient has been taking to a drug on the facilities formulary. This is also an issue with changes in an insurance company’s formulary. The substituted drug may or may not be satisfactory.

An update or conversion in an electronic records system at a medical clinic, facility may not contain all the information that was available at your last visit.
Double check the information every visit. It is not uncommon to have different medical software at your primary physicians, each specialist, the emergency room at the hospital and inpatients section of the hospital.

Changes in the body’s ability to metabolize drugs, such as changes in functionality of the liver or kidney, or normal changes due to age. Some individuals or ethnic groups may have genetic differences on how they metabolize drugs separate from general organ functionality.
It works both ways - an improvement in hepatitis or kidney function may result in some therapy becoming sub-therapeutic. Drugs that have been taken safely and effectively for decades may cause adverse reactions as the ability to metabolize drugs change and the ratio of body fat and muscle protein change.

Changes in behavior and lifestyle.
Positive changes to diet, exercise, social interaction or modification to home to improve your health may reduce the need for some medications you are taking or a reduced dose. It is better to monitor your blood pressure to notice the lower blood pressure, than taking a fall.
If you have Diabetes a plan should be in place on how to adjust or monitor meds if you can not eat your meals/ snacks as scheduled or become ill.

Changes in a chronic condition.
A change can cause one to alter which condition receives primary attention and treatment. A drug with significant adverse reactions may need to be tolerated to treat a condition or maintain a quality of life.

Two drug groups, corticosteroid (prednisone) and opioid, have generated significant discussion in DailyKos diaries. They tend to be prescribed for fairly minor health conditions and serious life changing conditions. I personally am not fond of the drugs and like to see them used until after thoughtful consideration , lowest effective dose and shortest time frame. Keeping in mind for some individuals it may be for decades.

Corticosteroids and opiods effect the immune system and can have wide ranging effects on the body. (The link is the only place I could find the full article. The site does delve into anti-vaxxer info). If you missed the press release, this year the long standing belief the lymph system is not part of the central nervous system was disproved by a study partially funded by the National Institutes of Health.

Resources

Prescription Package Inserts are FDA required publications by the drug manufacturer and repackager containing prescribing information for FDA approved uses of the drug formulation. The information is easily available and provides information on how to use the drug. If available review the insert of Brand Name drug. Generic drugs use a different application process than new drugs and may not have as robust package insert.

Since 2009 any new or revised package insert contain expanded information regarding patient instructions, adverse reaction monitoring, special instructions for initiating and stopping the drug, special dosages based on liver or kidney function, special dosages for geriatrics and pediatrics, adverse reactions, drug to drug interactions, suggested labs to monitor, warnings to consider for clinical decisions and Back Box Warnings. Black Box warning are for serious and life threatening adverse reactions or effects.

Food and Drug Administration maintains a website for most over-the counter, prescription package inserts, veterinary drugs and homeopathic formulations. I prefer a site that has limited advertising and I can scroll down a single page. If you are concerned about sensitivities to non-active ingredients in a medication, look up the drug with the NDC number and go to the end of the page to the Ingredients and Appearance section.

DrugInserts and VetLabel are commercial websites with FDA information

Physicians Desk Reference is a publication partially supported by pharmaceutical companies to print information contained in the Patient Package Insert for prescription medications. I generally use a website with current package insert information.

The books I generally turn to first are Drug Facts and Comparisons and AHFS Drug Information. Both contain information of FDA approved uses and common off label uses for prescription and over the counter medications. Facts is the easiest to use. Copies can be found in public libraries, many local pharmacies and hospitals. If you want your own book, a 2 to 5 year old copy from a used bookstore is dramatically less than the current annual version.

Beers Criteria 2015 is a list of potentially inappropriate medications for individuals over the age of 65. I will also use it for individuals with chronic conditions that appear to cause age related changes. First published in 1991 by Mark H. Beers MD to assist clinical decision making of physicians and is now maintained by the American Geriatrics Society. Table 7 has one of best lists of medications with anticholinergic activity.

Pill Identification pill-identifier - use to identify unlabeled drugs or loose pills.

Drugs.com - has a page to review a list of drugs for drug/drug interaction with clinical significance, therapy duplication and drug/food interactions.

RxList - provides information contained in FDA approved package inserts and Multnum consumer database.

The Peoples Pharmacy - easy to understand information on drug, herbs, home remedies and health concerns.

Anticholinergic drug discussion on accumulative effects from multiple drugs.

Report drug problems such as serious drug side effects, product use errors, product quality problems, and therapeutic failures to the FDA MedWatch.

Happy New Year - in the spirit of taking care of ourselves a reprint from DailyKos.