Learn from my disastrous medication error to prevent one of your own, while promoting medication adherence to your patients
Let me begin by sharing with you a true story that got my attention and taught me a valuable lesson.
It was 1982 and I was in practice for less than five years. I prescribed ciprofloxacin for a patient with acute prostatitis who also had a history of COPD. Three days later I received a phone call to come and see the patient in the intensive care unit.
My first thought was that the patient needed the insertion of a Foley catheter. When I arrived in the ICU, I found the patient had an endotracheal tube and was on a ventilator. I called the pulmonologist and asked why I was contacted to see the patient. He told me that the patient was taking theophylline and that the combination of theophylline and ciprofloxacin raised the blood level of theophylline to become toxic, resulting in acute respiratory failure.
I was unaware of that drug-drug interaction and immediately looked in the PDR regarding the precautions for using ciprofloxacin. Under adverse effects of ciprofloxacin, PDR reported that, “Ciprofloxacin may significantly increase the blood levels of theophylline, which may lead to potentially serious and life-threatening side effects.”
Now that certainly attracted my immediate attention and I will relate the “rest of the story” shortly.
The high toll of medication adverse events and patient compliance failure
Every year there are more than 125,000 deaths reported as a result of patients failing to be compliant with their medications. That’s a healthcare crisis that is preventable and doctors, including myself, can do something about this staggering statistic. This poor adherence to medication instructions leads to increased morbidity and death and is estimated to incur costs of approximately $100 billion per year.
America is a “polymedicated” society. Forty percent of middle age and older patients use five or more medications a day. It doesn’t take four years of medical school to know that the more medications a patient uses, the greater the risk of adverse events. The typical Medicare patient sees on average seven physicians per year: two primary care physicians and five specialists. This finding highlights the need for coordinated, team-approach strategies to improve medication compliance and that a pharmacist should be enlisted to participate in medication compliance.
It is also noteworthy that 75% of elderly patients use nonprescription medications including supplements and over-the-counter drugs. It is also significant that 20% of patients do not fill their prescriptions when they are written by their physicians; 50% will not refill the medication at the end of one year; and 80% will not be on the medication at the end of the second year after the prescription was written.
How the pharmacist can help doctors improve medication compliance
There are multiple reasons why patients don’t take their medications as prescribed by their doctor, including:
- Forgetting to take the medication.
- Ran out of medication.
- Away from home and forget to take the medication on the trip.
- Cost of the medication.
- Side effects.
- Medication wasn’t working.
- Didn’t feel medication was indicated.
- Didn’t like taking the medication.
We have an opportunity to improve compliance by enlisting the pharmacist as part of the patient’s healthcare team. The pharmacist and the pharmacy, such as Walgreens, offers an app that has daily medication reminders, clear dosing instructions and reminders for refills.
In addition, CMS allows patients to receive an annual medication review with a pharmacist. A medication review is a comprehensive approach to improve medication use, reduce the risk of adverse events, and improve medication compliance. Therefore, the programs include high-touch interventions to engage the patients and their physicians.
In general, each program should include prescriber interventions to promote coordinated care, an interactive comprehensive medication review, and discussion with the patient to assess her or his medication therapies. This will result in the creation of a written summary provided to the patient and his\her physician, plus frequent monitoring and follow-up of the patient’s medications.
Medication review payoff: 66% better outcomes & medication adherence
This medication review makes suggestions to the patient and his\her physician about discontinuing medications that might be producing side effects or recommending medications that are less expensive. At this time, less than 50% of patients take advantage of this annual medication review by a pharmacist.
The results of the annual medication review, for which the pharmacists receive compensation, showed that two-thirds of the patients who had a pharmacist on the team had improved outcomes and better compliance with their medications.
The comprehensive medication review by a pharmacist is particularly important with elderly patients, who may be on multiple medicines, use of supplements and over the counter medications, where adherence may have adverse consequences. A comprehensive medication review involves a discussion between a pharmacist and a patient, whereby the goal is to improve the patient’s knowledge, adherence, and use of medicines.
The medication review also provides an opportunity for a pharmacy to review the pharmacotherapy of a patient for both over-the-counter (OTC) drugs and prescribed ones. Pharmacists can identify which medicines a patient may not be taking, plus possible inappropriate drugs. The net effect is better care and less waste of medications.
A pharmacist can recommend appropriate and safe OTC medicines if they are required. Pharmacists may recommend generics rather than more costly branded medicines, lowering the costs for the patient and our healthcare system.
Self-medication with OTC products has been shown to contribute to adverse drug reactions and hospital admissions. With the advice of a pharmacist, patients can avoid spending money on possibly harmful OTCs and those that may not be effective. This can result in the patient needing less care, reduced hospitalization readmissions and fewer ER visits.
Lessons I learned from my ciprofloxacin/theophylline medication disaster
The patient spent four days in the ICU and seven more days in the hospital. He had complete resolution of his respiratory failure, and his pulmonary function returned to baseline levels. I was very attentive to his care and I had a very good rapport with the patient and his family. I spent at least 30 minutes a day with the patient and had very open avenues of communication with the family and the pulmonologist.
However, I learned that it was very important to review the patient’s medications including the medications prescribed by others, as well as supplements and OTC medications that the patient is using. And I learned that if I had any questions, I would consult with a pharmacist. I now encourage patients to contact the pharmacist and have at least an annual review of their medications and to see if any adjustments can be made to enhance compliance.
Bottom line: The issue of medication compliance has not received the proper attention that is necessary to reduce the more than 125,000 deaths every year from poor compliance. Doctors, including myself, need to take responsibility and make every effort to ensure we are properly monitoring our patients’ medications and are on the alert for poor compliance. No one wants to be called to the ICU to learn that a patient has a life-threatening situation because of our mistakes.
Please take this advice from a doctor who has been there and had the painful experience of not checking the patient’s medications and the drug-drug interactions. Lack of compliance with medications is a situation that requires more attention than we have given it in the past. I hope you will take this advice from my unfortunate experience and start improving medication compliance by including your pharmacist.
Outcomes, or 515.237.0001
Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353(5):487-497
Bodenheimer T. Coordinating care: a perilous journey through the health care system. N Engl J Med.2008;358(10):1064-1071