Victor Harris almost died after taking a new medicine for high blood pressure. Victor, a 52-year-old African American, was on a low dose of blood pressure medicine for two years. After a routine visit to his primary care office, the nurse practitioner he saw changed his medication to lisinopril.

Normally, he would have seen his doctor, but he was out that day.

When Victor went to the pharmacy to get his prescription filled, the pharmacist asked the question many pharmacists ask when you pick up a prescription: Do you have any questions?

Victor replied the way many of us do: No.

He took his first dose that afternoon. Around 3 a.m. he woke up thinking he had been snoring because his throat was bothering him. He tried to go back to sleep, but the sensation escalated until he looked at his throat in the mirror and found that the back had nearly swollen shut.

By this time he was having trouble breathing and called for an ambulance. When it arrived, the emergency medical technician (EMT) asked what medications he was taking. When he told them lisinopril, the EMT immediately said, “That’s your problem.”

They took Victor to the emergency room (ER), and after the ER doctor confirmed the EMT’s suspicion, they gave him medication to slow down the absorption of the lisinopril in his system.

Victor, who is single and lives alone, could have died if he hadn’t woken up during the night.

He later learned that the likelihood of African Americans having this reaction, called angioedema, to medications like lisinopril was greater than non-African Americans.

Victor’s sister, Vickie Harris, posed the questions: “Why did the provider miss the opportunity to share the risk of the medication? Why did the pharmacist miss the opportunity? Are we creating these situations that are causing the medication reactions that could be avoided by taking a few more minutes to help educate the patient?”

Vickie, a member of a Tennessee care coordination community supported by Qsource, shared her brother’s story with the community. She said that the pharmacists in the community knew before she had finished telling the story how it was going to end.

Vickie spent many years as a nursing home administrator, is the founder and president of QEC Partners, a Quality Assurance Performance Improvement (QAPI) management company. She is a healthcare system insider, and her goal is to close the gaps for seniors around aging and the issues associated with the handoff between long-term care and acute care.

“We’re a check-the-box system and don’t always think about the individual,” she said. “I don’t know what it is that I don’t know. Could the adverse drug events be decreased by just providing more information at the right time?”

Adverse drug events (ADEs), like Victor’s serious reaction, and other problems such as medication errors and overdoses result in approximately one million ER visits a year. They are a leading cause of preventable patient harm. The Centers for Disease Control and Prevention (CDC) estimates that:

• 82% of American adults take at least one medication and 29% take five or more
• 700,000 emergency department visits and 120,000 hospitalizations are due to ADEs annually
• $3.5 billion is spent on extra medical costs of ADEs annually
• At least 40% of costs of ambulatory (non-hospital settings) ADEs are estimated to be preventable

Qsource is working with care coordination communities, patients, caregivers, pharmacists and other healthcare providers to improve medication safety. Please join us in working together with people like Victor and Vickie to educate patients and caregivers about important medication questions. It might save your life or the life of someone you love.

Learn more about how to ignite powerful change in your community by reducing ADEs.

Krista Creel, Marketing Specialist

Krista’s 14-year marketing experience covers the scope of retail, service, distribution and non-profit. She currently serves as Qsource Marketing Specialist dedicated to the nursing home and care coordination tasks, focused on quality improvement initiatives aimed at improving the health and care of Medicare beneficiaries.