Abstract
Nurse-led monitoring of patients for signs and symptoms associated with documented 'undesirable effects' of medicines has potential to prevent avoidable harm, and optimise prescribing. The Adverse Drug Reaction Profile for polypharmacy (ADRe-p) identifies and documents putative adverse effects of medicines commonly prescribed in primary care. Nurses address some problems, before passing ADRe-p to pharmacists and prescribers for review, in conjunction with prescriptions. We investigated changes in: the number and nature of residents' problems as recorded on ADRe-p; prescription regimens; medicines optimisation: and healthcare costs. We explored aetiologies of problems identified and stakeholders' perspectives. In three UK care homes, 19 residents completed the study, December 2018 to May 2019. Two service users, three pharmacists, six nurses gave interviews. This mixed-method process evaluation integrated data from residents' ADRe-ps and medicines charts, at the study's start and 5-10 weeks later. We recruited three of 27 homes approached and 26 of 45 eligible residents; 19 completed ADRe-p at least twice. Clinical gains were identified for 17/19 residents (mean number of symptoms 3 SD 1.67, range 0-7). Examples included management of: pain (six residents), seizures (three), dyspnoea (one), diarrhoea (laxatives reduced, two), falls (two of five able to stand). One or more medicine was de-prescribed or dose reduced for 12/19 residents. ADRe administration and review cost ~£30 in staff time. ADRe-p helped carers and nurses bring residents' problems to the attention of prescribers. ADRe-p relieved unnecessary suffering. It supported carers and nurses by providing a tool to engage with pharmacists and prescribers, and was the only observable strategy for multidisciplinary team working around medicines optimisation. ADRe-p improved care by: a) regular systematic checks and problem documentation; b) information transfer from care home staff to prescribers and pharmacists; c) recording changes. NLM Identifier NCT03955133; ClinicalTrials.gov.
Highlights
The scale and complexity of inadvertent iatrogenic harm from both use and misuse of medicines underlie the World Health Organisation’s (WHO) Third Global Patient Safety Challenge—to reduce avoidable medication-related harm by 50% by 2022 [1]
The Adverse Drug Reaction Profile for polypharmacy (ADRe-p) identifies and documents putative adverse effects of medicines commonly prescribed in primary care
Between December 2018 and May 2019, ADRe-p was introduced into three independent private sector registered care homes with 158 residents in one Welsh University Health Board (UHB), unconnected with previous research sites [4,6]
Summary
The scale and complexity of inadvertent iatrogenic harm from both use and misuse of medicines underlie the World Health Organisation’s (WHO) Third Global Patient Safety Challenge—to reduce avoidable medication-related harm by 50% by 2022 [1]. Patient safety incidents due to acts of commission, excluding acts of omission, arise in 1–24 of every 100 primary care consultations, mainly due to misdiagnoses or medicines mismanagement; up to 44% of these lead to severe harm [9]. Both inappropriate- and under-prescribing increase mortality rates and hospital admissions [10]. Up to 92% of ADEs, adverse drug reactions (ADRs), and medicines’ mismanagement (including patient safety incidents where patients and professionals contribute) are preventable [11,12,13,14]; more are due to poor monitoring than poor prescribing [15,16,17,18,19] and are dose-related [20,21].
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