David P. Elliott

Medication discrepancies identified at time of hospital discharge in a geriatric population.

BACKGROUND It has been reported that 14.1% of geriatric patients experience ≥1 medication discrepancies after hospitalization. OBJECTIVE The goal of this study was to identify and characterize discharge medication list discrepancies among geriatric patients and to describe characteristics associated with discrepancies. METHODS An institutional review board-approved retrospective review was conducted of patients aged ≥65 years discharged from hospitalist and internal medicine services at a large tertiary care hospital from August 2008 to December 2009. A random cohort of 200 patients was selected and categorized by age, gender, attending medical service, and the absence or presence of a pharmacist on the service. Medication lists were obtained from physician discharge summaries, discharge orders, and nursing discharge lists. RESULTS A total of 1923 medication discrepancies were identified, consisting of 402 related to the absence or presence of a medication, 298 related to the dosage administered at one time, 223 related to the number of daily doses, and 1000 related to the route of administration. Physician discharge summaries contained the most medication discrepancies. There was no relationship between patient age and the number of medication discrepancies (r(2) = 0.006; P = 0.279), whereas there was a linear relationship between the number of medications and the number of discrepancies (r(2) = 0.249; P < 0.001). The internal medicine team with a pharmacist had a lower average number of discrepancies per patient compared with other medicine services that did not have a pharmacist present. CONCLUSIONS Medication discrepancies at the time of hospital discharge are a common occurrence for geriatric patients. Physician summaries might be the least reliable source of discharge medication lists. The number of discrepancies appears to not be associated with patient age, but rather with the number of medications at discharge. Discrepancies among medication lists are common, and the presence of a pharmacist may reduce the number that occur.

Treatment of Phenytoin Toxicity With Repeated Doses of Activated Charcoal

A 38-year-old woman ingested at least 10 g of phenytoin and was managed using repeated doses of oral activated charcoal. The peak serum concentration of 52 micrograms/mL was reached within 42.5 hours of ingestion. Signs and symptoms of phenytoin toxicity had disappeared four days after ingestion. The serum phenytoin concentration was in the therapeutic range six days after ingestion. The clinical course of this patient was shorter than those of other conventionally treated patients with phenytoin overdoses. Multiple-dose activated charcoal may have a role in the treatment of phenytoin overdoses by limiting the amount of gastrointestinal absorption and by enhancing elimination.

Implications for Pharmacy from the Institute of Medicine's Report on Health Care Workforce and an Aging America:

The Institute of Medicines report “Retooling for an Aging America: Building the Health Care Workforce” concluded that the US health care workforce will require significant overhaul to care for the estimated 70 million adults 65 years and older by 2030. No profession trains the numbers of geriatric specialists needed to maintain the current provider to patient ratio. Pharmacy is no exception; currently less than 1% of pharmacists are certified or have specialty training in geriatrics. Schools of pharmacy, accrediting and professional organizations, and boards of pharmacy will need to collaborate to ensure that pharmacists have the core competencies to care for older adults.

Preventing Upper Gastrointestinal Bleeding in Patients Receiving Nonsteroidal Antiinflammatory Drugs

Severe upper gastrointestinal (GI) bleeding is a serious adverse effect of nonsteroidal antiinflammatory drugs (NSAIDs) and the elderly are at increased risk of developing this complication. Bleeding episodes can be prevented. Replacing NSAIDs with acetaminophen may be appropriate when a simple analgesic is needed that eliminates the risk of GI bleeding. Using the lowest effective NSAID dose may decrease the incidence and severity of NSAID gastropathy. Histamine H2-receptor antagonists, sucralfate, and misoprostol have been studied for the prevention of NSAID gastropathy, but only misoprostol prevents mucosal injury in both the stomach and duodenum. Patients who have a history of peptic ulcer disease or gastric bleeding from NSAIDs are candidates for prophylactic measures. Although other patients are at risk, no one knows who should receive prophylactic therapy for NSAID gastropathy. Future studies should attempt to define patient populations that warrant prophylactic therapy.

Social Work’s Participation in the Geriatric Education Centers Educational Evaluation A Brief Report

This study was conducted to determine the level and types of participation of social workers in the activities of the Geriatric Education Centers (GECs). Through an online survey of GECs, the level of participation of social work professionals was compared with those in dentistry, nursing, medicine, and pharmacy, during the years 2010 to 2014. Thirty-one percent (14) of the 45 GECs completed the survey. The results found increases in participation for both social workers and nurses for both GEC activities and involvement in leadership positions within the centers. The GECs also identified caregiver and provider education and continuing education as activities in which social workers have had an increased interest in recent years. Implications from this study can inform the programming efforts of the new Geriatric Workforce Enhancement Program (GWEP) and other geriatric education programs.

An Assessment of the Drug Therapy Education Preferences of an Interdisciplinary Group Interested in the Elderly

A survey was conducted to measure the drug therapy education preferences of a diverse group of professionals interested in the elderly. Two hundred forty-four surveys were mailed and 119 were returned (48.8 percent). Seventy-two percent of the respondents were social workers; four percent were registered nurses; the remainder of the respondents (24 percent) were non-health professionals. Most respondents liked all common methods of instruction except self-directed activities and large group discussions. The five topics of greatest interest were drug interactions, adverse drug effects, drugs used to treat depression, drugs used to treat nervousness or anxiety, and drugs used to manage dementia. A survey is an economical means of assessing the preferences of an unfamiliar audience. The methods used to determine content for this program can be used by educators who are planning programs for similar audiences made up of health and non-health professionals.