Qsource Patient Advisory Council Profile

Medication Review and Being Proactive Key to Preventing Adverse Drug Events

By the time his wife died, Bill Gossard could tell time by what pill she had to take.

There was the morning pill.

The mid-morning pill.

The take-with-food pill.

The it-hurts-so-bad pill.

The I-can’t-sleep pill.

By the end of the day, Gossard had watched Helen swallow 18 medications prescribed by four different physicians. None of whom spoke to each other about how the combination of medications may negatively affect their patient’s health.

Helen’s story is not uncommon among older adults. Drugs do save lives, but few prescription medications are completely free of risks or side effects. When more drugs are taken at the same time, the risk of adverse interactions and potentially devastating side effects increases.

Side effects are usually the key indication that overmedication is occurring. For Gossard, the accumulation of medication happened gradually over time, usually with the addition of a new physician to treat a new ailment. With four to six doctors seen during 16 to 18 office visits each year, keeping track of all the medications and details for each was difficult. He did like most patients do, he said. He trusted the doctors to do what was best. Each doctor focused on the issue at hand, not how one treatment may be affecting another.

“The family physician would refer us to specialists, who would then prescribe medication,” he said. “You would think that the drugs being prescribed would be addressed at the doctor visits. But they never were. They would just ask if we needed refills. We just didn’t focus on it [overmedication] enough, I guess.”

The first indication that something was wrong came in 2011, Gossard said. His wife was already taking four inhalers daily for asthma, two medications issued by her cardiologist and other medications issued by her primary care physician. Adding yet another medication prescribed by a neurologist ultimately put his wife at a higher risk for an adverse drug event (ADE).

“The neurologist gave her medication for pain due to deteriorating discs in her spine. Those medications caused her to experience insomnia and hallucinations,” he said. “When we told him about the side effects, the neurologist simply added more medications. In retrospect, I think this was the basis for her incident. One evening her body just seemed to shut down. She began trembling, sweating, became nauseous and passed out.”

She spent the next few days in the hospital recovering, Gossard said. It was at that time the primary care physician and specialists actually looked at a prescription list Gossard had taken the initiative to compile himself. After a thorough review, they eliminated 13 medications.

“I made a spreadsheet listing the prescriptions, the reasons for taking them, amounts, times, manner and any allergies or reactions. It got to where the list was really essential,” he said. “You kinda needed the list to make sure you were filling the medication dispenser correctly. Then it got to the point to where you had to check off the pills to make sure you didn’t forget.”

Gossard said the list had been shared with each doctor during the time of his wife’s visits. However, he suspects that the doctors only looked at the drugs listed by their name, not those issued by the other physicians.

“Maybe the doctors only looked at their list and did not want to address what their peers are doing,” he said.

One clinician did scrutinize the list, but was unable to issue anything other than a counseling warning, Gossard said. The local pharmacists would make a habit of reviewing the list of medications when filled and identify drugs based on their potency, side effects or potential harm. The pharmacist would address the fact that some of the drugs may counteract each other or cause issues when taken together.

But Gossard said he didn’t give much thought to the advice. After all, it was the primary care physician he expected to be on the lookout for potential medication mishaps.

“I think the family physician should have looked at it and scrutinized the medication list a lot better,” he said.

It is not uncommon for the pharmacist to be the one to identify potential overmedication. Many pharmacists and doctors have partnered to recommend patients and caregivers do what is known as a “brown bag review”. This is where all prescribed drugs are taken to a pharmacist or doctor who screens each for appropriate dosage and potential interactions.

One of the resources clinicians may use is the medication regimen complexity index (MRCI), a tool for quantifying multiple features of drug complexity. The tool is similar to the spreadsheet Gossard had compiled on his own, except it takes overmedication into consideration.

The MRCI assigns each medication a numeric attribute to dosage forms, dosing frequencies and additional instructions collected from a patient’s chart and prescription information to determine if overmedication has occurred and if the risk for ADEs is likely.

“I have read research recommending these scores accompany a person’s health record. A coordinated effort among the doctor, the pharmacy and the patient, all aware of the score, would be helpful,” Gossard said.

Qsource is working closely with physicians and pharmacists across Tennessee, Kentucky, Indiana, Mississippi and Alabama to implement monitoring tools such as the MRCI. However, the MRCI is aimed at a clinical user and patients would not find it useful.

With this in mind, Amanda Ryan, Clinical Pharmacy Specialist for Qsource, has been working with Gossard and other patient advisors to develop a simplified patient version of the MRCI. The Patient Advisory Council consists of up to 15 members with varying backgrounds and healthcare experiences. The main purpose is to provided feedback to clinicians about care and clinical interventions.

The simplified MRCI takes a patient through three simple steps to answer six questions that can help them determine if they need to have a conversation with their physician about their medications.

“Too often patients take more medications than needed to manage their health. Our healthcare system is programmed to prescribe medications, but not to stop them when appropriate,” said Ryan. “The MRCI patient tool will encourage patients to talk to their clinicians about these issues, with the goal of improving medication safety.”

As a patient and caregiver, being proactive is essential, Gossard said. During the 20 years spent watching his wife’s health deteriorate, he was proactive in documenting activity, medications and any side effects that occurred. He also spent many hours educating himself about medical conditions, treatments and policies.

“I think the patient needs to become as knowledgeable as possible about their medications,” he said. “Know what, why, how and when to take your medications. Be alert to the regimen and reactions. Each person is an individual. We may have different effects from the same drug. Ask questions.”

Gossard admits that he gives this advice in hindsight. While he was proactive in keeping track of medications, doctors and other details, he still feels he should have been more proactive. Especially as the number of medications increased.

“Reason says taking 18 different chemicals of any kind deserves attention,” Gossard said.

Helen died of cardiac failure in April 2014 at age 76. She was down to four pills a day.

Lynn Maples,  Marketing/Communications Specialist

Lynn is an award-winning marketing/communications professional and former journalist. He has spent more than a decade sharing patient and provider stories on behalf of the Quality Improvement Organization community.