Medication management in hospitals is vitally important to the delivery of safe care. As the RARE campaign notes, "Medication management is one of five key areas known to reduce avoidable readmissions."
But medication management is also complex, with many moving parts and participants. As the Health Services Advisory Group notes, "Its components include medication reconciliation, medication therapy management, reduction of adverse drug events, teach-back for medication understanding, patient medication wallet cards, and medication adherence." This complexity brings with it numerous ways to derail efforts to effectively manage medications.
Here are seven challenges of medication management in hospitals.
1. Patient financial constraints
A Baltimore Sun headline effectively captures this challenge: "Doctor: high drug pricing kills patients." The story goes on to spotlight a heart attack patient who chose to postpone filling a heart medication for just a few days because of concerns about affording the drug and her other, non-medical expenses. Unfortunately, that delay was enough to cause her to suffer a second heart attack, which would claim her life.
Two eye-opening statistics highlighted in this article: "One in four Americans report difficulty affording their prescription drugs, and one in eight say they or a family member have rationed doses due to high costs." Two other rather incredible statistics, according to a CVS Caremark survey of more than 2,400 pharmacists: 62% of pharmacists believe the high cost of drugs is the biggest reason American's don't take prescriptions as prescribed. The pharmacists also estimated that, during the course of a year, nearly one in three customers choose not to fill a prescription due to price.
Considering the high number of patients who struggle to afford their care, including medication costs, hospital clinicians can no longer assume that the medications they prescribe will be filled, refilled, and taken appropriately. Effective medication management must go beyond the walls of the hospital and support patients following discharge.
2. Medication costs
Patients aren't alone in struggling with rising drug costs; hospitals are as well. A recent report released by the American Hospital Association (AHA), the Federation of American Hospitals, and the American Society of Health-System Pharmacists (ASHP) found the following:
- Average total drug spending per hospital admission increased by 18.5% between fiscal year (FY) 2015 and FY2017.
- Outpatient drug spending per admission increased by nearly 29% while inpatient drug spending per admission increased close to 10% between FY2015 and FY2017. This increase was on top of the 38% increase in inpatient drug spending between FY2013 and FY2015 noted in the organizations' previous report.
- Increases of over 80% of unit price were seen across different classes of drugs (e.g., anesthetics, parenteral solutions, chemotherapy).
- Over 90% of surveyed hospitals reported having to identify alternative therapies to manage spending.
In a news release, Rick Pollack, president and CEO of AHA, said, "This report confirms that we are in the midst of a prescription drug spending crisis that threatens patient access to care and hospitals' and health systems' ability to provide the highest quality of care."
3. Drug shortages
Also highlighted in the report as a challenge facing hospitals: medication shortages. According to the report, almost 80% of hospitals indicated that it was "extremely challenging" to obtain drugs experiencing shortages, and almost 80% also indicated that drug shortages resulted in an increase in spending on drugs to a moderate or large extent.
When drugs are in short supply, clinicians can be forced to make what can be difficult decisions. As an AAMCNews article notes, these actions include trying to find a substitute (which can be expensive and may raise the risk of medication error), conserve supplies (which can affect treatment), producing their own in a compounding pharmacy (typically a lengthy process), and choosing which patients receive medications and which can safely have their treatment delayed.
As Yoram Unguru, MD, a pediatric hematologist-oncologist, said in the AAMCNews article, "… one of the hardest [conversations] is sitting down with a patient and family and telling them there's a drug that's part of the curative regimen, but it's not available because there's a shortage. Patients and parents give you a look of complete incredulity. 'What do you mean it's not available?' Even after I explain why these shortages exist, many patients and families still have a hard time believing that a life-saving medication isn't available in the United States."
And as a Healthcare IT News column notes, "… drug shortages are causing significant patient-safety challenges, as clinicians could be called upon to use new medications that they're not familiar with and not appropriately educated on, from a prescribing and administrative point of view."
4. Safety risks
At least one medication error per day. That's what the Institute of Medicine estimated that hospitalized patients experience, on average. While a small portion of these mistakes actually harm patients, errors can lead to serious injuries — even death. Unfortunately, preventing errors from occurring is far from easy as there are numerous factors that can contribute to or cause an error. One could argue that if a single medication error occurs, medication management has failed.
Despite medication errors receiving significant attention, hospitals continue to struggle with them. This is apparent when one reviews "Targeted Medication Safety Best Practices for Hospitals," a report from the Institute for Safe Medication Practices (ISMP). The 14 best practices in this report, according to ISMP, "… were developed to identify, inspire, and mobilize widespread, national adoption of best practices for specific medication safety issues that continue to cause fatal and harmful errors in patients, despite repeated warnings in ISMP publications."
Furthermore, the World Health Organization (WHO) chose to focus on medication-related errors for its third global safety initiative, calling on facilities to reduce the rate of these errors in half by 2022. As Dr. Margaret Chan, WHO director-general at the time, said in a release, "We all expect to be helped, not harmed, when we take medication. Apart from the human cost, medication errors place an enormous and unnecessary strain on health budgets. Preventing errors saves money and saves lives."
5. Incomplete patient medication histories
For clinicians to provide the most effective medication management requires access to patients' medication histories — not just from their time at the hospital, but the complete continuum of care. That's much easier said than done.
As the Institute of Healthcare Improvement notes, "One of the most challenging aspects of improving medication safety involves ensuring that accurate information about a patient's medications — what he or she is taking, when, and in what dose — travels with that patient throughout the healthcare system, and that any changes to that list are shared with other providers."
If even a single detail about a medication is omitted from a patient's medication history, this will increase the risk of an adverse drug event. An article in the British Journal of Clinical Pharmacology notes, "Medication history errors, such as omitting drugs erroneously, are common and often have the potential to harm the patient. Hypersensitivity reactions are often poorly documented or not explored in detail, which may lead to unnecessary avoidance of a drug. Accurate documentation of concomitant herbal or alternative therapies is rare, despite the importance they may have in causing adverse effects or drug-drug interactions. Polypharmacy, specific drugs, and clinical specialty can affect the risk of medication history errors."
6. Care transition breakdowns
Every patient transition between clinicians, departments, and facilities (including the patient's home) brings increased difficulty and risk concerning medication management.
An Australian Prescriber article notes, "As patients move between health providers and settings, discrepancies and miscommunication in clinical records are common and lead to serious medication errors. Hospital admissions and discharges, interdepartmental transfers, or care shared between a specialist and a general practitioner, are often dangerous times for patients, especially those with long-term conditions or taking multiple medicines."
A Joint Commission article shares several factors that frequently lead to failures in care transitions related to medication management:
- Patients with limited English proficiency or low levels of health literacy who struggle to follow instructions on how to care for themselves or adhere to treatment regimens.
- Patients lacking sufficient understanding of their medical condition or the plan of care.
- Patients or family/friend caregivers receiving conflicting recommendations, confusing medication regimens, and unclear follow-up care instructions.
- Patients and caregivers excluded from the planning related to the transition process.
7. Opioid prescribing
A relatively newer medication management challenge facing hospital clinicians concerns the safe prescribing of opioids. Not only must clinicians carefully consider which patients should receive opioids and how much to prescribe, they must also strive to identify those patients who need the pain management compared to addicts (who require different care) or individuals seeking to acquire the drugs in hopes of selling them.
A recent Association of Medical Directors of Information Systems survey of chief medical information officers notes, "Sixty-five percent of respondents cited the need for an integrated clinician workflow that makes it easy for clinicians to coordinate the entire medication management process, including electronic prescribing of controlled substances like opioids, access to state prescription drug monitoring programs to identify patients' opioid histories, and electronic access to prescriptions from other providers and locations to avoid potentially harmful drug combinations. Similarly, 41 percent shared concerns about providers' abilities to prevent opioid abuse since they often cannot easily distinguish 'drug shoppers' from patients genuinely in need."