Hi I am Dr. Mike Evans and today we are talking about medication safety. This may sound intimidating
or scary or something that should only be the concern of your doctor or pharmacist…but
the reality is that you are the one who knows best what you are taking and how your meds
are affecting you. As we shall see as I run through some of the complexities of taking
medications, there is one simple solution that provides significant clarity, reduced
harm, and increased effectiveness...and that, my friend is an up to date medication list that outlines
what, and how, you are taking your meds… that you share with your healthcare team – your
doctor, pharmacist, dentist, nurse, specialist and maybe even caregivers like family and
friends who help out.
I love it when a patient says to me… ”not sure if its perfect.. but just so we are on
the same page, this is exactly what I am taking now" This will take some effort
on your part but making a list of all your prescription and non-prescription medications-
is a simple and often overlooked pathway to better health and less harm for you or your
loved one.
SO why is having an accurate and shared medication list so important? Well, lets start with a
reality check. Only about 25% of physicians surveyed could easily generate a list of an
individual patient’s medications.
If we look at transitions to the hospital … A systematic review by Dr. Ed Etchells
and his colleagues, published in the Canadian Medical Association Journal, found up to 2/3
of the time there was an error in medications at the time of admission. They deemed that
41% of these errors were clinically important and 22% had the potential to cause harm during
the patient's admission. Combine this with the fact that 2/3 of seniors are on 5 or more
prescription drugs, often prescribed by different providers, and you can see both the opportunity
for error- …but also the tremendous opportunity to prevent errors like this with an accurate,
up-to-date list that moves with the patient across the entire continuum of care.
If we look at patient end of things, there are issues even before people start taking
medications. A 2014 study published in the Annals of Internal Medicine led by Dr. Robyn
Tamblyn found that 31% of the patients didn't even fill their prescription in the first
place. This is in Quebec where they have a generous program of government coverage
for medications, especially for lower income people. You would think that people with more
severe illnesses, recent hospitalizations, or emergency visits would be more likely
to take their medications to prevent this from happening in the first place, but this
study found the reverse to be true.
When we follow people with chronic diseases, especially “silent’ ones where we don't
see many symptoms such as high blood pressure or high cholesterol, about 1 out every two
people stop taking their medications after a year. I have a bit of a Whaaaaat? reaction…
I mean..I get that we won’t reach 100% …but I feel a bit sad that 50% of people could
be missing the opportunity to drop their chances of having a heart attack or stroke by maybe
25% Also it’s important to know that there are some medications, like antidepressants,
where stopping them suddenly is definitely not a good idea…how you’re taking medications
can be as important as what you’re taking.
We know that for a bunch of different reasons you may not be taking medications exactly
as instructed by your healthcare team. We used to call this field medication compliance—but
the word compliance seems paternalistic …..A kind of one-way street where the doctor tells
you what to do, and if you don't comply- you have failed.But this doesn't get at
partnership or the why we do or don't do things. So, for example, maybe you aren’t
filling the prescription for perfectly good reasons, maybe it’s too expensive, or
you’ve thought about it and decided that the downsides of the medicine outweigh the
upsides, or you want more information before you take it. Or perhaps you started the drug
but stopped because you got better, or you developed a side effect and you are not sure
how to bring it to my attention, or are just unsure how to take the medicine in the
first place. Maybe you read or heard about a side-effect from a friend or the internet
or had a hard time putting the lengthy print out from the drug store into perspective.
Sometimes, people just stop taking their meds and they feel embarrassed about it and don’t
want to say anything.
Instead of compliance, we now use the word “adherence”. Adherence means “sticking
to” a treatment, and, I think, the term acknowledges that taking medications in the
way they’re prescribed is critical, but also acknowledges the complexities of taking
medication.
We do need your honesty, better systems for monitoring and sharing information, and so
on, but we also need to continue to improve the way we talk to one another. I know its
old school, but on my end if I just tell you - “this medication lowers your
blood pressure” .. well, that may not be enough… Taking a few more seconds to tell
you that I am prescribing it because “I want to decrease your chances of having a
stroke or a heart attack…” and explaining that “when your blood pressure is high,
your heart has to work harder and it becomes more bulky and stiff- and we don't want a
muscleman for a heart – we want a long distance runner. So by lowering your blood pressure,
we make things easier for your heart… and your brain and kidneys too… “
There are so many scenarios where poor communication leads to serious problems. A patient is embarrassed
to tell us about their meds for erectile dysfunction and without knowing that we prescribe another
medication that dilates blood vessels, and the patients blood pressure drops drastically
Or a patient gets a prescription for an antidepressant but hasn’t told the prescriber they’re
already taking st johns wort – this can lead to a very dangerous interaction. Or maybe
the dose of a diabetes medication is increased by one doctor who doesn't know that another
doctor added a new diabetes pill last week and the patient's blood sugar drops.
Your medication list also needs to include the stuff we don’t prescribe: your allergy
meds, cough meds, vitamins, pain pills, herbals, Chinese medicine, and so on...2/3 of Canadians
took an over the counter medication in the last 6 months… … all of these act like
medicines in your body and can cause side effects or interact with your other medicines.
And remember, medicines aren’t just pills…they can be sprays, puffers, patches, suppositories,
medicated creams, ointments,… and so on.
Your healthcare provider may already have something, but to help you keep a list, I’ll
direct you to some easy to use templates and apps at the end of this talk. These are
for you to fill in and keep with you… and will include the name of the medicine, the
strength, how, when and why you are taking it, and who prescribed it. To help complete
the list, you may be asked some obvious questions so for example if you've had a bad reaction
or allergy to a medication in the past and it’s especially helpful if you describe
the kind of reaction you had.
I also think the timing is important to keep in mind.. medication changes tend to happen
when you see different specialists, when you come into or out of a hospital or other care
facility, when you develop a new condition, and so on. It’s at these transition points
that you need to refresh your list and help keep your team up to date.
As I said before, the one constant as you move through the healthcare system is you,
and that's also true when things go wrong. Our system isn’t perfect and a key way we
can improve is to acknowledge our mistakes. I will give you a link at the end where you
can anonymously report any concerning medication incidents and receive more information about
safe medication practices. A medication incident is a mistake with medication, or a problem
that could cause a mistake with medication, like receiving the wrong medicine, or the
wrong dose from a pharmacy or hospital. The majority of medication incidents do not cause
harm, but unfortunately sometimes they do. We call these “adverse events” and they
are often preventable. You can report any medication incident involving the use of prescription
or non-prescription medications, a device, or a natural health product.
While we are on subject of good practice I do think its so important you ask your local
pharmacist for advice. They can be incredibly helpful. For instance, if you ask a pharmacist
can often perform what’s called a “comprehensive medication review” which can really improve
your medication use and can be especially effective when you are taking multiple medications.
Finally, it’s really helpful to get all your medications from the same pharmacy. This
helps minimize the potential for overprescribing, drug interactions and so on.
SO let me just summarize by saying that we invest heavily in finding new treatments—yet
30-50% of the time we aren’t doing a good job in taking the treatments that have already
been proven to work. As we transition through the health care system there are many opportunities
for error… so I think its time to start owning that and realizing the importance of
your own role, committing to one simple first step of just being on the same page with an
accurate and updated medication list, reviewing the list and partnering with your healthcare
team, and letting us know when there are problems.
I really hope this helps and take care.