ERROR RISKS AMONG POPULATIONS OF SPECIAL VULNERABILITY

The safety of all patients is of paramount concern for all healthcare providers. However, some patients—for example, the very young, the very old, and the very sick—are particularly vulnerable to the effects of medical errors, often due to their inability to participate actively as a member of the healthcare team due to communication issues. In addition, their physical status (including but not limited to body weight and body mass composition, nutritional status, and metabolism) may also cause them to react differently to interventions, putting them at special risk. Healthcare providers must recognize the special needs of these patients and act accordingly.

Older Adults

There are multiple issues of concern when providing healthcare to adults ages 65 and over. Failure to recognize the unique problems of this age group can result in adverse events.

POLYPHARMACY

Polypharmacy, the use of multiple medications, some of which may be clinically inappropriate and/or incompatible, creates a significant risk for adverse drug events. Multiple medications, often new to the patient during hospitalization, potentiate the risk of nutritional, functional, and cognitive decline during hospitalization as well as increase the overall mortality risk. Literature has reported an average polypharmacy rate of 40% to 50% in this population (Nguyen et al., 2020).

The older adult is more sensitive to the effects of certain drugs, particularly those that affect the central nervous system, and aging is associated with decreased regulatory functions. Therefore, an antihypertensive medication, for example, can more easily result in postural hypotension, increasing the risk for falls. Opiates can increase the risk of respiratory depression.

Older adult patients often have multiple comorbidities, putting them at risk for polypharmacy. When a patient enters a hospital, clinicians may not have access to the patient’s current or previous medication list and/or may fail to realize that a new symptom is an adverse drug reaction or a side effect, and so another drug may be prescribed to treat that symptom.

Patients who see several different physicians at several different locations also have an increased risk of duplicate medications or drug interactions. Other problems may arise due to repeat prescribing without proper review, failing to do regular medication reviews with patients, and poor knowledge of drug interactions on the part of the clinician (Nguyen et al., 2020).

Polypharmacy can also negatively affect medication adherence in the older adult due to a number of associated factors, such as visual or hearing impairment, cognitive or functional impairment, social isolation, and complexity of the therapeutic regimen (Trotter et al., 2020).

Medication management in the older adult population involves considerations for drug dosing, drug interactions, adverse effects, adherence, social issues, clinical practice guidelines, and altered physiology.

One of the most commonly used tools for identifying and assessing patients for polypharmacy-related issues is the American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (see “Resources” at end of this course).

COGNITIVE IMPAIRMENT

Confusion and/or delirium in the older adult, especially someone with preexisting cognitive impairment, can be due to certain aspects of hospitalization, such as changes in environment and sensory deprivation. Delirium can also be the result of polypharmacy. The most common medications to cause delirium are opiates, benzodiazepines, and anticholinergics. An anticholinergic effect can also worsen a developing dementia. Confusion can also worsen when sensory input is affected, such as when the patient does not have access to eyeglasses or hearing aids.

Effective measures include orientation protocols, environmental modification, nonpharmacologic sleep aids, early and frequent mobilization, minimizing use of physical restraints, use of vision and hearing aids, adequate pain relief, and reduction in polypharmacy (Mattison, 2020).

FUNCTIONAL DECLINE

Functional decline may be the result of lack of mobility resulting in physical deconditioning and muscle weakness. The older adult experiences functional decline when unable to engage in activities of daily living. When an older adult is hospitalized, functional decline can occur as early as the second day of hospitalization. Immobility can increase the risk for adverse events such as falls, delirium, skin breakdown, and venous thromboembolic disease.

Improved mobility during hospitalization has been linked to decreased risk of death. Activity order for bed rest should be avoided unless absolutely medically required. Patients should be assisted out of bed to a chair for meals, which can also decrease the risk of aspiration, and should be encouraged to walk several times a day (Mattison, 2020).

FALL RISK

Risk for falls is increased in the older adult and may be due to the effects of acute illness compounded by an unfamiliar environment and side effects of treatments. Tethering medical devices such as urinary catheters, IV lines, cardiac monitor leads, and restraints make it more difficult to mobilize patients safely and are associated with increased rates of delirium, infection, and falls.

Strategies to help prevent falls may include weighing the risks and benefits of medications with significant psychotropic and anticholinergic effects, monitoring patients when prescribed drugs that may increase fall risk, supervising high-risk patients when ambulating, and encouraging time out of bed walking or sitting in a chair to prevent orthostatic hypotension associated with prolonged immobility (Mattison, 2020).

MALNUTRITION / DEHYDRATION

Malnutrition and dehydration in hospitalized and nursing home older patients may result due to impairment in cognition, restriction of movement, no access to dentures, difficulty with self-feeding, missed or interrupted meals, reduced appetite due to illness or lack of activity, lack of assistance with meals and drinks, and severely restricted diet orders, such as nothing by mouth.

Simple interventions such as getting the person out of bed at mealtime and providing assistance with eating can be of benefit. Inpatient assessment by a nutritionist can identify deficiencies and, combined with nutritional follow-up after discharge, may decrease mortality (Mattison, 2020).

Infants and Children

The potential for adverse drug events is higher in the pediatric population than in hospitalized adult patients. Every year more than 200,000 medication errors are reported, and approximately 30% of these errors involve children under 6 years of age (Wu, 2018). Dosing errors are the most common medication error in this population. The factors that place them at higher risk include:

• Different and changing pharmacokinetic parameters between patients at various ages and stages in development
• Fewer internal reserves to buffer any medication errors that may occur
• Need for calculation of individualized doses based on the patient’s age, weight, body surface area, and clinical condition (weight changes requiring recalculation can occur quickly, particularly in neonates)
• Inadequate availability of appropriate dosage forms and concentrations needed
• Need for precise dosage measurement and appropriate delivery systems

Clinical pharmacists can help by checking dosing calculation, screening for drug-drug interactions, and counseling caregivers on proper administration and medication-storage safety. Accurate weight scales that only measure in metric units (kilograms or grams), standardized equipment throughout a system, drug dose range limits, programmable “smart” infusion pumps for hospitals, and standardized order sets should be used.

Infants and young children do not have the communication abilities needed to alert clinicians to effects they experience. Parents of infants and children need to be fully informed and involved in their child’s care during any encounter with the healthcare system and must be educated to question caregivers about medications and procedures. Studies have shown that in low-income populations, medication errors are more prevalent due to potentially inadequate or marginal literacy, leading to misunderstanding of medication-dosing instructions (Wu, 2018; Mueller et al., 2019).

Intensive Care Patients

Intensive care settings are one of the most complex environments in healthcare. Preventable harms contribute significantly to ICU morbidity, mortality, and costs. Medical errors and deaths due to preventable harms are more common in the ICU due to higher patient acuity and complexity of care.

A safety smart list integrated into intensive care patients’ electronic health records has been found to decrease complications and length of stay in the ICU. The checklist covers common ICU conditions that, when left unaddressed, have been associated with HAIs, thrombosis, and worse clinical outcomes. The checklist includes:

• Removing unnecessary catheters
• Verifying that deep venous thrombosis, gastrointestinal, and medication issues are addressed
• Assessing and managing sedation, analgesia, and delirium
• Advancing the patient’s enteral diet and mobility
• Improving communication with family members and people with power of attorney
  (Lemkin et al., 2020)

Patients with Limited English Proficiency

Persons with limited English proficiency (LEP) have a limited ability to read, speak, write, or understand English. According to U.S. census data, there at least 25 million people in the United States over the age of 5 years who can be classified as LEP (Claros, 2021).

Individuals with LEP have problems with language competence that negatively affect communication and can greatly define the ease with which they navigate all areas of the healthcare system. An analysis of adverse incidents in the hospital setting found that 49.1% of LEP patients experienced physical harm, compared to 29.5% of English-speaking patients (Claros, 2021).

Patients with linguistic differences may have problems advocating for themselves and may not be able to describe or explain their chief complaints or express their level of pain. They are at higher risk for complications because of poor comprehension of medication errors, inaccurate assessment, increased psychological stress, and poor compliance with treatment and follow-up. In addition, the use of family or friends as interpreters increases chances of error (Claros, 2021).

Both the Joint Commission and the Affordable Care Act mandate adequate medical interpreter and translation services for patients with LEP. Translation and interpreter services provided by Certified Medical Interpreters is the gold standard, with studies showing the rate of error as being far lower when professional interpreters with more than 100 hours of training are used (Goodwin, 2018).

Patients with Low Health Literacy

Health literacy is defined as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. Low health literacy may have a negative effect on a person’s adherence to a treatment regimen, which may decrease its benefits. Patients with low health literacy also tend to use the emergency department more often and are more likely to return to the emergency department after 2 weeks (ODPHP, 2020b).

Low health literacy may impact parent/caregiver behavior (e.g., medication dosing) and children’s health outcomes.

Factors that influence an individual’s health literacy include

• Poverty
• Education
• Race/ethnicity
• Age
• Disability
• Cultural beliefs

Insurance status may also impact health literacy. Uninsured and Medicaid-insured individuals are at high risk for low health literacy. Older adult Medicare beneficiaries with low health literacy have higher medical costs, increased ER visits and hospital admission, and decreased access to healthcare.

Since limited health literacy is common and may be difficult to recognize, it is recommended that clinicians assume all patients and caregivers may have difficulty comprehending health information and that they communicate in ways that anyone can understand. This includes

• Simplifying communication
• Confirming comprehension for all patients
• Making the healthcare system easier to navigate
• Supporting patients’ efforts to improve their health
  (ODPHP, 2020b)