**Transitions of Care: Complications and Solutions**

Philip Salen

[59] Julian D. The utilization of the logic model as a system level planning and evaluation

[60] Reed JE, McNicholas C, Woodcock T, Issen L, Bell D. Designing quality improvement initiatives: The action effect method, a structured approach to identifying and articulat-

[61] McLaughlin J, Jordan B. Logic models: A tool for telling your program's performance

[62] Ministero della Salute. Protocollo per il Monitoraggio degli Eventi Sentinella-V rapporto. Settembre 2005–Dicembre 2012. http://www.salute.gov.it/imgs/C\_17\_pubblica-

[63] Pravikoff DS, Tanner AB, Pierce ST. Readiness of US nurses for evidence-based practice: Many don't understand or value research and have had little or no training to help them find evidence on which to base their practice. The American Journal of Nursing,

[64] Davidoff F. Heterogeneity is not always noise: lessons from improvement. JAMA. 2009;

[65] Benn J, Burnett S, Parand A, et al. Studying large-scale programmes to improve patient safety in whole care systems: Challenges for research. Social Science and Medicine.

[66] Hulscher MEJL, Laurant MGH, Grol RPTM. Process evaluation on quality improvement

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36 Vignettes in Patient Safety - Volume 1

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Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.69381

#### **Abstract**

The delivery of medical care relies on effective, succinct, and ongoing communication between healthcare providers, called handoffs. Handoffs involve the transfer of professional responsibility and accountability for aspects of care for patients to another clinician or clinical team on a temporary or permanent basis. Handoffs have the potential for deleterious clinical impact if inadequately done. Only recently has data become available that demonstrate improvements in handoffs reduce the rate of subsequent clinical care error. This clinical vignette and subsequent discussion focuses on physician, particularly the resident physician in training, transfer of care: handoff complications, barriers to effective handoffs, regulatory agencies' input on handoff improvement, standardization of the handoff process, assessment of the quality of handoff, handoff error avoidance, and improving the quality of handoff.

**Keywords:** physician fatigue, resident duty hour restrictions, night float, physician burn out, resident education

#### **1. Clinical vignette**

An 84‐year‐old female presented to the emergency department (ED) for evaluation of left hip pain after a fall at her locked dementia unit. The patient could not ambulate and had a bruise over her left hip. Radiograph demonstrated a left hip fracture and orthopedic consultation was requested for evaluation of a hip fracture by the ED resident. The on‐call orthopedic resident after discussion with the orthopedic attending recommended placement of a single compression hip screw for treatment of the hip fracture and requested the internal medicine hospitalist service admit the patient for medical management of the patient's dementia and diabetes prior to operative repair of the hip. The internal medicine hospitalist service admitted

© 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

the patient for preoperative clearance prior to repair of her hip fracture. When approached by the orthopedic surgery resident the next day for signed consent for operative hip repair, the patient signed consent for operative repair of her hip. On arrival in the preoperative area during surgical time out, the patient confirmed that the right hip would be operatively repaired. After operative repair of the right hip, the patient returned to the hospitalist service with a request for initiation of enoxaparin anticoagulation to prevent deep venous thrombosis. Postoperative X‐ray demonstrated single compression hip screw in the right hip with a persistent left hip subcapsular fracture. Three days after the operation, the patient developed acute hypoxia, CT angiogram of the chest documented pulmonary embolism; the on‐call hospitalist noted there had been no initiation of prophylactic enoxaparin postoperatively. On return to the floor prior to the initiation of anticoagulation for pulmonary embolism, the patient became severely dyspneic and hypoxic followed by pulseless electrical activity cardiac arrest; resuscitation efforts failed to return spontaneous circulation and the patient expired.

**3. Transitions of care: handoff definition**

**4. Insufficient handoffs induce complications**

consequences [9, 10].

in hospitals [13, 14].

The Joint Commission (TJC) defines handoff as: a means to provide accurate information about a patient's care, treatment, and services; current physical condition; and any recent or anticipated changes in clinical course. Accurate information communicated during handoff must be accurate in order to meet safety goals [6]. The goal of quality handover of care is to ensure continuity of care and high‐quality, safe care decision making in a specific physical and cultural environment. More than merely the passive transfer of information, optimum handoffs necessitate the efficient communication of information among participants [3]. Expansion of duty hour restrictions for resident physician trainees in North America have increased handoff frequency, augmented the potential for ineffectual handoff‐induced complications, and stimulated the need for new interventions to improve handover quality [7]. The shift from the traditional model of continuous inpatient medicine to a team‐based model has further focused attention on patient handoffs [3]. Interunit handoffs, such as the transition from the ED to the inpatient setting, have special challenges, such as changes in personnel, provider specialty, and hospital location [8]. Over the last decade, considerable attention has been given on interventions to optimize the handoff process by enhancing patient safety in order to improve outcomes; adaptation of some enhancements were gleaned from industries such as nuclear power and space aviation in which transition errors also result in serious

Transitions of Care: Complications and Solutions http://dx.doi.org/10.5772/intechopen.69381 39

The Institute of Medicine attributes a substantial proportion of preventable adverse events to communication errors during handover [11]. The Agency for Healthcare Research and Quality identifies handoff communication miscues as implicated in surgical errors [12] and as a consequential cause of malpractice claims. TJC has correlated ineffective care transitions to higher rates of readmission [4]. Communication and handoff snafus are among the root causes of nearly two‐thirds of potentially significant, preventable adverse clinical outcomes

The consequences of substandard handoffs include: delays in therapy, inappropriate treatment, adverse events, care task omissions, increased hospital length of stay, avoidable readmissions, increased costs, and inefficiency from reevaluation [15]. Omissions of clinically important on‐call issues by fatigued on‐call residents when transferring care to the daytime team at the end of shifts are major contributors to miscommunications and can result in care implementation delays and adverse events [16]. Insufficient handoff communication result in incomplete, inaccurate, and omitted data and effectuate informational ambiguities between the departing and oncoming providers. Examples of information loss during handoffs are failure to communicate: drug allergy, critical comorbidity, relevant history, or current treatments. Distortion of patient history can result in: wrong medication dose, wrong surgical site, or incorrect diagnosis [10]. Cognitive load of handoff exceeding working memory capacity of the departing or oncoming physicians can further exacerbate information loss or distortion [9].

**Allegation:** The ED, orthopedic, hospitalist physicians, and staff were implicated in the wrong side operative repair of the left hip fracture and in the failure to initiate anticoagulation prophylaxis. The orthopedic and hospitalist physicians were implicated in the failure to initiate anticoagulation prophylaxis for deep venous thrombosis. At trial, attestation from the hospitalist and orthopedic physicians alleged that ED consultation for the right hip had been ordered.

**Disposition:** Pretrial mediation prior to the court case resulted in a large monetary settlement on behalf of the plaintiff's heirs.

#### **2. Introduction**

Healthcare organizations and providers struggle with the process of communicating crucial patient information from one caregiver to the next, or from one team of caregivers to another [1]. The delivery of medical care relies on effective, succinct, and ongoing communication between healthcare providers, called handoffs [2]. These clinical handoffs, also known as sign outs, shift reports, or handovers, take place throughout the healthcare system between multiple providers with various clinical responsibilities. Patient handoffs are complex, multifaceted events that occur at the beginning or end of clinical shifts [3]. Handoffs involve the transfer of professional responsibility and accountability for some or all aspects of care for the patient or groups of patients to another clinician or clinical team on a temporary or permanent basis [4]. Handoffs have the potential for deleterious clinical impact if inadequately done. Only recently has data become available that demonstrate improvements in handoffs reduce the rate of subsequent clinical care error [5].

This clinical vignette and subsequent discussion focuses on physician, particularly the resident physician in training, transfer of care: handoff complications, barriers to effective handoffs, regulatory agencies input on handoff improvement, standardization of the handoff process, assessment of the quality of handoff, handoff error avoidance, and improving the quality of handoff.

#### **3. Transitions of care: handoff definition**

the patient for preoperative clearance prior to repair of her hip fracture. When approached by the orthopedic surgery resident the next day for signed consent for operative hip repair, the patient signed consent for operative repair of her hip. On arrival in the preoperative area during surgical time out, the patient confirmed that the right hip would be operatively repaired. After operative repair of the right hip, the patient returned to the hospitalist service with a request for initiation of enoxaparin anticoagulation to prevent deep venous thrombosis. Postoperative X‐ray demonstrated single compression hip screw in the right hip with a persistent left hip subcapsular fracture. Three days after the operation, the patient developed acute hypoxia, CT angiogram of the chest documented pulmonary embolism; the on‐call hospitalist noted there had been no initiation of prophylactic enoxaparin postoperatively. On return to the floor prior to the initiation of anticoagulation for pulmonary embolism, the patient became severely dyspneic and hypoxic followed by pulseless electrical activity cardiac arrest;

resuscitation efforts failed to return spontaneous circulation and the patient expired.

ordered.

on behalf of the plaintiff's heirs.

38 Vignettes in Patient Safety - Volume 1

the rate of subsequent clinical care error [5].

**2. Introduction**

quality of handoff.

**Allegation:** The ED, orthopedic, hospitalist physicians, and staff were implicated in the wrong side operative repair of the left hip fracture and in the failure to initiate anticoagulation prophylaxis. The orthopedic and hospitalist physicians were implicated in the failure to initiate anticoagulation prophylaxis for deep venous thrombosis. At trial, attestation from the hospitalist and orthopedic physicians alleged that ED consultation for the right hip had been

**Disposition:** Pretrial mediation prior to the court case resulted in a large monetary settlement

Healthcare organizations and providers struggle with the process of communicating crucial patient information from one caregiver to the next, or from one team of caregivers to another [1]. The delivery of medical care relies on effective, succinct, and ongoing communication between healthcare providers, called handoffs [2]. These clinical handoffs, also known as sign outs, shift reports, or handovers, take place throughout the healthcare system between multiple providers with various clinical responsibilities. Patient handoffs are complex, multifaceted events that occur at the beginning or end of clinical shifts [3]. Handoffs involve the transfer of professional responsibility and accountability for some or all aspects of care for the patient or groups of patients to another clinician or clinical team on a temporary or permanent basis [4]. Handoffs have the potential for deleterious clinical impact if inadequately done. Only recently has data become available that demonstrate improvements in handoffs reduce

This clinical vignette and subsequent discussion focuses on physician, particularly the resident physician in training, transfer of care: handoff complications, barriers to effective handoffs, regulatory agencies input on handoff improvement, standardization of the handoff process, assessment of the quality of handoff, handoff error avoidance, and improving the The Joint Commission (TJC) defines handoff as: a means to provide accurate information about a patient's care, treatment, and services; current physical condition; and any recent or anticipated changes in clinical course. Accurate information communicated during handoff must be accurate in order to meet safety goals [6]. The goal of quality handover of care is to ensure continuity of care and high‐quality, safe care decision making in a specific physical and cultural environment. More than merely the passive transfer of information, optimum handoffs necessitate the efficient communication of information among participants [3]. Expansion of duty hour restrictions for resident physician trainees in North America have increased handoff frequency, augmented the potential for ineffectual handoff‐induced complications, and stimulated the need for new interventions to improve handover quality [7]. The shift from the traditional model of continuous inpatient medicine to a team‐based model has further focused attention on patient handoffs [3]. Interunit handoffs, such as the transition from the ED to the inpatient setting, have special challenges, such as changes in personnel, provider specialty, and hospital location [8]. Over the last decade, considerable attention has been given on interventions to optimize the handoff process by enhancing patient safety in order to improve outcomes; adaptation of some enhancements were gleaned from industries such as nuclear power and space aviation in which transition errors also result in serious consequences [9, 10].

#### **4. Insufficient handoffs induce complications**

The Institute of Medicine attributes a substantial proportion of preventable adverse events to communication errors during handover [11]. The Agency for Healthcare Research and Quality identifies handoff communication miscues as implicated in surgical errors [12] and as a consequential cause of malpractice claims. TJC has correlated ineffective care transitions to higher rates of readmission [4]. Communication and handoff snafus are among the root causes of nearly two‐thirds of potentially significant, preventable adverse clinical outcomes in hospitals [13, 14].

The consequences of substandard handoffs include: delays in therapy, inappropriate treatment, adverse events, care task omissions, increased hospital length of stay, avoidable readmissions, increased costs, and inefficiency from reevaluation [15]. Omissions of clinically important on‐call issues by fatigued on‐call residents when transferring care to the daytime team at the end of shifts are major contributors to miscommunications and can result in care implementation delays and adverse events [16]. Insufficient handoff communication result in incomplete, inaccurate, and omitted data and effectuate informational ambiguities between the departing and oncoming providers. Examples of information loss during handoffs are failure to communicate: drug allergy, critical comorbidity, relevant history, or current treatments. Distortion of patient history can result in: wrong medication dose, wrong surgical site, or incorrect diagnosis [10]. Cognitive load of handoff exceeding working memory capacity of the departing or oncoming physicians can further exacerbate information loss or distortion [9]. Omitted and undocumented issues introduce risk for delays in expeditious follow‐up of clinically relevant overnight issues. Research by Devlin et al. demonstrated that only 14% of clinically important issues from the overnight clinical shifts had an accompanying progress note from the on‐call trainee in the patient's medical record [16]. Discontinuity of care secondary to ineffectual handoffs has been correlated with longer hospital stays and increased costs [3]. The morning handover process is highly variable and unreliable and often occurs in a chaotic clinical care environment. On‐call trainees fail to hand over numerous clinically important issues to the daytime team and frequently do not document their assessments and responses to the on‐call issue in the medical records. These omissions have the potential to cause unnecessary delays and may result in a lack of follow‐up for important patient issues [16].

industries: interactive communications, "read‐back" and "repeat‐back" practices, verifying up‐to‐date and accurate information, limited interruptions, a process for verification, and an opportunity to review any relevant historical data. The Accreditation Council for Graduate Medical Education (ACGME) recently mandated that residency programs provide formal educational programs about patient care transitions and that faculty monitor ensure adequate handoff skills through direct observation [3, 19, 21]. TJC, the ACGME, and the Society of Hospital Medicine jointly encourage compliance with a structured format for verbally communicating information utilizing an ordered acronym mnemonic, SBAR: (1) Situation,

Transitions of Care: Complications and Solutions http://dx.doi.org/10.5772/intechopen.69381 41

House staff judge that strategies for handoff standardization most valuably improve quality of handoff and resident physician satisfaction with transition of care [16]. Most emergency medicine (EM) residency directors agree that standardized handoffs have the potential to reduce errors during transition of care, yet the majority of EM residency programs do not have a policy or a procedure regarding handoffs [17]. Didactic and interactive sessions teach key principles, and communication techniques of verbal and written handoffs utilizing mnemonics and checklists have shown to benefit in improving quality and standardization of handoff communications [19]. The SBAR mnemonic benefits handoff communication because of its simplicity, it provides a consistent framework for handoff scenarios, it can be utilized by different care providers, and it emphasizes on the clinician's assessment and response [16, 22]. Checklists have been effective in several different clinical settings in terms of decreasing medical errors and morbidity; utilization of checklists have the potential to improve the transfer of care process as well [23, 22]. Just as documentation in the electronic medical record about clinically important issues while on‐call facilitates communication, a structured, written clinical summary, such as a checklist, by the outgoing clinical team presented to the oncoming team facilitates understanding of critical issues regarding patient

Starmer et al. objectively demonstrated improved outcomes via an educational intervention utilizing a structured resident handoff bundle to standardize inpatient handovers in care thereby decreasing medical error in multiple institutions [13]. The bundle included three major elements: team training by using focused TeamSTEPPS communication strategies, implementation of a standardized template for the written or printed computerized handoff document, and introduction of several evidence‐based verbal handoff processes, specifically I‐PASS, an acronym mnemonic [10]. TeamSTEPPS, a teamwork system developed jointly by the Department of Defense and the Agency for Healthcare Research and Quality, works to improve institutional collaboration and communication relating to patient safety [20]. Starmer et al. instituted an I‐PASS mnemonic to provide a consistent, structured format for communicating handoff information: I—Illness severity, P—Patient summary, A—Action

list, S—Situation awareness and contingency planning, S—Synthesis by receiver [10].

(2) Background, (3) Assessment, and (4) Recommendation [7].

**7. Standardization of patient handoff**

care during transition of care in a standardized way.

#### **5. Barriers to effective handoffs**

Communication miscues and omissions, the most frequently numerated barrier to effective patient transition of care [17], correspond with the lack of consensus about the elements of effective handoff [2]. Substantial variability exists across, and sometimes within, institutions regarding preferred formats and processes for verbal and written handoffs. Research of residency training programs nationally indicate that handoff standardization has not been aggressively implemented and evaluated among residency training programs or implemented with variable compliance [2, 18].

Clinical staff often utilize handoffs as an avenue for socialization, education, and emotional support to facilitate integration and staff cohesion; while these activities have merit, they divert attention from effective patient communication [8]. Resident physicians participating in patient handoffs may not interact regularly with each other, may be located in different parts of the healthcare systems, may have different skill and experience levels, or may come from different clinical backgrounds [3]. Adherence to hierarchical norms between junior and senior residents or attendings can further exacerbate relational communication barriers reflecting differences across levels of training or between clinician types in the willingness to engage in interactive questioning strategies to assertively challenge erroneous assumptions and actions during a handover with peers [7, 17]. Entrenchment of handoff routines in departmental or hospital mores may require transformational change of an institution's culture in order to improve them [19].

#### **6. Regulatory agencies' input to enhance handoff**

In 2010, TJC incorporated the patient handoff into its health facility accreditation standards and has encouraged improving and standardizing transitions of care as a national safety goal via implementation of a standardized approach to handoff communications, including an opportunity to ask and respond to questions [3, 20]. TJC's National Patient Safety Goals document contains specific guidelines for the handoff process, many drawn from other high‐risk industries: interactive communications, "read‐back" and "repeat‐back" practices, verifying up‐to‐date and accurate information, limited interruptions, a process for verification, and an opportunity to review any relevant historical data. The Accreditation Council for Graduate Medical Education (ACGME) recently mandated that residency programs provide formal educational programs about patient care transitions and that faculty monitor ensure adequate handoff skills through direct observation [3, 19, 21]. TJC, the ACGME, and the Society of Hospital Medicine jointly encourage compliance with a structured format for verbally communicating information utilizing an ordered acronym mnemonic, SBAR: (1) Situation, (2) Background, (3) Assessment, and (4) Recommendation [7].

#### **7. Standardization of patient handoff**

Omitted and undocumented issues introduce risk for delays in expeditious follow‐up of clinically relevant overnight issues. Research by Devlin et al. demonstrated that only 14% of clinically important issues from the overnight clinical shifts had an accompanying progress note from the on‐call trainee in the patient's medical record [16]. Discontinuity of care secondary to ineffectual handoffs has been correlated with longer hospital stays and increased costs [3]. The morning handover process is highly variable and unreliable and often occurs in a chaotic clinical care environment. On‐call trainees fail to hand over numerous clinically important issues to the daytime team and frequently do not document their assessments and responses to the on‐call issue in the medical records. These omissions have the potential to cause unnecessary

Communication miscues and omissions, the most frequently numerated barrier to effective patient transition of care [17], correspond with the lack of consensus about the elements of effective handoff [2]. Substantial variability exists across, and sometimes within, institutions regarding preferred formats and processes for verbal and written handoffs. Research of residency training programs nationally indicate that handoff standardization has not been aggressively implemented and evaluated among residency training programs or implemented with

Clinical staff often utilize handoffs as an avenue for socialization, education, and emotional support to facilitate integration and staff cohesion; while these activities have merit, they divert attention from effective patient communication [8]. Resident physicians participating in patient handoffs may not interact regularly with each other, may be located in different parts of the healthcare systems, may have different skill and experience levels, or may come from different clinical backgrounds [3]. Adherence to hierarchical norms between junior and senior residents or attendings can further exacerbate relational communication barriers reflecting differences across levels of training or between clinician types in the willingness to engage in interactive questioning strategies to assertively challenge erroneous assumptions and actions during a handover with peers [7, 17]. Entrenchment of handoff routines in departmental or hospital mores may require transformational change of an institution's culture in

In 2010, TJC incorporated the patient handoff into its health facility accreditation standards and has encouraged improving and standardizing transitions of care as a national safety goal via implementation of a standardized approach to handoff communications, including an opportunity to ask and respond to questions [3, 20]. TJC's National Patient Safety Goals document contains specific guidelines for the handoff process, many drawn from other high‐risk

delays and may result in a lack of follow‐up for important patient issues [16].

**5. Barriers to effective handoffs**

variable compliance [2, 18].

40 Vignettes in Patient Safety - Volume 1

order to improve them [19].

**6. Regulatory agencies' input to enhance handoff**

House staff judge that strategies for handoff standardization most valuably improve quality of handoff and resident physician satisfaction with transition of care [16]. Most emergency medicine (EM) residency directors agree that standardized handoffs have the potential to reduce errors during transition of care, yet the majority of EM residency programs do not have a policy or a procedure regarding handoffs [17]. Didactic and interactive sessions teach key principles, and communication techniques of verbal and written handoffs utilizing mnemonics and checklists have shown to benefit in improving quality and standardization of handoff communications [19]. The SBAR mnemonic benefits handoff communication because of its simplicity, it provides a consistent framework for handoff scenarios, it can be utilized by different care providers, and it emphasizes on the clinician's assessment and response [16, 22]. Checklists have been effective in several different clinical settings in terms of decreasing medical errors and morbidity; utilization of checklists have the potential to improve the transfer of care process as well [23, 22]. Just as documentation in the electronic medical record about clinically important issues while on‐call facilitates communication, a structured, written clinical summary, such as a checklist, by the outgoing clinical team presented to the oncoming team facilitates understanding of critical issues regarding patient care during transition of care in a standardized way.

Starmer et al. objectively demonstrated improved outcomes via an educational intervention utilizing a structured resident handoff bundle to standardize inpatient handovers in care thereby decreasing medical error in multiple institutions [13]. The bundle included three major elements: team training by using focused TeamSTEPPS communication strategies, implementation of a standardized template for the written or printed computerized handoff document, and introduction of several evidence‐based verbal handoff processes, specifically I‐PASS, an acronym mnemonic [10]. TeamSTEPPS, a teamwork system developed jointly by the Department of Defense and the Agency for Healthcare Research and Quality, works to improve institutional collaboration and communication relating to patient safety [20]. Starmer et al. instituted an I‐PASS mnemonic to provide a consistent, structured format for communicating handoff information: I—Illness severity, P—Patient summary, A—Action list, S—Situation awareness and contingency planning, S—Synthesis by receiver [10].

#### **8. Assessing quality and competency of handoffs**

The ACGME requires that residency programs assess the competency of trainees in handoff communication. Detecting discrepancies between levels of quality of handoff communication requires training and is made more complicated by the existence of few standardized methods for assessing the competency of sign‐out communication [3, 10, 24]. Horwitz et al. developed an evaluation tool for direct observation of house staff and hospitalists during sign out that generates quantifiable data of handoff assessment and performs consistently across different institutions and among both trainees and attendings [24]. Horwitz et al. utilized peers to conduct handoff assessments, reasoning that peers familiarity with the handoff issues would recognize miscues that external evaluators might miss [24]. Starmer et al., as part of their standardized sign‐out bundle, developed direct observation assessment tools for assessment of quality of the departing and oncoming clinicians' adherence to the components of their handoff protocol and verbal engagement with one another [19].

and sustainability of their handoff curriculum. Recognizing the importance of local agents of change, Starmer et al. conducted focus groups with residents and other stakeholders from seven different institutions to develop "advertising" strategies to encourage adherence to their handoff protocol [19]. To remind clinicians about key handoff concepts, they created point‐of‐care references, including pocket reference cards and computer monitor frames with handoff mnemonic details. Recruiting teams of faculty champions, respected faculty members actively involved in patient care and resident education, encouraged rapid and early

Transitions of Care: Complications and Solutions http://dx.doi.org/10.5772/intechopen.69381 43

Active communication strategies by the oncoming clinician improve patient safety by detecting erroneous assessments and actions, thereby confronting diagnostic momentum and fixation bias [7]. Face‐to‐face group handoff, an active communication strategy, enriches the quality of handoffs more than a reliance on written or electronic notes [16]. Face‐to‐face verbal communication with interactive questioning and updates from oncoming and departing clinicians facilitate these discussions [25]. A vibrant, encouraging communications culture, characterized by openness to and willingness of clinicians, regardless of the level of training, to speak up, to ask questions, and to provide feedback, enhances quality of transfer of information and inculcates a culture of safety among both departing and oncoming clinical teams [4]. The oncoming clinician summarizing the handoff dialogue and restating key actions as part of a standardized handoff bundle has demonstrated benefit in patient outcomes [10]. These clinical team meetings during transition of care promote meaningful dialogue and engender an opportunity to identify and correct errors in real time [3]. Minimizing distractions, limiting interruptions such as nonurgent pages (e.g., ask nursing and allied health staff to defer nonurgent pages), and providing a dedicated space for handover will further supplement

**12. Culture of collaboration and professionalism to improve handoffs**

Medical professionalism includes a commitment to collaboration to quality clinical decision making, prudent medical error surveillance, and the voluntary reporting of adverse events [3]. Proactive discussion of pitfalls during shift change can impact potential for medical miscues by the oncoming providers during shift changes. A collaborative culture facilitates handoff of responsibility between the departing and oncoming providers by requests for assistance, by voicing clinical concerns, and by clarifying issues through bidirectional conversations. This process creates a shared mental model of the patient's clinical conditional and plan of care [4]. Oncoming clinicians foster the assumption of clinical responsibility by personally reassessing the patient and informing the patient of his or her evaluation with updated results during

adoption of the handoff curriculum [19].

**11. Active communication enhances handoffs**

end‐of‐shift patient management discussions [16].

walking rounds at the conclusion of patient handover [23].

#### **9. Simulation improves handoff experience**

Simulation activities provide residents opportunities to practice handoff skills prior to clinical practice. Patient care simulation enhances skill acquisition and behavioral modification through practice and reflection. The incorporation of illustrative videos and role‐play simulations into the handoff education curriculum can simulate both ideal and less‐than‐ideal handoff behaviors. Learners rotate the roles of giving, receiving, observing, and evaluating patient handoff [19]. Research has demonstrated that the most efficacious elements of patient handoff simulation include use of trigger videos reviewing particularly challenging handoff scenarios. The opportunity to practice giving and receiving handoffs utilizing new skills during simulation exercises enhances handoff performance in the clinical arena [19].

#### **10. Increasing awareness of handoff culture**

Communicating a vision of improved handoffs through institutionalizing an intervention to improve handoffs enhances awareness of this patient safety intervention. Understanding the complex social structures in which residents and attending physicians work, as well as the unwritten rules that govern the handoff of patient responsibilities, must be accounted for because interdisciplinary trust enables negotiating shared care plans and mitigates conflict to encourage a safer transition of patient care [8]. Training programs should introduce new or expand existing handover curricula to raise awareness about the distinct entity of transitions of care and to improve the communication process during this period [16]. Starmer et al. created a Campaign Subcommittee, which was charged with "branding" I‐PASS, their acronym for their handoff improvement intervention, to support the communication, implementation, and sustainability of their handoff curriculum. Recognizing the importance of local agents of change, Starmer et al. conducted focus groups with residents and other stakeholders from seven different institutions to develop "advertising" strategies to encourage adherence to their handoff protocol [19]. To remind clinicians about key handoff concepts, they created point‐of‐care references, including pocket reference cards and computer monitor frames with handoff mnemonic details. Recruiting teams of faculty champions, respected faculty members actively involved in patient care and resident education, encouraged rapid and early adoption of the handoff curriculum [19].

#### **11. Active communication enhances handoffs**

**8. Assessing quality and competency of handoffs**

42 Vignettes in Patient Safety - Volume 1

of their handoff protocol and verbal engagement with one another [19].

**9. Simulation improves handoff experience**

**10. Increasing awareness of handoff culture**

The ACGME requires that residency programs assess the competency of trainees in handoff communication. Detecting discrepancies between levels of quality of handoff communication requires training and is made more complicated by the existence of few standardized methods for assessing the competency of sign‐out communication [3, 10, 24]. Horwitz et al. developed an evaluation tool for direct observation of house staff and hospitalists during sign out that generates quantifiable data of handoff assessment and performs consistently across different institutions and among both trainees and attendings [24]. Horwitz et al. utilized peers to conduct handoff assessments, reasoning that peers familiarity with the handoff issues would recognize miscues that external evaluators might miss [24]. Starmer et al., as part of their standardized sign‐out bundle, developed direct observation assessment tools for assessment of quality of the departing and oncoming clinicians' adherence to the components

Simulation activities provide residents opportunities to practice handoff skills prior to clinical practice. Patient care simulation enhances skill acquisition and behavioral modification through practice and reflection. The incorporation of illustrative videos and role‐play simulations into the handoff education curriculum can simulate both ideal and less‐than‐ideal handoff behaviors. Learners rotate the roles of giving, receiving, observing, and evaluating patient handoff [19]. Research has demonstrated that the most efficacious elements of patient handoff simulation include use of trigger videos reviewing particularly challenging handoff scenarios. The opportunity to practice giving and receiving handoffs utilizing new skills dur-

Communicating a vision of improved handoffs through institutionalizing an intervention to improve handoffs enhances awareness of this patient safety intervention. Understanding the complex social structures in which residents and attending physicians work, as well as the unwritten rules that govern the handoff of patient responsibilities, must be accounted for because interdisciplinary trust enables negotiating shared care plans and mitigates conflict to encourage a safer transition of patient care [8]. Training programs should introduce new or expand existing handover curricula to raise awareness about the distinct entity of transitions of care and to improve the communication process during this period [16]. Starmer et al. created a Campaign Subcommittee, which was charged with "branding" I‐PASS, their acronym for their handoff improvement intervention, to support the communication, implementation,

ing simulation exercises enhances handoff performance in the clinical arena [19].

Active communication strategies by the oncoming clinician improve patient safety by detecting erroneous assessments and actions, thereby confronting diagnostic momentum and fixation bias [7]. Face‐to‐face group handoff, an active communication strategy, enriches the quality of handoffs more than a reliance on written or electronic notes [16]. Face‐to‐face verbal communication with interactive questioning and updates from oncoming and departing clinicians facilitate these discussions [25]. A vibrant, encouraging communications culture, characterized by openness to and willingness of clinicians, regardless of the level of training, to speak up, to ask questions, and to provide feedback, enhances quality of transfer of information and inculcates a culture of safety among both departing and oncoming clinical teams [4]. The oncoming clinician summarizing the handoff dialogue and restating key actions as part of a standardized handoff bundle has demonstrated benefit in patient outcomes [10]. These clinical team meetings during transition of care promote meaningful dialogue and engender an opportunity to identify and correct errors in real time [3]. Minimizing distractions, limiting interruptions such as nonurgent pages (e.g., ask nursing and allied health staff to defer nonurgent pages), and providing a dedicated space for handover will further supplement end‐of‐shift patient management discussions [16].

#### **12. Culture of collaboration and professionalism to improve handoffs**

Medical professionalism includes a commitment to collaboration to quality clinical decision making, prudent medical error surveillance, and the voluntary reporting of adverse events [3]. Proactive discussion of pitfalls during shift change can impact potential for medical miscues by the oncoming providers during shift changes. A collaborative culture facilitates handoff of responsibility between the departing and oncoming providers by requests for assistance, by voicing clinical concerns, and by clarifying issues through bidirectional conversations. This process creates a shared mental model of the patient's clinical conditional and plan of care [4]. Oncoming clinicians foster the assumption of clinical responsibility by personally reassessing the patient and informing the patient of his or her evaluation with updated results during walking rounds at the conclusion of patient handover [23].

#### **13. Summary**

Effective transitions of care facilitate teams of multiple clinicians to deliver secure and effective care without compromising the continuity of care [26]. At a minimum, departing clinicians should provide patient identification, diagnostic summary, the patient's current condition and trajectory, a plan of care, a prioritized to‐do list, and a plan for anticipated events. The oncoming clinicians should be able to understand likely contingencies and changes in the patient's condition [3]. To ensure regulatory compliance and improve patient security, educating residents and medical students to effectively perform patient handoffs offers synergistic benefits, including patient safety, continuity of care, and professionalism through teamwork [3]. Best practices ensure communication of essential information including: structured face‐to‐face and written sign‐out, interactive questioning, and checklists in distraction free settings [9]. A culture of professionalism can mitigate errors and procedural violations that arise primarily from aberrant mental processes such as forgetfulness, inattention, low motivation, carelessness, or negligence [8]. A shared common language utilizing a standardized regimen protocol for patient transitions of care communications across all provider types and practice settings will promote a culture of patient safety and enhance patient outcomes [22].

[5] Horwitz LI. Does improving handoffs reduce medical error rates? JAMA. 2013;**310**:

Transitions of Care: Complications and Solutions http://dx.doi.org/10.5772/intechopen.69381 45

[6] Tapia NM, Fallon SC, Brandt ML, Scott BG, Suliburk JW. Assessment and standardization of resident handoff practices: PACT project. Journal of Surgical Research. 2013;**184**:71‐77.

[7] Rayo MF, Mount‐Campbell AF, O'Brien JM, White SE, Butz A, Evans K, et al. Interactive questioning in critical care during handovers: A transcript analysis of communication behaviours by physicians, nurses and nurse practitioners. BMJ Quality & Safety.

[8] Smith CJ, Britigan DH, Lyden E, Anderson N, Welniak TJ, Wadman MC. Interunit handoffs from emergency department to inpatient care: A cross‐sectional survey of physicians at a university medical center. Journal of Hospital Medicine. 2015;**10**:711‐717. DOI:

[9] Young JQ, Irby DM, Barilla‐LaBarca M‐L, Ten Cate O, O'Sullivan PS. Measuring cognitive load: Mixed results from a handover simulation for medical students. Perspectives

[10] Starmer AJ, Spector ND, Srivastava R, Allen AD, Landrigan CP, Sectish TC. I‐PASS, a mnemonic to standardize verbal handoffs. Pediatrics. 2012;**129**:201‐204. DOI: 10.1542/

[11] Rourke L, Amin A, Boyington C, Ao P, Frolova N. Improving residents' handovers through just‐in‐time training for structured communication. BMJ Quality Improvement

[12] Cohen MD, Hilligoss B, Kajdacsy‐Balla Amaral AC. A handoff is not a telegram: An understanding of the patient is co‐constructed. Critical Care. 2012;**16**:303. DOI: 10.1186/

[13] Starmer AJ, Sectish TC, Simon DW, Keohane C, McSweeney ME, Chung EY, et al. Rates of medical errors and preventable adverse events among hospitalized children following implementation of a resident handoff bundle. JAMA. 2013;**310**:2262‐2270. DOI: 10.1001/

[14] Cohen MD, Hilligoss PB. The published literature on handoffs in hospitals: Deficiencies identified in an extensive review. Quality & Safety in Health Care. 2010;**19**:493‐497. DOI:

[15] Joint Commission Center For Improving Transitions of Care: Hand‐off communications. In: center for transforming healthcare.org [Internet]. Available from: http://www.center-

[16] Devlin MK, Kozij NK, Kiss A, Richardson L, Wong BM. Morning handover of on‐call issues: Opportunities for improvement. JAMA Internal Medicine. 2014;**174**:1‐7. DOI:

on Medical Education. 2016;**5**:24‐32. DOI: 10.1007/s40037‐015‐0240‐6

Reports. 2016;**5**:1-3. DOI: 10.1136/bmjquality.u209900.w4090

2255‐2256. DOI: 10.1001/jama.2013.281827

2014;**23**:483‐489. DOI: 10.1136/bmjqs‐2013‐002341

DOI: 10.1016/j.jss.2013.04.063

10.1002/jhm.2431

peds.2011‐2966

cc10536

jama.2013.281961

10.1136/qshc.2009.033480

fortransforminghealthcare.org/

10.1001/jamainternmed.2014.3033

#### **Author details**

Philip Salen

Address all correspondence to: philip.salen@sluhn.org

St. Luke's University Hospital EM Residency, St. Luke's University Hospital, Bethlehem, PA, USA

#### **References**


[5] Horwitz LI. Does improving handoffs reduce medical error rates? JAMA. 2013;**310**: 2255‐2256. DOI: 10.1001/jama.2013.281827

**13. Summary**

44 Vignettes in Patient Safety - Volume 1

**Author details**

Philip Salen

**References**

5, 2017]

USA

Effective transitions of care facilitate teams of multiple clinicians to deliver secure and effective care without compromising the continuity of care [26]. At a minimum, departing clinicians should provide patient identification, diagnostic summary, the patient's current condition and trajectory, a plan of care, a prioritized to‐do list, and a plan for anticipated events. The oncoming clinicians should be able to understand likely contingencies and changes in the patient's condition [3]. To ensure regulatory compliance and improve patient security, educating residents and medical students to effectively perform patient handoffs offers synergistic benefits, including patient safety, continuity of care, and professionalism through teamwork [3]. Best practices ensure communication of essential information including: structured face‐to‐face and written sign‐out, interactive questioning, and checklists in distraction free settings [9]. A culture of professionalism can mitigate errors and procedural violations that arise primarily from aberrant mental processes such as forgetfulness, inattention, low motivation, carelessness, or negligence [8]. A shared common language utilizing a standardized regimen protocol for patient transitions of care communications across all provider types and practice settings

St. Luke's University Hospital EM Residency, St. Luke's University Hospital, Bethlehem, PA,

[1] Project Detail. The Center for Transforming Healthcare [Internet]. Available from: http:// www.centerfortransforminghealthcare.org/projects/detail.aspx?Project=1 [Accessed: March

[2] Hern Jr HG, Gallahue FE, Burns BD, Druck J, Jones J, Kessler C, et al. Handoff practices in emergency medicine: Are we making progress? Academic Emergency Medicine.

[3] Wohlauer MV, Arora VM, Horwitz LI, Bass EJ, Mahar SE, Philibert I, et al. The patient handoff: A comprehensive curricular blueprint for resident education to improve continuity of care. Academic Medicine. 2012;**87**:411‐418. DOI: 10.1097/ACM.0b013e318248e766

[4] Lee S‐H, Phan PH, Dorman T, Weaver SJ, Pronovost PJ. Handoffs, safety culture, and practices: Evidence from the hospital survey on patient safety culture. BMC Health

Services Research. 2016;**16**:254. DOI: 10.1186/s12913‐016‐1502‐7

will promote a culture of patient safety and enhance patient outcomes [22].

Address all correspondence to: philip.salen@sluhn.org

2016;**23**:197‐201. DOI: 10.1111/acem.12867


[17] Riesenberg LA, Leitzsch J, Massucci JL, Jaeger J, Rosenfeld JC, Patow C, et al. Residents' and attending physicians' handoffs: A systematic review of the literature. Academic Medicine. 2009;**84**:1775‐1787. DOI: 10.1097/ACM.0b013e3181bf51a6

**Chapter 4**

**Dangers of Polypharmacy**

Pamela L. Valenza, Thomas C. McGinley,

Najmus Liang, Roopa Anmolsingh and

http://dx.doi.org/10.5772/intechopen.69169

its associated complications.

Noble McNaughton

**Abstract**

**1. Introduction**

James Feldman, Pritiben Patel, Kristine Cornejo,

Additional information is available at the end of the chapter

Although the definition of polypharmacy has evolved over time, it has been and remains to be an issue in healthcare. With the prevalence of polypharmacy increasing, those in the health care field must remain vigilant of the adverse effects of medications and work to coordinate care and maintain appropriate prescribing practices. Here we present a clinical vignette that describes an encounter of a patient on multiple medications and the individual, provider, and systems‐level issues that may have contributed to an adverse event resulting in a hospital stay. We will discuss the definition of polypharmacy, review the prevalence and economic implications of drug prescription practices, and examine the consequences and complications of polypharmacy in a number of different patient populations. We will discuss a number of scenarios involving polypharmacy that lead to medication errors, decreased quality of life, and patient harm, and then review evidence‐ based methods of interventions aimed at reducing the prevalence of polypharmacy and

**Keywords:** polypharmacy, risk factors, root causes, complications, interventions

Although the definition of polypharmacy has evolved over time, it has been and remains to be an issue in healthcare. With the prevalence of polypharmacy increasing, those in the health care field must remain vigilant of the adverse effects of medications and work to coordinate care and maintain appropriate prescribing practices. Here we present a clinical vignette that describes an encounter of a patient on multiple medications and the individual,

> © 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


#### **Chapter 4**

## **Dangers of Polypharmacy**

Pamela L. Valenza, Thomas C. McGinley, James Feldman, Pritiben Patel, Kristine Cornejo, Najmus Liang, Roopa Anmolsingh and Noble McNaughton

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.69169

#### **Abstract**

[17] Riesenberg LA, Leitzsch J, Massucci JL, Jaeger J, Rosenfeld JC, Patow C, et al. Residents' and attending physicians' handoffs: A systematic review of the literature. Academic

[18] Lee S, Jordan J, Hern H, Kessler C, Promes S, Krzyzaniak S, et al. Transition of care practices from emergency department to inpatient: A survey data and the development of algorithm. The Western Journal of Emergency Medicine. 2016;**28**(1):86‐92. Available:

[19] Starmer AJ, O'Toole JK, Rosenbluth G, Calaman S, Balmer D, West DC, et al. Development, implementation, and dissemination of the I‐PASS handoff curriculum: A multisite educational intervention to improve patient handoffs. Academic Medicine. 2014;**89**:876‐884.

[20] TeamSTEPPS Fundamentals Course: Module 3. Communication | Agency for Healthcare Research & Quality [Internet]. Available from: https://www.ahrq.gov/teamstepps/instruc-

[21] Defective Hand‐Off Communication forces Defendant Physician & Hospital to Settle Lawsuit: MagMutual [Internet]. 2015. Available from: https://www.magmutual.com/ learning/claimslesson/defective‐hand‐communication‐forces‐defendant‐physician‐hos-

[22] Lee SY, Dong L, Lim YH, Poh CL, Lim WS. SBAR: Towards a common interprofessional team‐based communication tool. Medical Education. 2016;**50**:1167‐1168. DOI: 10.1111/

[23] Milano A, Salen P, Stankewicz H. 290 The impact of a standardized checklist on transition of care during emergency physician change of shift. Annals of Emergency Medicine. Elsevier. 2016;**68**:S113. http://www.annemergmed.com/article/S0196‐0644(16)30763‐6/abstract [24] Horwitz LI, Rand D, Staisiunas P, Van Ness PH, Araujo KLB, Banerjee SS, et al. Development of a handoff evaluation tool for shift‐to‐shift physician handoffs: The Handoff CEX. Journal of Hospital Medicine. 2013;**8**:191‐200. DOI: 10.1002/jhm.2023 [25] Patterson ES, Roth EM, Woods DD, Chow R, Gomes JO. Handoff strategies in settings with high consequences for failure: Lessons for health care operations. International Journal for Quality in Health Care. 2004;**16**:125‐132. Available: http://www.ncbi.nlm.nih.

[26] Colvin MO, Eisen LA, Gong MN. Improving the patient handoff process in the intensive care unit: Keys to reducing errors and improving outcomes. Seminars in Respiratory

and Critical Care Medicine. 2016;**37**:96‐106. DOI: 10.1055/s‐0035‐1570351

tor/fundamentals/module3/igcommunication.html [Accessed: February 10, 2017]

Medicine. 2009;**84**:1775‐1787. DOI: 10.1097/ACM.0b013e3181bf51a6

http://escholarship.org/uc/item/0xc35653

DOI: 10.1097/ACM.0000000000000264

pital‐settle [Accessed: March 5, 2017]

medu.13171

46 Vignettes in Patient Safety - Volume 1

gov/pubmed/15051706

Although the definition of polypharmacy has evolved over time, it has been and remains to be an issue in healthcare. With the prevalence of polypharmacy increasing, those in the health care field must remain vigilant of the adverse effects of medications and work to coordinate care and maintain appropriate prescribing practices. Here we present a clinical vignette that describes an encounter of a patient on multiple medications and the individual, provider, and systems‐level issues that may have contributed to an adverse event resulting in a hospital stay. We will discuss the definition of polypharmacy, review the prevalence and economic implications of drug prescription practices, and examine the consequences and complications of polypharmacy in a number of different patient populations. We will discuss a number of scenarios involving polypharmacy that lead to medication errors, decreased quality of life, and patient harm, and then review evidence‐ based methods of interventions aimed at reducing the prevalence of polypharmacy and its associated complications.

**Keywords:** polypharmacy, risk factors, root causes, complications, interventions

#### **1. Introduction**

Although the definition of polypharmacy has evolved over time, it has been and remains to be an issue in healthcare. With the prevalence of polypharmacy increasing, those in the health care field must remain vigilant of the adverse effects of medications and work to coordinate care and maintain appropriate prescribing practices. Here we present a clinical vignette that describes an encounter of a patient on multiple medications and the individual,

© 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

provider, and systems‐level issues that may have contributed to an adverse event resulting in a hospital stay. We will discuss the definition of polypharmacy, review the prevalence and economic implications of drug prescription practices, and examine the consequences and complications of polypharmacy in a number of different patient populations. We will discuss a number of scenarios involving polypharmacy that lead to medication errors, decreased quality of life, and patient harm, and then review evidence‐based methods of interventions aimed at reducing the prevalence of polypharmacy and its associated complications.

medications and vitamins that are often not reported and as clinicians, it is not improbable to be treating patients with multiple conditions requiring multiple medications for optimal control. However, most clinicians would agree that polypharmacy is defined as the concomi‐ tant use of five to nine medications and hyperpolypharmacy, or excessive polypharmacy, is

Dangers of Polypharmacy

49

http://dx.doi.org/10.5772/intechopen.69169

Across all persons aged 20 or older, the prevalence of polypharmacy increased from an esti‐ mated 8.2% in 1999–2000 to 15% in 2011–2012 [6]. If the use of non‐prescription medications is included, the prevalence of polypharmacy in the adult population increases to 29% [7]. The National Center for Health Statistics estimated that in 2014, approximately 2.8 billion prescription medications were ordered in the ambulatory office setting, of which the most fre‐ quently prescribed medications were analgesics, antihypertensives, and antidepressants [8]. Meanwhile, in the hospital outpatient departments, 329.2 million medications were prescribed with the most commonly ordered agents being analgesics, antidiabetics and antihyperlipid‐ emics [8]. Overall, prescription drug use increased in many of the most common drug classes used by Americans including antihypertensives, antihyperlipidemics, antidepressants, antidi‐ abetic agents, prescription analgesics, prescription proton‐pump inhibitors, anticonvulsants, bronchodialators, and muscle relaxants [6]. Outpatient pediatric (aged ≤ 18) polypharmacy is also substantial with a prevalence rate of 10%, occurring more often in the setting of a complex

Individuals greater than 65 years old are the biggest consumers of medications; however, evidence shows that greater than 50% of elderly patients are taking at least one medication that is not medically necessary [10]. Nearly 40% of elderly adults take more than five prescrip‐ tion medications and almost 20% take more than 10 [6, 11]. Additionally, approximately half of the elderly population takes at least one over‐the‐counter drug and approximately half of the elderly population takes at least one nutritional supplement in combination with prescription medications [6, 11]. Polypharmacy declines in patients older than 85 years of age secondary to poor drug tolerance with age and increasing deprescribing practices as medical providers fear

In 2014, the United States (US) was estimated to have spent \$3 trillion on total national health care expenditures, of which 9.8% (\$294 million) was spent on prescription drugs [8]. Approximately, \$77.7 billion was spent on total expenditures on Medicare Part D program in 2014, and an estimated \$165.1 billion will be utilized by 2022 [13].This number will continue to increase as the estimated number of Americans >65 years of age by 2050 is projected to be 88.5 million, more than double that of 2010 (40.2 million) [14]. The US Center for Medicare and

serious adverse drug reactions that may be more common in the very elderly [12].

defined as the use of ten or more medications [3–5].

**4. Drug prescription practices**

chronic condition [9].

**5. Economic implications**

#### **2. Patient vignette**

An 89‐year old male presents to his primary care provider for follow‐up after a recent hos‐ pitalization for a non‐displaced hip fracture after a fall at home. He has poorly controlled hypertension, gastroesophageal reflux disease, hyperlipidemia, depression, prediabetes, arthritis, cataracts, and a remote history of heart disease with stents placed years ago. He reports two new medications were started in the hospital but he does not know why they were prescribed. The hospital did not fax over any records and the patient did not bring his discharge information summary to his appointment. At this time, he does not report any side effects of the new medicines but he would like to discuss getting treatment for ongoing fatigue, insomnia, and worsening joint pain. He reports seeing his cardiologist a couple months ago, who changed the dose of one of his blood pressure medicines but the patient is not sure which medicine was changed or the milligrams of the new dose. When asked to fill out a release of information to send to the cardiologist, the patient replies his cardiologist retired not long after his last appointment and the patient needs a referral to see a new cardiologist. In addition to a cardiologist, the patient also follows with a gastro‐ enterologist, psychologist, psychiatrist, and ophthalmologist. None of the providers utilize the same electronic medical record system. On review of the list of medications the primary care provider has on file, the patient only recognizes eight out of sixteen medicines. In addi‐ tion, his primary care provider personally prescribes only six of the medications on the list. When asked about compliance, the patient is adamant he always takes his medications as prescribed, but states his wife, who is currently at home, helps him take his medicines because he has some difficulty reading the labels and remembering to take them at the appropriate times.

#### **3. Defining polypharmacy**

Polypharmacy first appeared in the medical literature more than a century and a half ago [1]. Polypharmacy has multiple meanings without a clear consensus in the scientific com‐ munity of a strict definition. This is most apparent in the wide range of research into the subject and how such datacan be applied differently to various definitions of the term [2]. Defining polypharmacy can be further complicated by patients taking over‐the‐counter medications and vitamins that are often not reported and as clinicians, it is not improbable to be treating patients with multiple conditions requiring multiple medications for optimal control. However, most clinicians would agree that polypharmacy is defined as the concomi‐ tant use of five to nine medications and hyperpolypharmacy, or excessive polypharmacy, is defined as the use of ten or more medications [3–5].

#### **4. Drug prescription practices**

provider, and systems‐level issues that may have contributed to an adverse event resulting in a hospital stay. We will discuss the definition of polypharmacy, review the prevalence and economic implications of drug prescription practices, and examine the consequences and complications of polypharmacy in a number of different patient populations. We will discuss a number of scenarios involving polypharmacy that lead to medication errors, decreased quality of life, and patient harm, and then review evidence‐based methods of interventions

aimed at reducing the prevalence of polypharmacy and its associated complications.

An 89‐year old male presents to his primary care provider for follow‐up after a recent hos‐ pitalization for a non‐displaced hip fracture after a fall at home. He has poorly controlled hypertension, gastroesophageal reflux disease, hyperlipidemia, depression, prediabetes, arthritis, cataracts, and a remote history of heart disease with stents placed years ago. He reports two new medications were started in the hospital but he does not know why they were prescribed. The hospital did not fax over any records and the patient did not bring his discharge information summary to his appointment. At this time, he does not report any side effects of the new medicines but he would like to discuss getting treatment for ongoing fatigue, insomnia, and worsening joint pain. He reports seeing his cardiologist a couple months ago, who changed the dose of one of his blood pressure medicines but the patient is not sure which medicine was changed or the milligrams of the new dose. When asked to fill out a release of information to send to the cardiologist, the patient replies his cardiologist retired not long after his last appointment and the patient needs a referral to see a new cardiologist. In addition to a cardiologist, the patient also follows with a gastro‐ enterologist, psychologist, psychiatrist, and ophthalmologist. None of the providers utilize the same electronic medical record system. On review of the list of medications the primary care provider has on file, the patient only recognizes eight out of sixteen medicines. In addi‐ tion, his primary care provider personally prescribes only six of the medications on the list. When asked about compliance, the patient is adamant he always takes his medications as prescribed, but states his wife, who is currently at home, helps him take his medicines because he has some difficulty reading the labels and remembering to take them at the

Polypharmacy first appeared in the medical literature more than a century and a half ago [1]. Polypharmacy has multiple meanings without a clear consensus in the scientific com‐ munity of a strict definition. This is most apparent in the wide range of research into the subject and how such datacan be applied differently to various definitions of the term [2]. Defining polypharmacy can be further complicated by patients taking over‐the‐counter

**2. Patient vignette**

48 Vignettes in Patient Safety - Volume 1

appropriate times.

**3. Defining polypharmacy**

Across all persons aged 20 or older, the prevalence of polypharmacy increased from an esti‐ mated 8.2% in 1999–2000 to 15% in 2011–2012 [6]. If the use of non‐prescription medications is included, the prevalence of polypharmacy in the adult population increases to 29% [7]. The National Center for Health Statistics estimated that in 2014, approximately 2.8 billion prescription medications were ordered in the ambulatory office setting, of which the most fre‐ quently prescribed medications were analgesics, antihypertensives, and antidepressants [8]. Meanwhile, in the hospital outpatient departments, 329.2 million medications were prescribed with the most commonly ordered agents being analgesics, antidiabetics and antihyperlipid‐ emics [8]. Overall, prescription drug use increased in many of the most common drug classes used by Americans including antihypertensives, antihyperlipidemics, antidepressants, antidi‐ abetic agents, prescription analgesics, prescription proton‐pump inhibitors, anticonvulsants, bronchodialators, and muscle relaxants [6]. Outpatient pediatric (aged ≤ 18) polypharmacy is also substantial with a prevalence rate of 10%, occurring more often in the setting of a complex chronic condition [9].

Individuals greater than 65 years old are the biggest consumers of medications; however, evidence shows that greater than 50% of elderly patients are taking at least one medication that is not medically necessary [10]. Nearly 40% of elderly adults take more than five prescrip‐ tion medications and almost 20% take more than 10 [6, 11]. Additionally, approximately half of the elderly population takes at least one over‐the‐counter drug and approximately half of the elderly population takes at least one nutritional supplement in combination with prescription medications [6, 11]. Polypharmacy declines in patients older than 85 years of age secondary to poor drug tolerance with age and increasing deprescribing practices as medical providers fear serious adverse drug reactions that may be more common in the very elderly [12].

#### **5. Economic implications**

In 2014, the United States (US) was estimated to have spent \$3 trillion on total national health care expenditures, of which 9.8% (\$294 million) was spent on prescription drugs [8]. Approximately, \$77.7 billion was spent on total expenditures on Medicare Part D program in 2014, and an estimated \$165.1 billion will be utilized by 2022 [13].This number will continue to increase as the estimated number of Americans >65 years of age by 2050 is projected to be 88.5 million, more than double that of 2010 (40.2 million) [14]. The US Center for Medicare and Medicaid Services (CMS) states that polypharmacy has been estimated to cost US health plans over \$50 billion annually [8, 15, 16]. With respect to medication discrepancies and patient adherence, if patients took all appropriate medications exactly as prescribed, it is estimated it would save 13% (\$290 billion) of total US health care expenditures due to avoidable medical costs [17].

An estimated \$16.4 billion and \$4.2 billion are spent on inpatient and outpatient preventable medication errors, respectively [18].Adverse drug events (ADEs) occur commonly in hospital settings, which in turn increase the likelihood of morbidity, length of stay (LOS), and the cost of care. A multicenter retrospective cohort study conducted in six community hospitals significantly showed that ADEs are associated with an increased adjusted average hospital‐ ization cost of \$6910 and increased length of stay of 5 days [19]. The severity of ADEs are asso‐ ciated with further increased costs and length of stay (\$9768 in patients and LOS 7.79 days with significant ADEs versus \$15,033 in patients and LOS 10.56 days with life‐threatening ADEs) [19]. Research evaluating the effect of computerized provider order entry (CPOE) in the outpatient setting has shown the potential to result in fewer medication errors and ADEs by 1.5 million and 14,500, respectively, with the potential to save \$18 million dollars [20]. In the hospital setting, the implementation of CPOE is associated with an estimated 50% reduc‐ tion of ADEs and medication errors [21].

#### **6. Root causes of polypharmacy**

The prevalence of polypharmacy is multifactorial with risk factors spanning from the individ‐ ual/patient level (increasing longevity, coexistence of chronic medical conditions, availability of over‐the‐counter drugs, use of more than one pharmacy) to the physician level (medical guidelines, prescribing practices) to systems‐level issues (multiple prescribing providers, electronic medical records, transitions of care) [22]. See **Figure 1** for a comprehensive list of the factors associated with polypharmacy [23, 24]. Medical practitioners rely on clinical guidelines to guide their medical practice and clinical decisions to provide the best care to patients. Available clinical guidelines are usually devised with focus on a single disease and often overlook the possibility of comorbidities and the consumption of other medications by the patient [1].Adherence to clinical guidelines for multiple concomitant chronic condi‐ tions may inadvertently lead to adverse outcomes for patients due to complications from multiple medications for multiple medical conditions [25]. In the post‐acute transition of care setting, patients can often see their medication list expand or see changes in dosages due to their recent debilitation and hospitalization [3].There are often multiple clinicians, sometimes in the form of multidisciplinary teams, making medical decisions. Lack of communication between treatment teams and disruption in communication during transitions of care from the inpatient setting to the outpatient setting and vice‐versa can precipitate polypharmacy [23]. If we look at our patient in the clinical vignette, there exists several risk factors for poly‐ pharmacy: elderly age, multiple chronic conditions, decreased ability to function, multiple providers, poor physician‐patient communication, poor physician‐physician communication, multiple prescribers, and disjointed electronic medical records.

**7. Polypharmacy complications and consequences**

use without periodic review [26, 29].

**Figure 1.** Factors associated with polypharmacy.

The more drugs an individual takes, the more likely he or she will suffer a complication or adverse outcome [4]. Polypharmacy is associated with increases in many adverse outcomes including adverse drug reactions, drug to drug interactions, drug to disease interactions, non‐adherence, falls, cognitive impairment, hospital admission and mortality [4, 12, 26].

Dangers of Polypharmacy

51

http://dx.doi.org/10.5772/intechopen.69169

Adverse drug reactions (ADRs) are defined as undesired or noxious effects of standard drug treatment doses which include amplified drug effects, side effects, interactions with other drugs and interactions with other nutrients or diseases [11]. ADRs are a common cause of hospital admissions and emergency department visits [27, 28]. Many factors contribute to adverse drug reactions including unnecessary drug use, inappropriate drug choice, therapeutic duplication, inappropriate dosing regimen, physician‐patient communication, and long‐term medication

In the hospital setting, polypharmacy is a strong predictor of adverse drug reactions in both adults and pediatrics [30]. Not only are hospitalized adults at risk of adverse events from potentially inappropriate medications or drug‐drug interactions, patients with polyphar‐ macy are at higher risk due to medication discrepancies that may result from unintended discrepancies in actual regimen versus recorded regimen during transitions from outpatient to inpatient and vice‐versa, changes to medication regimens while in the hospital, and poor

**Figure 1.** Factors associated with polypharmacy.

Medicaid Services (CMS) states that polypharmacy has been estimated to cost US health plans over \$50 billion annually [8, 15, 16]. With respect to medication discrepancies and patient adherence, if patients took all appropriate medications exactly as prescribed, it is estimated it would save 13% (\$290 billion) of total US health care expenditures due to avoidable medical

An estimated \$16.4 billion and \$4.2 billion are spent on inpatient and outpatient preventable medication errors, respectively [18].Adverse drug events (ADEs) occur commonly in hospital settings, which in turn increase the likelihood of morbidity, length of stay (LOS), and the cost of care. A multicenter retrospective cohort study conducted in six community hospitals significantly showed that ADEs are associated with an increased adjusted average hospital‐ ization cost of \$6910 and increased length of stay of 5 days [19]. The severity of ADEs are asso‐ ciated with further increased costs and length of stay (\$9768 in patients and LOS 7.79 days with significant ADEs versus \$15,033 in patients and LOS 10.56 days with life‐threatening ADEs) [19]. Research evaluating the effect of computerized provider order entry (CPOE) in the outpatient setting has shown the potential to result in fewer medication errors and ADEs by 1.5 million and 14,500, respectively, with the potential to save \$18 million dollars [20]. In the hospital setting, the implementation of CPOE is associated with an estimated 50% reduc‐

The prevalence of polypharmacy is multifactorial with risk factors spanning from the individ‐ ual/patient level (increasing longevity, coexistence of chronic medical conditions, availability of over‐the‐counter drugs, use of more than one pharmacy) to the physician level (medical guidelines, prescribing practices) to systems‐level issues (multiple prescribing providers, electronic medical records, transitions of care) [22]. See **Figure 1** for a comprehensive list of the factors associated with polypharmacy [23, 24]. Medical practitioners rely on clinical guidelines to guide their medical practice and clinical decisions to provide the best care to patients. Available clinical guidelines are usually devised with focus on a single disease and often overlook the possibility of comorbidities and the consumption of other medications by the patient [1].Adherence to clinical guidelines for multiple concomitant chronic condi‐ tions may inadvertently lead to adverse outcomes for patients due to complications from multiple medications for multiple medical conditions [25]. In the post‐acute transition of care setting, patients can often see their medication list expand or see changes in dosages due to their recent debilitation and hospitalization [3].There are often multiple clinicians, sometimes in the form of multidisciplinary teams, making medical decisions. Lack of communication between treatment teams and disruption in communication during transitions of care from the inpatient setting to the outpatient setting and vice‐versa can precipitate polypharmacy [23]. If we look at our patient in the clinical vignette, there exists several risk factors for poly‐ pharmacy: elderly age, multiple chronic conditions, decreased ability to function, multiple providers, poor physician‐patient communication, poor physician‐physician communication,

costs [17].

50 Vignettes in Patient Safety - Volume 1

tion of ADEs and medication errors [21].

**6. Root causes of polypharmacy**

multiple prescribers, and disjointed electronic medical records.

#### **7. Polypharmacy complications and consequences**

The more drugs an individual takes, the more likely he or she will suffer a complication or adverse outcome [4]. Polypharmacy is associated with increases in many adverse outcomes including adverse drug reactions, drug to drug interactions, drug to disease interactions, non‐adherence, falls, cognitive impairment, hospital admission and mortality [4, 12, 26].

Adverse drug reactions (ADRs) are defined as undesired or noxious effects of standard drug treatment doses which include amplified drug effects, side effects, interactions with other drugs and interactions with other nutrients or diseases [11]. ADRs are a common cause of hospital admissions and emergency department visits [27, 28]. Many factors contribute to adverse drug reactions including unnecessary drug use, inappropriate drug choice, therapeutic duplication, inappropriate dosing regimen, physician‐patient communication, and long‐term medication use without periodic review [26, 29].

In the hospital setting, polypharmacy is a strong predictor of adverse drug reactions in both adults and pediatrics [30]. Not only are hospitalized adults at risk of adverse events from potentially inappropriate medications or drug‐drug interactions, patients with polyphar‐ macy are at higher risk due to medication discrepancies that may result from unintended discrepancies in actual regimen versus recorded regimen during transitions from outpatient to inpatient and vice‐versa, changes to medication regimens while in the hospital, and poor communication of medication changes to both patient and next provider of care [31]. Large numbers of hospitalized pediatric patients are exposed to polypharmacy with increased risk associated with longer lengths of stay and presence of complex chronic conditions [32, 33]. Polypharmacy increases potential drug–drug interactions in pediatrics, often due to off‐label prescribing of drugs, lack of therapeutic profiles for less common medications, and weight‐ based medication errors [34].

medications, or fail to take one or more medications as prescribed [40]. These issues occur for a variety of reasons including financial hardship, symptom improvement, and unreported

Dangers of Polypharmacy

53

http://dx.doi.org/10.5772/intechopen.69169

Accidental inappropriate drug use may result from erroneous or repeat doses from poor eye‐ sight or forgetfulness [46]. In addition, patients may not be able to accurately read and under‐ stand the labels on medications prescribed. With more than 33,000 trademarked medications, errors have commonly been linked to drugs with similar sounding names. Adding to the drug name confusion, are problems with similar packaging and labeling, incomplete knowledge, illegible handwriting, prescriptions which are orally communicated and a significant number

The following sections briefly touch on unique considerations when addressing polypharmacy

Older adults with comorbidities are often excluded from drug trials, therefore, the use of drugs in older populations to a large extent can be considered experimental [48].The use of multiple clinical guidelines that do not account for multiple comorbid conditions, along with the knowledge of altered pharmacodynamics due to the physiological changes in older adults, can become dangerous to the elderly patient. Certain classes of drugs have been associated with cognitive impairment and falls, with elderly patients being more susceptible than others. Polypharmacy in elderly patients has been shown to be a predictor of frequent hospitaliza‐ tions, nursing home placement, death, hypoglycemia, fracture, impaired mobility, pneumo‐ nia, and malnutrition [22]. As the elderly age, they are at increased risk of complications from polypharmacy including the inability to effectively metabolize and excrete multiple medica‐ tions due to changes in liver and kidney function [22]. To confound this further, age‐related change in pharmacodynamics resulting from changes in drug receptor affinity alters the con‐ centrations of drugs that are effective and toxic [49]. Additionally, increasing use and num‐ ber of medications seems to have a negative impact on nutrient intake and nutritional status overall in the elderly not only from drug‐nutrient interactions, but also from compounded side effects such as nausea, decreased appetite, dry mouth and metallic taste which ultimately

In elderly patients at the end of life, pain is a common symptom [50]. Patients undergoing palliative treatment are especially vulnerable to unwanted adverse effects of medications sec‐ ondary to their altered metabolism, organ dysfunction, and high likelihood of polypharmacy with ensuing drug‐drug and drug‐host interactions [51]. In one study, potential drug‐drug interactions (DDIs) were detected in 61% of inpatient hospice patients [52]. Polypharmacy was the major predictor for DDIs and the most commonly implicated drugs in therapeutically potential DDIs were antipsychotics, antiemetics, antidepressants, insulin, glucocorticoids,

of new products continually being introduced into the marketplace [47].

**8. Special considerations in different patient populations**

in different patient populations and certain medical conditions.

side effects.

**8.1. Elderly/end of life**

decrease food intake [46].

Medical record discrepancies in the outpatient setting occur in about 75% of cases, with a strong positive correlation with polypharmacy, with rates escalating as high as 95% [17]. Discrepancies may include active prescriptions that the patient did not include on their medi‐ cation record or patient‐reported medications that were not documented in the electronic health record. Adverse events due to medical record discrepancy occur not only from failure to perform reconciliation, but failure to ensure and promote patient adherence to the regimen as intended by the provider [17].

Medication errors cause at least one death every day and injure 1.3 million people annually in the United States [35]. Several factors contribute to medication errors secondary to poly‐ pharmacy. Errors can easily occur when patients are seeing multiple specialty providers for comorbid conditions. Nearly 40% of all medication errors and 50% of adverse drug events are a result from errors in prescribing such as overdosing of medications, underdosing of medications, allergies, improper dose, improper drug, and duplication of therapy [36]. Lack of communication and coordination between treating providers increases the likelihood of prescribing medications which may result in adverse drug reactions, side effects or worse. Failing to review patient records and reconcile medications at regular visits by all providers poses greater risk for the occurrence of errors [37]. Omission of performing adequate medica‐ tion reconciliation, including asking about over‐the‐counter medications, herbals, vitamins, and nutritional supplements, and patients' failure to disclose other medication use may contribute to the occurrence of a preventable harmful drug‐drug interaction [38]. To ensure accurate medication reconciliation, patients should be asked to bring all medications to each provider visit [39].

Transitions of care pose a danger of medication errors and include a change in setting, prac‐ titioner, type of service and move from one level of care to another [40]. Ineffective processes during transitions of care can result in adverse events and higher hospital readmission rates and costs [41]. During transitions of care, patient education regarding complicated regimens, lack of accountability of the clinical entity to provide coordination across settings, and lack of effective communication between providers are most often the root causes [42, 43].

Patient adherence to polypharmacy regimens presents another juncture at which errors may arise. Adherence is defined as the extent to which an individual's behavior, including taking medicine, following a certain type of diet, or lifestyle modifications, corresponds with recom‐ mendations from a healthcare provider as agreed upon by the patient [44]. Nonadherence is defined as the improper intake of medication [44]. The complexity of a medicine regimen is inversely related to medication adherence with increasingly complex regimens (increased frequency of dose, decreased patient education) associated with lower rates of adherence [45]. Issues of adherence include patients who do not fill their prescriptions, decide to stop taking medications, or fail to take one or more medications as prescribed [40]. These issues occur for a variety of reasons including financial hardship, symptom improvement, and unreported side effects.

Accidental inappropriate drug use may result from erroneous or repeat doses from poor eye‐ sight or forgetfulness [46]. In addition, patients may not be able to accurately read and under‐ stand the labels on medications prescribed. With more than 33,000 trademarked medications, errors have commonly been linked to drugs with similar sounding names. Adding to the drug name confusion, are problems with similar packaging and labeling, incomplete knowledge, illegible handwriting, prescriptions which are orally communicated and a significant number of new products continually being introduced into the marketplace [47].

### **8. Special considerations in different patient populations**

The following sections briefly touch on unique considerations when addressing polypharmacy in different patient populations and certain medical conditions.

#### **8.1. Elderly/end of life**

communication of medication changes to both patient and next provider of care [31]. Large numbers of hospitalized pediatric patients are exposed to polypharmacy with increased risk associated with longer lengths of stay and presence of complex chronic conditions [32, 33]. Polypharmacy increases potential drug–drug interactions in pediatrics, often due to off‐label prescribing of drugs, lack of therapeutic profiles for less common medications, and weight‐

Medical record discrepancies in the outpatient setting occur in about 75% of cases, with a strong positive correlation with polypharmacy, with rates escalating as high as 95% [17]. Discrepancies may include active prescriptions that the patient did not include on their medi‐ cation record or patient‐reported medications that were not documented in the electronic health record. Adverse events due to medical record discrepancy occur not only from failure to perform reconciliation, but failure to ensure and promote patient adherence to the regimen

Medication errors cause at least one death every day and injure 1.3 million people annually in the United States [35]. Several factors contribute to medication errors secondary to poly‐ pharmacy. Errors can easily occur when patients are seeing multiple specialty providers for comorbid conditions. Nearly 40% of all medication errors and 50% of adverse drug events are a result from errors in prescribing such as overdosing of medications, underdosing of medications, allergies, improper dose, improper drug, and duplication of therapy [36]. Lack of communication and coordination between treating providers increases the likelihood of prescribing medications which may result in adverse drug reactions, side effects or worse. Failing to review patient records and reconcile medications at regular visits by all providers poses greater risk for the occurrence of errors [37]. Omission of performing adequate medica‐ tion reconciliation, including asking about over‐the‐counter medications, herbals, vitamins, and nutritional supplements, and patients' failure to disclose other medication use may contribute to the occurrence of a preventable harmful drug‐drug interaction [38]. To ensure accurate medication reconciliation, patients should be asked to bring all medications to each

Transitions of care pose a danger of medication errors and include a change in setting, prac‐ titioner, type of service and move from one level of care to another [40]. Ineffective processes during transitions of care can result in adverse events and higher hospital readmission rates and costs [41]. During transitions of care, patient education regarding complicated regimens, lack of accountability of the clinical entity to provide coordination across settings, and lack of

Patient adherence to polypharmacy regimens presents another juncture at which errors may arise. Adherence is defined as the extent to which an individual's behavior, including taking medicine, following a certain type of diet, or lifestyle modifications, corresponds with recom‐ mendations from a healthcare provider as agreed upon by the patient [44]. Nonadherence is defined as the improper intake of medication [44]. The complexity of a medicine regimen is inversely related to medication adherence with increasingly complex regimens (increased frequency of dose, decreased patient education) associated with lower rates of adherence [45]. Issues of adherence include patients who do not fill their prescriptions, decide to stop taking

effective communication between providers are most often the root causes [42, 43].

based medication errors [34].

52 Vignettes in Patient Safety - Volume 1

as intended by the provider [17].

provider visit [39].

Older adults with comorbidities are often excluded from drug trials, therefore, the use of drugs in older populations to a large extent can be considered experimental [48].The use of multiple clinical guidelines that do not account for multiple comorbid conditions, along with the knowledge of altered pharmacodynamics due to the physiological changes in older adults, can become dangerous to the elderly patient. Certain classes of drugs have been associated with cognitive impairment and falls, with elderly patients being more susceptible than others. Polypharmacy in elderly patients has been shown to be a predictor of frequent hospitaliza‐ tions, nursing home placement, death, hypoglycemia, fracture, impaired mobility, pneumo‐ nia, and malnutrition [22]. As the elderly age, they are at increased risk of complications from polypharmacy including the inability to effectively metabolize and excrete multiple medica‐ tions due to changes in liver and kidney function [22]. To confound this further, age‐related change in pharmacodynamics resulting from changes in drug receptor affinity alters the con‐ centrations of drugs that are effective and toxic [49]. Additionally, increasing use and num‐ ber of medications seems to have a negative impact on nutrient intake and nutritional status overall in the elderly not only from drug‐nutrient interactions, but also from compounded side effects such as nausea, decreased appetite, dry mouth and metallic taste which ultimately decrease food intake [46].

In elderly patients at the end of life, pain is a common symptom [50]. Patients undergoing palliative treatment are especially vulnerable to unwanted adverse effects of medications sec‐ ondary to their altered metabolism, organ dysfunction, and high likelihood of polypharmacy with ensuing drug‐drug and drug‐host interactions [51]. In one study, potential drug‐drug interactions (DDIs) were detected in 61% of inpatient hospice patients [52]. Polypharmacy was the major predictor for DDIs and the most commonly implicated drugs in therapeutically potential DDIs were antipsychotics, antiemetics, antidepressants, insulin, glucocorticoids, cardiovascular drugs and NSAIDs [52]. In elderly patients, the remaining life expectancy of the patient should be considered when prescribing medication, as benefits of certain medica‐ tions may not be valid or may not outweigh risks in a patient with a lower life expectancy. As patients age, it may be important to consider de‐prescribing to optimize the patient's total health and reduce unnecessary polypharmacy [48].

**8.4. Mental illness**

**8.6. Chronic pain**

significant cognitive‐impairing effects [70].

**8.5. Intellectual and developmental disabilities**

contribute to overuse or underuse of medications [74].

ing both total medical costs and the risk of drug‐drug interactions.

Prescribing patterns in the adult outpatient psychiatric setting show the median number of prescriptions prescribed per visit have doubled, largely with increased psychotropic poly‐ pharmacy (defined as ≥2 psychiatric medications in the same patient) with antidepressant and antipsychotic prescriptions in adults aged 45–64 [66]. Additionally, this number may be an underrepresentation in patients who see multiple providers [66]. Psychotropic polyphar‐ macy is also increasingly seen in the outpatient pediatric population with prevalence esti‐ mates ranging from 13 to 35% [67–69]. In this population of patients, both psychotrophic and non‐psychotrophic drugs contribute to polypharmacy and brings with it, the associated com‐ plications. Low adherence, noncompliance, ADRs, and DDIs contribute to the detrimental effects of multiple drug therapy. In this cohort, polypharmacy increases the risk of potentially inappropriate medication (PIMs) administration, and prolonged polypharmacy can have

Dangers of Polypharmacy

55

http://dx.doi.org/10.5772/intechopen.69169

Patients with intellectual disabilities are reported to have more than twice as many health problems as the general population and a higher rate of comorbid somatic or mental health disorders [71]. There is a considerably wide range of prevalence of polypharmacy noted in the literature for this population [72, 73]. Similarly to other patient populations, the larger the number of comorbidities, the more likely there is to be polypharmacy and all its associated complications. Specific to this patient population, living in a residential facility and increasing severity of intellectual disability increases risk of exposure to polypharmacy [71]. Affective disorders, psychoses, and anxiety are the three leading co‐morbid mental health disorders among adults with intellectual disabilities [74]. However, it may be difficult to make a distinc‐ tion between the disorders based on behavioral patterns or traditional diagnoses which may

Chronic pain has been estimated to affect 116 million adults and costs \$560–\$635 billion annu‐ ally in the US [75]. There is a multimodal approach utilized for chronic pain that includes nonpharmacological and pharmacological interventions. Previous studies have reported that patients diagnosed with chronic lower back pain or osteoarthritis, and who were prescribed an analgesic such as an opioid, have overall higher health care costs [76, 77]. When looking at more recent literature, the increased financial impact of chronic non‐cancer patients con‐ tinues to persist [78]. Costs for chronic non‐cancer pain patients are increased both in older and younger patients, likely secondary to complications from increased drug‐drug exposure (DDE) and increased prescription costs related to polypharmacy, respectively [79]. In patients on chronic opioids, the risk of DDE increases with each additional medication a patient is prescribed, with a rate greater than 60% in patients taking four or more prescription medica‐ tions compared to 14% in patients taking no other prescription medications [80]. Therefore, addressing polypharmacy in chronic pain patients may be an important component in reduc‐

#### **8.2. HIV population**

With the evolution and advancement of antiretroviral therapies worldwide, HIV is now being considered a chronic disease. Life expectancy for HIV patients has been shown in recent years to closely approximate that of non‐infected HIV persons [53]. The HIV population is also aging. Statistics show over 10% of HIV positive persons globally are over the age of 50, with projected data estimating this to increase by an additional 20% in the next 15 years [54]. In the United States alone, it is estimated that more than half of persons living with HIV are ≥50 years old [55]. In 2010, the prevalence of polypharmacy in persons living with HIV was estimated to be 35%, surpassing that of persons not living with HIV [55]. HIV patients have been noted to have greater cardiovascular, renal, neurologic, oncologic and osteoporotic disease despite having decreased viral loads or increased CD4 counts [56]. Presence of age‐associated comor‐ bidities increases the risk of polypharmacy in HIV patients, with higher rates of prescriptions for gastrointestinal, neurologic, respiratory, analgesic, or anti‐infective drugs than the general population [57]. Antiretroviral therapy has a high risk for DDIs and toxicity, and optimiz‐ ing management to address this risks and decrease pill burden can be difficult [54]. In older HIV patients, 77% are at risk of potential DDIs due to polypharmacy, with the highest risk in patients with concomitant cardiovascular drug use [58].

#### **8.3. Kidney disease and liver disease**

There is a high incidence of polypharmacy in patients with chronic kidney disease (CKD) [59]. Significant medication‐related problems, including drug‐drug interactions, high incidence of adverse drug reactions (ADRs) and low adherence have been noted [60]. Complex medication regimens may be necessary in CKD to treat related comorbid conditions, however patients are at high risk of DDIs, especially due to changes in pharmacokinetic and pharmacodynamic parameters associated with decreased kidney function, and therefore require constant adjust‐ ment of medication doses accordingly [61]. Complicated medication regimens and concerns about side effects were frequently cited as a cause of low or non‐adherence in patients with CKD [62]. Additionally, use of certain contraindicated over‐the‐counter or herbal remedies may put the patient at increased risk of adverse drug events and interactions due to interference with CKD medications [63].

Liver pathology is of special importance especially when treatment of disease includes poly‐ pharmacy. Multiple drug regimens have shown to cause development of various forms of hepatotoxic reactions, and many patients with cirrhosis often have complicated medication regimens and are at higher risk for complications from polypharmacy [64]. Frequent reas‐ sessment of the patient's baseline renal and hepatic function, medication properties, doses administered and length of therapy are helpful in achieving reduction in DDIs and ADRs [65].

#### **8.4. Mental illness**

cardiovascular drugs and NSAIDs [52]. In elderly patients, the remaining life expectancy of the patient should be considered when prescribing medication, as benefits of certain medica‐ tions may not be valid or may not outweigh risks in a patient with a lower life expectancy. As patients age, it may be important to consider de‐prescribing to optimize the patient's total

With the evolution and advancement of antiretroviral therapies worldwide, HIV is now being considered a chronic disease. Life expectancy for HIV patients has been shown in recent years to closely approximate that of non‐infected HIV persons [53]. The HIV population is also aging. Statistics show over 10% of HIV positive persons globally are over the age of 50, with projected data estimating this to increase by an additional 20% in the next 15 years [54]. In the United States alone, it is estimated that more than half of persons living with HIV are ≥50 years old [55]. In 2010, the prevalence of polypharmacy in persons living with HIV was estimated to be 35%, surpassing that of persons not living with HIV [55]. HIV patients have been noted to have greater cardiovascular, renal, neurologic, oncologic and osteoporotic disease despite having decreased viral loads or increased CD4 counts [56]. Presence of age‐associated comor‐ bidities increases the risk of polypharmacy in HIV patients, with higher rates of prescriptions for gastrointestinal, neurologic, respiratory, analgesic, or anti‐infective drugs than the general population [57]. Antiretroviral therapy has a high risk for DDIs and toxicity, and optimiz‐ ing management to address this risks and decrease pill burden can be difficult [54]. In older HIV patients, 77% are at risk of potential DDIs due to polypharmacy, with the highest risk in

There is a high incidence of polypharmacy in patients with chronic kidney disease (CKD) [59]. Significant medication‐related problems, including drug‐drug interactions, high incidence of adverse drug reactions (ADRs) and low adherence have been noted [60]. Complex medication regimens may be necessary in CKD to treat related comorbid conditions, however patients are at high risk of DDIs, especially due to changes in pharmacokinetic and pharmacodynamic parameters associated with decreased kidney function, and therefore require constant adjust‐ ment of medication doses accordingly [61]. Complicated medication regimens and concerns about side effects were frequently cited as a cause of low or non‐adherence in patients with CKD [62]. Additionally, use of certain contraindicated over‐the‐counter or herbal remedies may put the patient at increased risk of adverse drug events and interactions due to interference

Liver pathology is of special importance especially when treatment of disease includes poly‐ pharmacy. Multiple drug regimens have shown to cause development of various forms of hepatotoxic reactions, and many patients with cirrhosis often have complicated medication regimens and are at higher risk for complications from polypharmacy [64]. Frequent reas‐ sessment of the patient's baseline renal and hepatic function, medication properties, doses administered and length of therapy are helpful in achieving reduction in DDIs and ADRs [65].

health and reduce unnecessary polypharmacy [48].

patients with concomitant cardiovascular drug use [58].

**8.3. Kidney disease and liver disease**

with CKD medications [63].

**8.2. HIV population**

54 Vignettes in Patient Safety - Volume 1

Prescribing patterns in the adult outpatient psychiatric setting show the median number of prescriptions prescribed per visit have doubled, largely with increased psychotropic poly‐ pharmacy (defined as ≥2 psychiatric medications in the same patient) with antidepressant and antipsychotic prescriptions in adults aged 45–64 [66]. Additionally, this number may be an underrepresentation in patients who see multiple providers [66]. Psychotropic polyphar‐ macy is also increasingly seen in the outpatient pediatric population with prevalence esti‐ mates ranging from 13 to 35% [67–69]. In this population of patients, both psychotrophic and non‐psychotrophic drugs contribute to polypharmacy and brings with it, the associated com‐ plications. Low adherence, noncompliance, ADRs, and DDIs contribute to the detrimental effects of multiple drug therapy. In this cohort, polypharmacy increases the risk of potentially inappropriate medication (PIMs) administration, and prolonged polypharmacy can have significant cognitive‐impairing effects [70].

#### **8.5. Intellectual and developmental disabilities**

Patients with intellectual disabilities are reported to have more than twice as many health problems as the general population and a higher rate of comorbid somatic or mental health disorders [71]. There is a considerably wide range of prevalence of polypharmacy noted in the literature for this population [72, 73]. Similarly to other patient populations, the larger the number of comorbidities, the more likely there is to be polypharmacy and all its associated complications. Specific to this patient population, living in a residential facility and increasing severity of intellectual disability increases risk of exposure to polypharmacy [71]. Affective disorders, psychoses, and anxiety are the three leading co‐morbid mental health disorders among adults with intellectual disabilities [74]. However, it may be difficult to make a distinc‐ tion between the disorders based on behavioral patterns or traditional diagnoses which may contribute to overuse or underuse of medications [74].

#### **8.6. Chronic pain**

Chronic pain has been estimated to affect 116 million adults and costs \$560–\$635 billion annu‐ ally in the US [75]. There is a multimodal approach utilized for chronic pain that includes nonpharmacological and pharmacological interventions. Previous studies have reported that patients diagnosed with chronic lower back pain or osteoarthritis, and who were prescribed an analgesic such as an opioid, have overall higher health care costs [76, 77]. When looking at more recent literature, the increased financial impact of chronic non‐cancer patients con‐ tinues to persist [78]. Costs for chronic non‐cancer pain patients are increased both in older and younger patients, likely secondary to complications from increased drug‐drug exposure (DDE) and increased prescription costs related to polypharmacy, respectively [79]. In patients on chronic opioids, the risk of DDE increases with each additional medication a patient is prescribed, with a rate greater than 60% in patients taking four or more prescription medica‐ tions compared to 14% in patients taking no other prescription medications [80]. Therefore, addressing polypharmacy in chronic pain patients may be an important component in reduc‐ ing both total medical costs and the risk of drug‐drug interactions.

#### **9. Interventions to reduce polypharmacy**

There is a growing body of research regarding the development of evidence‐based interven‐ tions to reduce polypharmacy, inappropriate prescribing, and patient nonadherence. While many of the published tools and interventions have focused on the elderly population, the evi‐ dence‐based studies encompass numerous themes involving various strategies. The themes include interventions to:

patient‐physician medication reviews have utilized physician notifications about high‐risk patients, "medication management" reports listing information regarding patient prescrip‐ tions, and clinical practice guidelines for preventing and managing inappropriate prescrib‐ ing resulting in about half of all physicians making at least one change in the patients' medication regimens [87]. These guidelines encouraged "brown bag" medication reviews of medications, including non‐prescription medications, during patient office visits. As a result, 20% of patients recorded discontinuation of medication, 29% reported a change in medication and 17% reported taking medication that their physician was unaware of [87]. While numerous studies have demonstrated successful interventions in deprescribing potentially inappropriate medications, there is a paucity of data causally linking generalized deprescribing to clinically significant improvements in hospital admissions, mortality, and patients' overall quality of life [88, 89]. However, targeted patient‐specific interventions may have a role in reducing mortality [89]. In elderly patients undergoing a deprescribing pro‐ tocol, there was a successful reduction in the number of regular medicines taken by elderly patients in residential care settings with no significant adverse effects on survival or other

Dangers of Polypharmacy

57

http://dx.doi.org/10.5772/intechopen.69169

Collaborative interdisciplinary teams have been used to improve the quality of care given to patients. The concept of Comprehensive Geriatric Assessment (CGA) is a multipronged approach to provide integrated care of elderly patients through the use of interdisciplin‐ ary teams. These teams assess medical, psychosocial and functional capabilities of elderly patients and often include physicians, social workers, nurses and other healthcare pro‐ viders [91]. CGA uses protocols to assess functional, cognitive, affective, and nutritional status as well as caregiver and social support. CGA also assesses for geriatric problems such as incontinence and falls, and pays particular attention to medication management with a goal of decreasing adverse drug events [91, 92]. Utilizing multidisciplinary teams have been shown to reduce serious adverse drug events by 35% when compared to those

Many researchers have also looked at the use of validated tools (e.g., Beers criteria, Medication Appropriateness Index [MAI], Screening Tool of Older Persons Prescriptions [STOPP], Screening Tool to Alert Doctors to Right Treatment [START]) to identify elderly patients at risk for high‐risk prescribing practices. In older patients with a potentially preventable medi‐ cation‐related hospital admission, the use of STOPP/START 2008 criteria resulted in a 34.1% decrease in potentially inappropriate medications and a 57.7% decrease in potential prescrib‐ ing omissions [93]. The Beers criteria, based on a consensus panel of experts, has been used for many years in United States as a guide to assist health care practitioners in determining whether or not certain medications may be unsafe for use in the elderly [26]. Altering or adjusting clinical targets may also have a benefit in discerning appropriate versus inappropri‐ ate medication prescribing. It appears that setting strict clinical targets in some populations may have adverse outcomes. In the famous Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, there was an increased risk of hypoglycemia, adverse events and death in those with tight glycemic control [94]. By liberalizing our clinical targets, we may decrease medication use and improve clinical outcomes with regards to certain medications and cer‐

clinical outcomes [90].

in usual care [86].

tain groups of patients.


#### **9.1. Appropriate versus inappropriate prescribing patterns by physicians**

A concept that has been discussed in the literature when addressing reducing complications of polypharmacy deals not just with the number of medications, but also with the appropriateness of the treatment regimen. Several guidelines have been established evaluating clinical necessity of medications, irrespective of the number of medications. The theory behind addressing the appropriateness of prescribing and not just the absolute number of medications is that patients with multiple comorbidities may, in fact, necessitate a number of medications, thus being clini‐ cally appropriate polypharmacy. Additionally, patients may experience adverse drug events on fewer medications, however they may not get identified through current screening protocols based strictly on number of prescriptions [81].

There are a number of evidence‐based studies advocating the use of computerized alerts to decrease potentially inappropriate medications. Using an automated clinical decision sup‐ port system in an electronic medical record system to prompt physicians to update patient problem lists during inpatient computerized physician order entry can result in increased updated problem list accuracy at a rate of about 95% [82]. That being said, recent studies report between 69 and 91% of medication alerts were overridden by physicians as the alerts were considered irrelevant by the prescribing physicians [52]. Electronic medical record‐ based interventions have also achieved a significant reduction in the number of medications initiated during the intervention period [83]. Medical decision‐making tools and checklists have also been utilized to reduce potentially inappropriate prescribing. Checklists used by physicians to support therapeutic reasoning of the physicians in order to improve the quality of drug prescriptions have resulted in a 22% reduction in the risk of ≥1 of potentially inap‐ propriate medication being prescribed at discharge [84].

There are also a number of published studies advocating the use of review of patient medica‐ tions to decrease polypharmacy and potentially inappropriate prescribing [85, 86]. Increased patient‐physician medication reviews have utilized physician notifications about high‐risk patients, "medication management" reports listing information regarding patient prescrip‐ tions, and clinical practice guidelines for preventing and managing inappropriate prescrib‐ ing resulting in about half of all physicians making at least one change in the patients' medication regimens [87]. These guidelines encouraged "brown bag" medication reviews of medications, including non‐prescription medications, during patient office visits. As a result, 20% of patients recorded discontinuation of medication, 29% reported a change in medication and 17% reported taking medication that their physician was unaware of [87]. While numerous studies have demonstrated successful interventions in deprescribing potentially inappropriate medications, there is a paucity of data causally linking generalized deprescribing to clinically significant improvements in hospital admissions, mortality, and patients' overall quality of life [88, 89]. However, targeted patient‐specific interventions may have a role in reducing mortality [89]. In elderly patients undergoing a deprescribing pro‐ tocol, there was a successful reduction in the number of regular medicines taken by elderly patients in residential care settings with no significant adverse effects on survival or other clinical outcomes [90].

**9. Interventions to reduce polypharmacy**

• Address appropriate versus inappropriate prescribing

• Ameliorate high‐risk error areas such as transitions of care

• Reduce nonintentional nonadherence by patients.

based strictly on number of prescriptions [81].

propriate medication being prescribed at discharge [84].

• Promote better medication reconciliation

• Strengthen patient education and patient‐physician communication

**9.1. Appropriate versus inappropriate prescribing patterns by physicians**

include interventions to:

56 Vignettes in Patient Safety - Volume 1

There is a growing body of research regarding the development of evidence‐based interven‐ tions to reduce polypharmacy, inappropriate prescribing, and patient nonadherence. While many of the published tools and interventions have focused on the elderly population, the evi‐ dence‐based studies encompass numerous themes involving various strategies. The themes

• Enhance physician to physician communication and interprofessional collaboration

A concept that has been discussed in the literature when addressing reducing complications of polypharmacy deals not just with the number of medications, but also with the appropriateness of the treatment regimen. Several guidelines have been established evaluating clinical necessity of medications, irrespective of the number of medications. The theory behind addressing the appropriateness of prescribing and not just the absolute number of medications is that patients with multiple comorbidities may, in fact, necessitate a number of medications, thus being clini‐ cally appropriate polypharmacy. Additionally, patients may experience adverse drug events on fewer medications, however they may not get identified through current screening protocols

There are a number of evidence‐based studies advocating the use of computerized alerts to decrease potentially inappropriate medications. Using an automated clinical decision sup‐ port system in an electronic medical record system to prompt physicians to update patient problem lists during inpatient computerized physician order entry can result in increased updated problem list accuracy at a rate of about 95% [82]. That being said, recent studies report between 69 and 91% of medication alerts were overridden by physicians as the alerts were considered irrelevant by the prescribing physicians [52]. Electronic medical record‐ based interventions have also achieved a significant reduction in the number of medications initiated during the intervention period [83]. Medical decision‐making tools and checklists have also been utilized to reduce potentially inappropriate prescribing. Checklists used by physicians to support therapeutic reasoning of the physicians in order to improve the quality of drug prescriptions have resulted in a 22% reduction in the risk of ≥1 of potentially inap‐

There are also a number of published studies advocating the use of review of patient medica‐ tions to decrease polypharmacy and potentially inappropriate prescribing [85, 86]. Increased Collaborative interdisciplinary teams have been used to improve the quality of care given to patients. The concept of Comprehensive Geriatric Assessment (CGA) is a multipronged approach to provide integrated care of elderly patients through the use of interdisciplin‐ ary teams. These teams assess medical, psychosocial and functional capabilities of elderly patients and often include physicians, social workers, nurses and other healthcare pro‐ viders [91]. CGA uses protocols to assess functional, cognitive, affective, and nutritional status as well as caregiver and social support. CGA also assesses for geriatric problems such as incontinence and falls, and pays particular attention to medication management with a goal of decreasing adverse drug events [91, 92]. Utilizing multidisciplinary teams have been shown to reduce serious adverse drug events by 35% when compared to those in usual care [86].

Many researchers have also looked at the use of validated tools (e.g., Beers criteria, Medication Appropriateness Index [MAI], Screening Tool of Older Persons Prescriptions [STOPP], Screening Tool to Alert Doctors to Right Treatment [START]) to identify elderly patients at risk for high‐risk prescribing practices. In older patients with a potentially preventable medi‐ cation‐related hospital admission, the use of STOPP/START 2008 criteria resulted in a 34.1% decrease in potentially inappropriate medications and a 57.7% decrease in potential prescrib‐ ing omissions [93]. The Beers criteria, based on a consensus panel of experts, has been used for many years in United States as a guide to assist health care practitioners in determining whether or not certain medications may be unsafe for use in the elderly [26]. Altering or adjusting clinical targets may also have a benefit in discerning appropriate versus inappropri‐ ate medication prescribing. It appears that setting strict clinical targets in some populations may have adverse outcomes. In the famous Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, there was an increased risk of hypoglycemia, adverse events and death in those with tight glycemic control [94]. By liberalizing our clinical targets, we may decrease medication use and improve clinical outcomes with regards to certain medications and cer‐ tain groups of patients.

#### **9.2. Strengthen patient education and patient‐physician communication**

In the vignette above, the patient was not educated appropriately regarding the new medi‐ cations he was prescribed nor did he appear to have a good understanding of his overall medication regimen. While health care professionals are most frequently viewed as integral to smooth transitions of care, patients and caregivers, and their understanding of treatment needs and readiness to actively participate, are essential to the process. Patient education and understanding of their conditions, necessary treatments, and the importance of follow through with recommendations are key in helping to promote a more seamless flow of move‐ ment during transitions of care. Implementing patient education is a potential intervention for reducing the rates of polypharmacy [88]. Educational packets or patient information leaflets, specifically designed and targeted according to patient literacy can improve out‐ comes and effectively manage polypharmacy [95]. Educational materials can be in various forms including but certainly not limited to videos, individual or group teaching sessions and teach back techniques [96].

the number of patients using 10 or more medications had decreased [103]. Mekonnen and colleagues performed a meta‐analysis of pharmacist‐led medication reconciliation programs on clinical outcomes at hospital transitions involving 19 studies, including 11 randomized controlled trials [104]. A total of more than 15,000 patients were included in the data. The results revealed that pharmacist‐led interventions were effective strategies to reduce medica‐ tion discrepancies with a greater impact on admission and discharge transitions as compared to other hospital transitions of care [104]. Additionally, patients should also be encouraged to carry a list of their medications with them for emergencies and visits to all providers [100].

Dangers of Polypharmacy

59

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"The root cause of adverse events associated with transitions of care is poor transfer of informa‐ tion between providers" [105]. Multiple studies demonstrate that improving communication to enhance coordinated care during transitions can result in more cost‐efficient care, reduced rate of errors and near misses, and improved patient satisfaction [106–108]. Communication of essential patient medical information among treating providers within and between health care settings is paramount to ensuring safe and comprehensive transitions of care. Several com‐ ponents have been identified which are felt to be key in reducing adverse events as patients move from one level or setting of care to another. As electronic health records have become the primary tool for documenting and storing patient information, they can facilitate the timely sharing of information required for continuity of care [109]. The primary mode of commu‐ nication with the highest rates of direct transfer of patient information from one provider to another occurs via telephonic communication, with successful communication occurring approximately 70% of the time [110]. Additional interventions, which have been implemented to improve patient care during transitions of care, include patient education, the scheduling of outpatient visits prior to discharge and telephone follow‐up. Further, scheduling follow‐up appointments with a primary care physician in a timely manner and, when available, home visits, all serve to help provide a greater structure for a more seamless transition [100].

The role of pharmacists has become a greater focus of attention as part of the care team and as a component of the discharge or transition of care for patients. Evidence exists which supports the benefits of involving pharmacists in the process of medication reconciliation at various point of transitions including admission, transfer from the ICU, and upon and following hospital discharge [111–113]. Pharmacists play a significant role in education for both patients and their caregivers. They are uniquely qualified to clearly explain why specific medications have been recommended, and why these medications are the most appropriate for each patient. While it is clear other health professionals can provide such information, pharmacists more likely possess the greatest insight as to the reason for specific medications

There are currently several emerging models of care designed to address various interven‐ tions and resources to help ensure safe transitions for patients and caregivers. The focus of these efforts is to enhance patient safety, improve communication and reduce hospital read‐ missions. Two notable models include The Care Transitions Intervention and The Transitional

**9.4. Ameliorate high‐risk error areas such as transitions of care**

targeted to a patient's condition [114].

Care Model [115, 116].

The EMPOWER [Eliminating Medications Through Patient Ownership of End Results] study that evaluated a benzodiazepine therapy cessation program found that after 6 months, patients aged 65‐95 had a 27% discontinuance of their use of benzodiazepines in comparison to 5% in the control group [97, 98].Through the EMPOWER study, it was demonstrated that consumer education is directly related to effectively eliciting shared decision‐making around the overuse of medication. The patient‐centered process aims to reinforce known enablers and address barriers to medication cessation. This increases the shared responsibility in deci‐ sion‐making with healthcare providers [99]. Therefore, direct patient education can effec‐ tively stimulate shared decision‐making around overuse of medications that increase the risk of harmful effects.

#### **9.3. Promote better medication reconciliation**

Medication errors and other adverse events during care transitions led the Joint Commission to identify medication reconciliation as a National Patient Safety Goal in 2005 [37]. In 2014, the requirement to inform patients regarding the importance of maintaining updated medi‐ cation information was added to existing safety goals [100]. The use of interventions to improve medication reconciliation has had direct and positive effects on clinical outcomes. Improvement in electronic medication reconciliation has also been shown to reduce the inci‐ dence of medication discrepancies during transitions of care in hospitals, especially regarding medication omissions but also including other areas such as medication error dosing [101]. Some of these interventions have used pharmacists while others have relied on the electronic medical record interventions or other healthcare providers. Hazra and colleagues showed a threefold decrease in the prevalence of antipsychotic polypharmacy after a pharmacist‐ led intervention provided education to prescribers [102]. Milos and colleagues performed a randomized controlled clinical trial in nursing home patients ≥75 years of age where medi‐ cation reviews by clinical pharmacists based on nurse‐initiated symptom assessments pro‐ vided feedback to physicians [103]. Two months after the medication reviews, the number of patients in the intervention group with at least one potentially inappropriate medication and the number of patients using 10 or more medications had decreased [103]. Mekonnen and colleagues performed a meta‐analysis of pharmacist‐led medication reconciliation programs on clinical outcomes at hospital transitions involving 19 studies, including 11 randomized controlled trials [104]. A total of more than 15,000 patients were included in the data. The results revealed that pharmacist‐led interventions were effective strategies to reduce medica‐ tion discrepancies with a greater impact on admission and discharge transitions as compared to other hospital transitions of care [104]. Additionally, patients should also be encouraged to carry a list of their medications with them for emergencies and visits to all providers [100].

#### **9.4. Ameliorate high‐risk error areas such as transitions of care**

**9.2. Strengthen patient education and patient‐physician communication**

teach back techniques [96].

58 Vignettes in Patient Safety - Volume 1

of harmful effects.

**9.3. Promote better medication reconciliation**

In the vignette above, the patient was not educated appropriately regarding the new medi‐ cations he was prescribed nor did he appear to have a good understanding of his overall medication regimen. While health care professionals are most frequently viewed as integral to smooth transitions of care, patients and caregivers, and their understanding of treatment needs and readiness to actively participate, are essential to the process. Patient education and understanding of their conditions, necessary treatments, and the importance of follow through with recommendations are key in helping to promote a more seamless flow of move‐ ment during transitions of care. Implementing patient education is a potential intervention for reducing the rates of polypharmacy [88]. Educational packets or patient information leaflets, specifically designed and targeted according to patient literacy can improve out‐ comes and effectively manage polypharmacy [95]. Educational materials can be in various forms including but certainly not limited to videos, individual or group teaching sessions and

The EMPOWER [Eliminating Medications Through Patient Ownership of End Results] study that evaluated a benzodiazepine therapy cessation program found that after 6 months, patients aged 65‐95 had a 27% discontinuance of their use of benzodiazepines in comparison to 5% in the control group [97, 98].Through the EMPOWER study, it was demonstrated that consumer education is directly related to effectively eliciting shared decision‐making around the overuse of medication. The patient‐centered process aims to reinforce known enablers and address barriers to medication cessation. This increases the shared responsibility in deci‐ sion‐making with healthcare providers [99]. Therefore, direct patient education can effec‐ tively stimulate shared decision‐making around overuse of medications that increase the risk

Medication errors and other adverse events during care transitions led the Joint Commission to identify medication reconciliation as a National Patient Safety Goal in 2005 [37]. In 2014, the requirement to inform patients regarding the importance of maintaining updated medi‐ cation information was added to existing safety goals [100]. The use of interventions to improve medication reconciliation has had direct and positive effects on clinical outcomes. Improvement in electronic medication reconciliation has also been shown to reduce the inci‐ dence of medication discrepancies during transitions of care in hospitals, especially regarding medication omissions but also including other areas such as medication error dosing [101]. Some of these interventions have used pharmacists while others have relied on the electronic medical record interventions or other healthcare providers. Hazra and colleagues showed a threefold decrease in the prevalence of antipsychotic polypharmacy after a pharmacist‐ led intervention provided education to prescribers [102]. Milos and colleagues performed a randomized controlled clinical trial in nursing home patients ≥75 years of age where medi‐ cation reviews by clinical pharmacists based on nurse‐initiated symptom assessments pro‐ vided feedback to physicians [103]. Two months after the medication reviews, the number of patients in the intervention group with at least one potentially inappropriate medication and "The root cause of adverse events associated with transitions of care is poor transfer of informa‐ tion between providers" [105]. Multiple studies demonstrate that improving communication to enhance coordinated care during transitions can result in more cost‐efficient care, reduced rate of errors and near misses, and improved patient satisfaction [106–108]. Communication of essential patient medical information among treating providers within and between health care settings is paramount to ensuring safe and comprehensive transitions of care. Several com‐ ponents have been identified which are felt to be key in reducing adverse events as patients move from one level or setting of care to another. As electronic health records have become the primary tool for documenting and storing patient information, they can facilitate the timely sharing of information required for continuity of care [109]. The primary mode of commu‐ nication with the highest rates of direct transfer of patient information from one provider to another occurs via telephonic communication, with successful communication occurring approximately 70% of the time [110]. Additional interventions, which have been implemented to improve patient care during transitions of care, include patient education, the scheduling of outpatient visits prior to discharge and telephone follow‐up. Further, scheduling follow‐up appointments with a primary care physician in a timely manner and, when available, home visits, all serve to help provide a greater structure for a more seamless transition [100].

The role of pharmacists has become a greater focus of attention as part of the care team and as a component of the discharge or transition of care for patients. Evidence exists which supports the benefits of involving pharmacists in the process of medication reconciliation at various point of transitions including admission, transfer from the ICU, and upon and following hospital discharge [111–113]. Pharmacists play a significant role in education for both patients and their caregivers. They are uniquely qualified to clearly explain why specific medications have been recommended, and why these medications are the most appropriate for each patient. While it is clear other health professionals can provide such information, pharmacists more likely possess the greatest insight as to the reason for specific medications targeted to a patient's condition [114].

There are currently several emerging models of care designed to address various interven‐ tions and resources to help ensure safe transitions for patients and caregivers. The focus of these efforts is to enhance patient safety, improve communication and reduce hospital read‐ missions. Two notable models include The Care Transitions Intervention and The Transitional Care Model [115, 116].

#### **9.5. Enhance physician to physician communication and interprofessional collaboration**

Others factors that may impact adherence include medication beliefs, increasing numbers of chronic diseases leading to complicated regimens, and sociodemographic factors such as high costs, co‐payments, and lack of understanding [122, 124]. The utilization of cue‐based interventions (i.e., phone reminders or alarms) may be helpful for forgetfulness but less likely to reduce non‐adherence due to passive inconsistent behaviors [123, 125]. Health literacy interventions can improve patients' education regarding their medications and therefore potentially improve the patients' role in their management of medications. The importance of assessing patient literacy and readiness to be an active member of the health care team is the responsibility of the health care system. A health literacy pilot study found that 40% of patients had a low health literacy, which is defined as below 9th grade reading level [126]. After just 3 months of one patient literacy intervention, patients' self‐reported adherence had

Dangers of Polypharmacy

61

http://dx.doi.org/10.5772/intechopen.69169

Polypharmacy is a multifactorial, complex issue. There are a number of targeted interventions that focus on addressing a variety of determinants with varying levels of evidentiary support. Optimizing prescribing, reducing potentially inappropriate medications, and minimizing risk is a common theme across all interventions, however implementation must be highly

Pamela L. Valenza\*, Thomas C. McGinley, James Feldman, Pritiben Patel, Kristine Cornejo,

Department of Family Medicine‐Warren, St. Luke's University Health Network, Phillipsburg,

[1] Mortazavi SS, et al. Defining polypharmacy in the elderly: A systematic review protocol.

[2] Gillette C, et al. A new lexicon for polypharmacy: Implications for research, practice, and education. Research in Social and Administrative Pharmacy. 2015;**11**(3):468‐471

[3] Runganga M, Peel NM, Hubbard RE. Multiple medication use in older patients in post‐ acute transitional care: A prospective cohort study. Clinical Interventions in Aging.

Najmus Liang, Roopa Anmolsingh and Noble McNaughton \*Address all correspondence to: pamela.valenza@sluhn.org

improved [126].

**10. Conclusion**

**Author details**

NJ, USA

**References**

individualized for each patient.

BMJ Open. 2016;**6**(3):e010989

2014;**9**:1453‐1462

In order to overcome obstacles to reduce polypharmacy, it is imperative to communicate with patients and healthcare providers to understand what their perceptions of those obstacles are and how to work together to overcome them. Palaygi and colleagues performed a qualitative study in long‐term care facilities involving focus groups to address perceptions of medica‐ tion use and deprescribing [117]. Deprescribing was defined as withdrawal of inappropriate medications with the goal of reducing polypharmacy. The focus groups included physicians, pharmacists, nurses, patients, and relatives. All participants acknowledged the burden of too many medications, yet displayed passive tendencies toward reduction. The primary care physician was the central trusted figure in medication initiation and alteration. The primary care physicians complained of systems barriers including poor medical record uniformity, time constraints, challenges with staff and pharmacy collaboration, and the effects of mul‐ tiple prescribing specialists as obstacles to deprescribing [117]. Skinner conducted an extensive literature review looking for polypharmacy protocol for primary care. Mnemonics, algorithms, clinical practice guidelines, and clinical strategies for addressing polypharmacy were noted, as well as the use of screening instruments for assessing potentially inappropriate medication prescribing [118]. However, there appears to be no standard protocol to address polypharmacy [118]. From these two publications, many problems were identified. However, the importance of communication, particularly physician to physician communication, as well as the need for a standardized polypharmacy protocol, particularly involving deprescribing, seemed to represent the most challenging obstacles in overcoming barriers to successful polypharmacy reduction. Farrell and colleagues have set out to develop guidelines for deprescribing [119].

Additional studies also point out the need for better interprofessional collaboration and com‐ munication among other problems. The main concerns and perceptions by general practitioners of factors involved in contributing to polypharmacy include difficulty in keeping exact medica‐ tion intake lists, challenges in overcoming patients' strong beliefs in their medications and in self‐medicating, the involvement of multiple prescribers, the lack of regular medication reviews and revisions, and the pressures placed upon physicians in using medications based upon evi‐ dence‐based protocols [120]. Lavan and colleagues published a review article about reducing prescribing errors in elderly patients and noted that published data support a few interventions including prescriber education in pharmacotherapy, application of STOPP/START criteria to reduce potentially inappropriate prescribing, electronic prescribing, and a close liaison between pharmacists and physicians to perform structured medication reviews and reconciliations [121].

#### **9.6. Reduce nonintentional nonadherence by patients**

75% of Americans have difficulty taking their medication as prescribed with the cost of nonad‐ herence ranging from \$100 billion to \$300 billion every year [122]. Intentional nonadherence refers to the patient making a certain amount of decision‐making in their care often based on their trust in their medical provider and knowing the effects of their medications [44]. The patient's adherence improves when patients feel well informed about their illness and the importance of necessary treatment [44]. In patients over 65 years of age, the most signifi‐ cant predictors for non‐intentional non‐adherence are forgetfulness and carelessness [123]. Others factors that may impact adherence include medication beliefs, increasing numbers of chronic diseases leading to complicated regimens, and sociodemographic factors such as high costs, co‐payments, and lack of understanding [122, 124]. The utilization of cue‐based interventions (i.e., phone reminders or alarms) may be helpful for forgetfulness but less likely to reduce non‐adherence due to passive inconsistent behaviors [123, 125]. Health literacy interventions can improve patients' education regarding their medications and therefore potentially improve the patients' role in their management of medications. The importance of assessing patient literacy and readiness to be an active member of the health care team is the responsibility of the health care system. A health literacy pilot study found that 40% of patients had a low health literacy, which is defined as below 9th grade reading level [126]. After just 3 months of one patient literacy intervention, patients' self‐reported adherence had improved [126].

#### **10. Conclusion**

**9.5. Enhance physician to physician communication and interprofessional collaboration**

60 Vignettes in Patient Safety - Volume 1

In order to overcome obstacles to reduce polypharmacy, it is imperative to communicate with patients and healthcare providers to understand what their perceptions of those obstacles are and how to work together to overcome them. Palaygi and colleagues performed a qualitative study in long‐term care facilities involving focus groups to address perceptions of medica‐ tion use and deprescribing [117]. Deprescribing was defined as withdrawal of inappropriate medications with the goal of reducing polypharmacy. The focus groups included physicians, pharmacists, nurses, patients, and relatives. All participants acknowledged the burden of too many medications, yet displayed passive tendencies toward reduction. The primary care physician was the central trusted figure in medication initiation and alteration. The primary care physicians complained of systems barriers including poor medical record uniformity, time constraints, challenges with staff and pharmacy collaboration, and the effects of mul‐ tiple prescribing specialists as obstacles to deprescribing [117]. Skinner conducted an extensive literature review looking for polypharmacy protocol for primary care. Mnemonics, algorithms, clinical practice guidelines, and clinical strategies for addressing polypharmacy were noted, as well as the use of screening instruments for assessing potentially inappropriate medication prescribing [118]. However, there appears to be no standard protocol to address polypharmacy [118]. From these two publications, many problems were identified. However, the importance of communication, particularly physician to physician communication, as well as the need for a standardized polypharmacy protocol, particularly involving deprescribing, seemed to represent the most challenging obstacles in overcoming barriers to successful polypharmacy reduction. Farrell and colleagues have set out to develop guidelines for deprescribing [119].

Additional studies also point out the need for better interprofessional collaboration and com‐ munication among other problems. The main concerns and perceptions by general practitioners of factors involved in contributing to polypharmacy include difficulty in keeping exact medica‐ tion intake lists, challenges in overcoming patients' strong beliefs in their medications and in self‐medicating, the involvement of multiple prescribers, the lack of regular medication reviews and revisions, and the pressures placed upon physicians in using medications based upon evi‐ dence‐based protocols [120]. Lavan and colleagues published a review article about reducing prescribing errors in elderly patients and noted that published data support a few interventions including prescriber education in pharmacotherapy, application of STOPP/START criteria to reduce potentially inappropriate prescribing, electronic prescribing, and a close liaison between pharmacists and physicians to perform structured medication reviews and reconciliations [121].

75% of Americans have difficulty taking their medication as prescribed with the cost of nonad‐ herence ranging from \$100 billion to \$300 billion every year [122]. Intentional nonadherence refers to the patient making a certain amount of decision‐making in their care often based on their trust in their medical provider and knowing the effects of their medications [44]. The patient's adherence improves when patients feel well informed about their illness and the importance of necessary treatment [44]. In patients over 65 years of age, the most signifi‐ cant predictors for non‐intentional non‐adherence are forgetfulness and carelessness [123].

**9.6. Reduce nonintentional nonadherence by patients**

Polypharmacy is a multifactorial, complex issue. There are a number of targeted interventions that focus on addressing a variety of determinants with varying levels of evidentiary support. Optimizing prescribing, reducing potentially inappropriate medications, and minimizing risk is a common theme across all interventions, however implementation must be highly individualized for each patient.

#### **Author details**

Pamela L. Valenza\*, Thomas C. McGinley, James Feldman, Pritiben Patel, Kristine Cornejo, Najmus Liang, Roopa Anmolsingh and Noble McNaughton

\*Address all correspondence to: pamela.valenza@sluhn.org

Department of Family Medicine‐Warren, St. Luke's University Health Network, Phillipsburg, NJ, USA

#### **References**


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**Chapter 5**

**Wrong Patient, Wrong Drug: An Unfortunate**

Older adults, aged 65 years or older, represent 14.9% of U.S. population, and are projected to increase to 22% by 2050. It is estimated that almost half of hospitalized patients are older adults and is expected to increase as the population ages. Hospitalized older adults are most vulnerable to adverse events because of aging‐related conditions, physiological changes, and multiple comorbidities as well as fragmented care. The primary goal of health care providers is to improve patient safety and decrease adverse events. This chapter will use a complex clinical scenario with numerous potential overlapping risks to address the many active and latent factors that lead to patient safety‐related adverse events. Factors involved, as well as preventive strategies, will be discussed in detail.

**Keywords:** patient safety, medication dosing, elderly, delirium prevention, falls, restraints, culture of safety, clinical informatics, same or similar name, handoffs,

Patient safety events are unfortunately a common occurrence in healthcare systems across the United States [1, 2]. Medication errors, hospital acquired infections, wrong site surgery, and other types of errors contribute to increased morbidity and mortality in hospitalized patients [3, 4]. The question, of course, is how do such errors occur and how can they be prevented? James Reason's 1990 book, "Human Error" created a conceptual framework, commonly known

> © 2017 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**Confluence of Events**

Alaa‐Eldin A Mira and Ric Baxter

http://dx.doi.org/10.5772/intechopen.69168

**Abstract**

disclosing error

**1. Introduction**

Anna Njarlangattil Thomas, Danielle Belser,

Amaravani Mandalapu, Michael Pipestone,

Additional information is available at the end of the chapter

Stephanie Rabenold, Omalara Olabisi Bamgbelu,

