Grant Fuller, PharmD Candidate 1,2
Kendra Carroll, HBSc, PharmD Candidate 2,3
Alan Ho Lun Li, BPharm Candidate 4
Certina Ho, RPh, BScPhm, MISt, MEd, PhD 2,3
1 School of Pharmacy, University of Waterloo
2 Institute for Safe Medication Practices Canada
3 Leslie Dan Faculty of Pharmacy, University of Toronto
4 School of Pharmacy, The Chinese University of Hong Kong
INTRODUCTION
The kidneys are one of the main organs responsible for eliminating drugs from the body. Decreased renal function may lead to reduced drug clearance and a subsequent increase in plasma drug concentration. If dosing adjustments are not made based on a patient’s renal function, increased exposure to the medication may put the patient at risk of side effects, serious harm, or death.1
As our population ages and requires an increasing number of medications, situations of inappropriate medication use in patients with reduced renal function may become more frequent.2 Renal impairment, regardless of the cause, introduces further complexity and opportunity for errors within the medication-use process. The likelihood of medication incidents involving this population is particularly high in communities when healthcare practitioners have limited access to patient medical records and lab values. Despite these challenges, pharmacists are responsible for providing safe and effective care to patients. Acknowledging the limitations of our current health care system will help us implement feasible improvements in the medication-use process.
To protect patients with renal impairment, many medications must be dose-adjusted according to the patient’s renal function. A list of common medications requiring dose adjustment or avoidance in renal impairment is presented in Table 1. The objective of this multi-incident analysis is to examine medication incidents involving patients with renal impairment within the community pharmacy setting. Common themes and potential contributing factors are provided as well as recommendations to improve the care of these patients (Tables 2-5).
Table 1. Examples of Top 100 prescribed drugs that must be considered for dose adjustment or avoidance in renal impairment 3.4
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Disclaimer: This list is not comprehensive of all medications requiring dose adjustment in renal impairment. Refer to the Ontario Renal Network and other resources as appropriate to confirm dose adjustments or contraindications in renal impairment.
METHODS
A total of 172 incident reports were extracted from the ISMP Canada Community Pharmacy Incident Reporting (CPhIR) program database from June 2014 to May 2019. The CPhIR program aggregates medication incident data from different provinces, including incident reports from jurisdictions where pharmacists have access to patient lab values.* A collection of broad renal-associated search terms including but not limited to: “GFR”, “dialysis”, “kidney” and “renal” were used to capture incidents involving patients with renal impairment. Thirty-eight incidents were excluded, as they did not involve the target patient population. A total of 134 incidents met the inclusion criteria and were evaluated in this qualitative incident analysis. Two independent analysts conducted a multi-incident analysis of the data, identifying common themes, subthemes, contributing factors, and recommendations to improve patient safety.
Of note, 86 of the 134 incidents analyzed were classified by reporters as “near misses” that were caught before reaching the patient. Therefore, many of the following incident examples should be interpreted as demonstrating best practices by pharmacy professionals, rather than errors that should be avoided. Where applicable, we will differentiate mitigating factors or best pharmacy practices in preventing medication harm from potential contributing factors to medication incidents in Tables 2 to 4 below.
* Note: While incident examples included in this article are not specific to Ontario, we believe that the shared learning and experiences from these near misses and medication incidents are still beneficial to pharmacy professionals in Ontario.
RESULTS
Table 2. Main Theme 1 – Recognition of Renal Impairment
Subtheme 1 – Checking/Availability of Lab Values | ||
Incident Examples | Contributing Factors | Commentary |
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Subtheme 2 – Patient-Related Factors | ||
Incident Examples | Mitigating Factors / Best Practice in Preventing Medication Harm | Commentary |
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Subtheme 3 – Drug-Related Factors | ||
Incident Examples | Mitigating Factors / Best Practice in Preventing Medication Harm | Commentary |
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Subtheme 4 – Documentation and Computerization | ||
Incident Examples | Mitigating Factors / Best Practice in Preventing Medication Harm | Commentary |
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Table 3. Main Theme 2 – Additional Safeguards for Patients With Renal Impairment
Subtheme 1 – Additional Renal-Specific Care Providers | ||
Incident Examples | Mitigating Factors / Best Practice in Preventing Medication Harm | Commentary |
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Subtheme 2 – Additional Education Provided to Renal Patients | ||
Incident Examples | Mitigating Factors / Best Practice in Preventing Medication Harm | Commentary |
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Table 4. Main Theme 3 – Additional Risk Introduced by Renal Impairment
Subtheme 1 – Dialysis | ||
Incident Examples | Contributing Factors | Commentary |
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Subtheme 2 – Drug Therapy Changes Relating to Renal Function | ||
Incident Examples | Contributing Factors | Commentary |
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DISCUSSION
Access to patient diagnostic test results (e.g. lab values) should be accessible to all healthcare professionals where access to these results would improve the quality of care they provide to the patient. This includes pharmacists who require access to indicators of patient renal function to evaluate the appropriateness of medication therapy and to recommend suitable alternatives if necessary. Furthermore, healthcare practitioners are encouraged to remind patients to share with them if they have any changes to their medical conditions or medications and if they have any recent blood work done. A resource that pharmacists can share and recommend patients to use is the 5 Questions to Ask About Your Medications handout where patients can learn about common questions that they should ask their healthcare providers regarding their medications at each encounter.
Table 5. Summary of Recommendations
For Pharmacists | For Prescribers |
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CONCLUSION
This multi-incident analysis has highlighted several reasons that patients with renal impairment may be prone to medication incidents. These patients are cared for by multiple providers and they work closely with their healthcare team. Collaboration is needed within this circle of care to prevent errors and provide the best possible care.
ACKNOWLEDGEMENTS
ISMP Canada would like to acknowledge support from the Ontario Ministry of Health and Long-Term Care for the development of the Community Pharmacy Incident Reporting (CPhIR) Program. The CPhIR Program contributes to the Canadian Medication Incident Reporting and Prevention System (CMIRPS). A primary objective of CMIRPS is to analyze medication incident reports and develop recommendations for enhancing medication safety across all healthcare settings.
AIMS PROGRAM REMINDER
Please be reminded that as part of the AIMS program, pharmacy professionals must report medication incidents and near misses in the AIMS Pharmapod platform, as well as document the details of the medication incidents, analyze them to identify causal factors and share the learnings with their team in a timely manner.
REFERENCES
- Levy, G. Pharmacokinetics in renal disease. Am J Med. 1977 Apr;62(4):461-5.
- Lubran, MM. Renal function in the elderly. Ann Clin Lab Sci. 1995 Mar-Apr;25(2):122-33.
- Ontario Renal Network. Medications that must be considered for dose adjustment or avoidance. Available from: https://www.ontariorenalnetwork.ca/en/medicationsafety
- Paquette A. Special Report: Top Drugs of 2015. Canadian Healthcare Network. Available from: http://www.canadianhealthcarenetwork.ca/pharmacists/news/special-reports/special-report-top-drugs-of-2015-36905