Adverse Drug Events After Hospital Discharge in Older Adults: Types, Severity, and Involvement of Beers Criteria Medications

Abstract

Objectives To characterize adverse drug events (ADEs) occurring within the high-risk 45-day period post-hospitalization in older adults. Design Clinical pharmacists reviewed the ambulatory records of 1000 consecutive discharges. Setting A large multispecialty group practice closely aligned with a Massachusetts-based health plan. Participants Hospitalized patients aged 65 years and older who were discharged to home. Measurements Possible drug-related incidents occurring during the 45-day period post-hospitalization were identified and presented to a pair of physician-reviewers who classified incidents as to whether an ADE was present, whether the event was preventable, and the severity of the event. Medications implicated in ADEs were further characterized according to their inclusion in the 2012 Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Results At least one ADE was identified during the 45-day period in 18.7% (187) of the 1000 discharges. Of the 242 ADEs identified, 35% (n=84) were deemed preventable, of which 32% (n=27) were characterized as serious, and 5% (n=4) as life threatening. Over half of all ADEs occurred within the first 14 days post-hospitalization. The percentage of ADEs in which Beers Criteria medications were implicated was 16.5% (n=40). Beers Criteria medications with both a high quality of evidence and strong strength of recommendation were implicated in 6.6% (n=16) of the ADEs. Conclusion ADEs are common and often preventable among older adults following hospital discharge, underscoring the need to address medication safety during this high-risk period in this vulnerable population. Beers Criteria medications played a small role in these events suggesting that efforts to improve the quality and safety of medication use during this critical transition period must extend beyond a singular focus on Beers criteria medications.

How to Implement a Geriatric Assessment in Your Clinical Practice

“…The use of multiple medications can increase the incidence of adverse drug reactions and drug-to-drug interactions [88]. Adverse drug events are a significant cause of morbidity and mortality in older adults and are associated with substantial health care resource use [116][117][118][119]. In several countries, the Beers Criteria are used to avoid prescribing potentially inappropriate medications to older adults; this list was last updated in 2012 [55].…”

“…In several countries, the Beers Criteria are used to avoid prescribing potentially inappropriate medications to older adults; this list was last updated in 2012 [55]. Recent studies have shown that currently most adverse drug events are related to drugs not on the Beers list [117,119], stressing the importance of a comprehensive drug review. Among cancer patients receiving systematic anticancer therapy, one or more drug-to-drug interactions occurred in 27% of the patients [91,92].…”

After Rescue

“…4 A thorough medication assessment prior to discharge from critical care may benefit older adults by reducing complications from ADEs. 5 Although evidence in the literature has noted the importance of Beers Criteria application in outpatient and hospital settings, none has focused on incorporating this best practice in the critical care unit.…”

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“…In fact, one study showed that almost a quarter of all postdischarge errors were considered serious or life-threatening and that most of these errors happened within the first 14 days after discharge. 11 The highest predictors of postdischarge errors included low health literacy and low subjective numeracy (self-reported measure of the ability to perform mathematical tasks and the preference for numerical versus prose [words] information). 10 Interestingly, numeracy was not specifically associated with misunderstandings in the numerical aspects of medications such as dose or frequency, but rather with taking a medication no longer prescribed, omitting a prescribed medication, or misunderstanding a medication's indication.…”

“…Between 30% and 70% of patients make a medication error in the immediate weeks following hospitalization, [7][8][9][10][11] and the Centers for Medicare & Medicaid Services reports an average national hospital readmission rate of 17.5% to 19.5%. 12 The discharge process is often rushed and interrupted, making it difficult to ensure patients know what medications to take, the correct doses, and how to take them after discharge.…”