Theme: Medication Safety
Colleagues, while we were celebrating National Fall Prevention Awareness Week, Sept. 18-24, the World Health Organization (WHO) had just launched its 4th Annual Global Patient Safety Day on September 17th, addressing Medication Safety. Their slogan was “Medication without Harm”. All countries were urgently called upon to achieve this goal.
While September 17th has come and gone, I assert that this patient safety priority is directly aligned to our efforts to prevent medication-related anticipated physiological falls. In reviewing the WHO resources and tools for this year’s actions, I want to share them with you in hopes they will be valuable to your medication safety efforts.
But first, I want to provide you with some context about the WHO’s global annual Patient Safety activities. In 2019, the World Health Assembly approved a resolution that designated September 17th as World Patient Safety Day. The aim of this designation was to “increase public awareness and engagement, enhance global understanding, and work towards global solidarity and action by countries and partners to promote safety in health care” (WHO, Sept. 16, 2022, available here).
A specific topic is highlighted each year to underscore a priority area critical to patient safety. The past themes have been:
- 2021: “Together for safe and respectful maternal and newborn care.”
- 2020: “Speak up for health worker safety!”
- 2019: “Speak Up f or Patient safety! No one should be harmed.”
Their annual event is dedicated to enhancing the global understanding of patient safety, increasing public engagement in healthcare safety, and promoting global action to prevent and reduce avoidable harm in healthcare.
Their rationale for addressing medication safety is based on the patient safety/patient harm evidence.
According to the WHO (2022, Sept. 16):
- Unsafe medication practices and medication errors are one of the main causes of injury and avoidable harm in health-care system across the world.
- Global cost associated with medication errors has been estimated at US $42 billion annually.
- Medication errors happen due to systemic issues and/or human factors.
- Medication harm accounts for 50% of the overall preventable harm in medical care.
To support countries’ actions aligned with the WHO, they prepared a toolkit of resources that may be of interest to your organization. These resources include campaign materials and logos for interested parties, individuals, and organizations to disseminate through various channels.
Their toolkit includes key messaging for four audience groups: policy-makers and program managers; health care leaders and facility managers; health workers; and patients, families and general public here
And of course to support your efforts, they have developed a toolkit to help you launch a successful campaign here
I love their activity ideas, policy and advocacy activities, along with suggested medication safety improvement projects. They even have posters and souvenirs (T-shirts, cups, diary, ball-cap, lab coats, and an annual calendar: 12 months of medication safety, Sept 2022 – Sept 2023), available here in a variety of languages.
Medication safety and preventing medication-related harm is an ongoing priority of mine. To help WHO achieve its goal, Medication Without Harm (to reduce severe avoidable medication-related harm by 50% globally in the next five years as stated here), view these resources, be creative, and plan events and activities that your Fall and Fall Injury Prevention Committee believes will make the most impact for your patients and your community. Also, review their strategic framework domains and subdomains.
Colleagues, the complexity and interaction effects of falls risks are widely known, but most importantly in the predictable and preventable risks due to medications – their side effects – those are the fall risks. One quote widely repeated during fall prevention webinars that address medications is:
“No risk factor for falls is as potentially preventable or reversible as medication use”
(Leipzig, 1999.)
As you know, medications are a fall risk — specifically cardiovascular and central nervous system medications, diuretics, and chemotherapy, that predict the likelihood of anticipated physiological falls. Consistent with evidence that has existed for years, specific classes of medications within CNS and CVS medications increase a patient’s risk for falling. These classes include benzodiazepines, antidepressants, antihypertensives, antipsychotics and analgesics (Leipzig, et al., 1999).
Medications are an extrinsic fall risk factor, external to the individual, because of the side effects. You may be asking “What are these side effects?” You should know the most common because it is within your scope of practice to observe, assess, and report these side effects. So, I am delighted to the highlight these side effects and corresponding observations and symptoms.
Ataxia is a toxic effect of medications on the cerebellum, vestibulosensory or proprioceptive control system that result in increased body sway of loss of balance, resulting from such classes of medications as sedatives and hypnotics
Drug-induced Parkinsonism because observation with increased muscle tone, rigidity, resting tremor, impaired postural responses to change in position, hypokinesia, difficulty turning, postural instability – as a result of antipsychotics and any drug that interferes with dopamine transmission.
Myopathies are more long-term side effects that are visible as muscle wasting, weakness associated with long-term steroid use or statins
Peripheral neuropathies that first present as paresthesias, sensory changes before motor changes, often associated with chemotherapy, heart or blood pressure medications, anticonvulsants, and anti-alcohol drugs.
Postural or orthostatic hypotension is a known side effect that is quite complex, but simply drop of BP upon change in position (lying to standing or sitting if unable to stand), which often results from of tricyclic antidepressants, antipsychotics, antihypertensives, and diuretics.
Psychomotor slowing may also be visible with focused clinical observation and assessment as a patient demonstrates lack of attention or distraction from gait and balance problems, safety awareness and judgement programs, and decrease reflexes. Medication classes that can produce these side effects are generally benzodiazepines and anticonvulsants.
Many of these side effects can be first observed by nurses at the point of care, the nurse through expert and essential baseline and ongoing observation and assessment. By highlighting these drug side effects, you are refreshed in your knowledge of the importance fall risks that are most likely to result in a preventable fall: confusion; symptomatic and asymptomatic OH; changes in gait balance (erratic foot placement, widened stance, scissoring gait, or exaggerated steppage); and changes in balance when turning, transferring, or standing.
As we address the classes of medications and their side effects that increase fall risks, the total number of medications (polypharmacy) are also associated with falls (Boyle, et al., 2010). We also appreciated that increased medication use is directly related to increased medical conditions, which moves our focus to that of older adults. All nurses know that older adults are at greater risk for falling because they have multiple chronic conditions, like hypertension, arthritis, sleep problems, depression, and anxiety, for which medications are prescribed. Older adults will be taking prescribed an over-the-counter medications, resulting in a mix of medications that result in complications specific to therapeutic effects or adverse drug effects.
While this resource has focused on fall risks, medications are prescribed as well to reduce fall risks, it is important to emphasize that medications are used to reduce fall risk conditions – improve normal blood pressure, balance, gait, and more. Still, when fall-risk inducing meds are involved, fall risks can increase even with fewer than five prescribed medications. This risk further increases in patients with more advanced age, use of ambulation devices, and overall poorer health (Fritsch, et al, 2019). Although medications are an important factor in improving and maintaining quality of life for older adults, polypharmacy places them at greater risk of an acute care admission for medication-related problems and other complications. In acute hospital inpatients, prior research as revealed that polypharmacy accounted for 20% increased risk of falling (Boyle, 2010).
I hope this resource is interesting to you, because Medication Safety is Fall Prevention.
I look forward to your comments and to WHO’s 2023 Patient Safety Day Theme.
Thank you for reading this resource.
Pat Quigley
References
Boyle, N., Naganathan, V., & Cumming, R. (2010). Medications and falls: Risk optimization. Clinics in Geriatric Medicine, 26: 583-605.
Leipzig, R. M., Cumming, R. G., & Tinetti, M. E. (1999b). Drugs and falls in older people: A systematic review and meta-analysis: II. Cardiac and analgesic drugs. Journal of American Geriatric Society, 47, 40–50.
Fritsch, M.A., & Shelton, P.S. (2019). Geriatric polypharmacy. Pharmacist as key facilitator in assessment for fall risk: 2019 update. Clinics in Geriatric Medicine, 35: 185-204.
World Health Organization (2022, Sept. 16). WHO calls for urgent action by countries for achieving Medication Without Harm. WHO News. Available here Accessed 091822.
