Medication safety of older patients in the hospital setting: a scoping review

Abstract

Objective  To identify the scientific evidence available in the literature on medication safety for older adults in the hospital setting.

Method  A scoping review was conducted on medication safety among older patients in the hospital setting involving searches of the LILACS, SCIELO, MEDLINE, and PUBMED databases Health descriptors were used according to DECS: patient safety, elderly, medications, hospital. The study included complete articles available in full, in Portuguese, English or Spanish. Duplicate articles, theses and dissertations were excluded.

Results  The search retrieved 172 publications. After reading of titles and abstracts, 8 articles that met the inclusion criteria were selected. The final sample of this scoping review comprised 8 selected studies, while the rest were excluded for being off-topic. The review allowed mapping of a significant number of publications on medication safety for hospitalized older adults.

Conclusion  This review found proposed strategies for preventing medication errors in the hospital environment.

Keywords Patient Safety; Nursing; Aged; Pharmacological Treatment; Hospital

Resumo

Objetivo  Identificar as evidências científicas disponíveis na literatura sobre segurança medicamentosa de pessoas idosas no contexto hospitalar.

Método  Trata-se de uma Revisão de escopo. Foram feitas buscas nas seguintes bases de dados: LILACS, SCIELO, MEDLINE, e PUBMED, sobre a temática segurança medicamentosa de pacientes idosos no contexto hospitalar. Utilizaram-se os descritores em saúde de acordo com o DECS: Segurança do paciente, idoso, medicamentos, hospital. Foram incluídos na pesquisa: artigos completos disponíveis na íntegra, com os idiomas português, inglês e espanhol. Excluídos artigos duplicados, teses e dissertações.

Resultados  A busca resultou 172 publicações. Após leitura dos títulos e resumos, oito artigos foram selecionados por se adequarem aos critérios de inclusão. A amostra final desta revisão de escopo totalizou oito estudos selecionados e excluídos o restante por não contemplarem o tema da pesquisa. A revisão possibilitou mapear um quantitativo expressivo de publicações sobre segurança medicamentosa de pessoas idosas hospitalizadas.

Conclusão  Esta revisão encontrou propostas de estratégias de prevenção de erros de medicação no ambiente hospitalar.

Palavras-Chave: Segurança do Paciente; Enfermagem; Idoso; Tratamento Farmacológico; Hospital

INTRODUCTION

Aging is defined as a natural irreversible progressive process, common to all beings of a species, accompanied by biological, psychological and social changes of an individual. This process of physiological decline encompasses a group of functional and structural changes which can result in motor impairment or psychological and social difficulties, negatively impacting the health and disease process¹.

This scenario of physiological decline is marked by a steady increase in the prevalence of chronic diseases and number of medications used, often culminating in multiple drugs use, or polypharmacy (concomitant use of ≥5 medications). Polypharmacy is common in hospitalized older adults and can lead to an increase in the occurrence of potential drug-drug interactions and Adverse Drug Reactions (ADRs), posing a risk to the safety of older patients in the administration of drugs².

Frailty and the numerous chronic diseases found in the older population, concomitant with polypharmacy, renders the individual more vulnerable to adverse drug events (ADEs), such as drug-drug interactions, medication errors, falls risk, increased hospitalization rate, among other negative therapeutic aspects³.

Adverse events in the hospital setting occur in around 10% of hospitalized patients⁴. However, studies show that this percentage can range from 5 to 41%. Moreover, investigations report that, of the different adverse events, medication error can occur in 3 to 54% of cases⁵,⁶.

Although studies on medication safety in older adults are available in the Brazilian literature, few of these specifically address this issue in hospitalized older patients. Therefore, the main contribution of the present study to the literature in the field is informing future professionals with a view to enhancing the safety of care in health services⁷.

Thus, the objective of the study was to explore the available scientific evidence on medication safety for older adults within the hospital setting with a view to defining integrative health and care strategies and promoting medication safety in this age group.

METHOD

A scoping review study was carried out in accordance with the method recommended by the Joanna Briggs Institute Reviewers’ Manual⁸ and technical framework proposed by Arksey and O’Malley⁹. This type of study entails an exploratory reviewed aimed at mapping, based on the scientific output, publications relevant to a given area of study¹⁰, and public registration on the Open Science Framework Platform (https://doi.org/10.17605/OSF.IO/RP3NB).

The scoping review involved the following stages: identifying the research question, inclusion criteria, research strategy, and extraction and reporting of results. The sixth optional stage (consultation) was not employed¹⁰.

The research question was developed using the PCC strategy, with P: Population = hospitalized older adults; C: Concept = medication safety; and C: Context = Hospital environment, and the following guiding research question was devised: What is the available scientific evidence on medication safety for older adults in the hospital setting?

The articles retrieved were screened based on the eligibility criteria. The inclusion criteria were: original articles, published in Portuguese, Spanish or English on medication safety, whose research subjects included hospitalized older adults, published between 2018 and 2023. Duplicate studies, reviews, editorials, theses, dissertations, experience reports, theoretical trials, reflection studies and books were excluded.

One of the data sources searched was the Biblioteca Virtual em Saúde which included the following databases: Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), International Literature on Health Science (MEDLINE), Índice Bibliográfico Espanhol de Ciências da Saúde (IBECS), Base de Dados de Enfermagem (BDENF) and Cumulative Index to Nursing and Allied Health Literature (CINAHL). The search of indexed publications on the virtual libraries included: The Cochrane Library, Scientific Electronic Library Online (SciELO), and the National Library of Medicine (PubMed and Web of Science). The Google Scholar tool and lists of references in the relevant literature were also checked.

The following controlled term descriptors suggested by the Medical Subject Headings (MeSH) and the Descritores em Ciências da Saúde (DeCS) were selected: Patient safety, Aged, Pharmaceutical preparations and Hospitals. All of these terms were search in their equivalent forms in Spanish and Portuguese. The search strategy was tailored according to the definition of each corresponding database. The Boolean operator AND was employed with the following combinations: Patient Safety AND Aged AND Pharmaceutical preparation AND Hospitals; Patient Safety AND Aged AND Pharmaceutical preparation; Patient Safety AND Pharmaceutical preparation. All of these search strategies were applied in their equivalent forms in English, Spanish and Portuguese in April 2023.

The PRISMA Extension for Scoping Reviews (PRISMA ScR) methodology was used to systematize the study inclusion process. A total of 121 studies were retrieved from the data sources selected. After removal of paid material and exclusion based on initial reading of titles and abstracts, as well as removal of duplicates, 8 studies remained for inclusion in the review.

A reference management tool was employed to help organize the material and carry out study selection. The 121 articles selected were screened for title and abstract by 2 independent examiners to include, exclude or select the “doubt” field through blinding of reviewers and automatic identification of duplicity. Disagreements were discussed and resolved by consensus, where a minimum agreement of 75% between reviewers was established. The doubts existing and conflicts were resolved by consensus in May after blinding of reviewers was lifted. Following selection, the studies were analyzed by full reading.

Studies that failed to meet the selection criteria, lacked data pertinent to the study objective, or did not address the elected concept or context were excluded.

Polypharmacy was defined as the use of 5 different medications or more, a common phenomenon among older adults. This situation poses a challenge in health services and care provision owing to the series of complications which can arise due to prescription of inappropriate medications, harmful drug-drug interactions, increased risk and severity of adverse reactions, cumulative toxicity, iatrogenic issues, poor adherence to treatment, besides the occurrence of hospitalizations and deaths³.

The concept of Adverse Drug Events (ADEs) can be defined as harm experienced by a patient as a result of exposure to a medication, with some cases resulting in death. Improving medication safety of hospitalized older adults requires a fitting approach to manage the balance between efficacy and safety in the prescribing and use of medications. In addition, close monitoring of signs, symptoms and laboratory parameters to detect and assess the occurrence and severity of possible adverse events is also necessary in order to offer proper treatment¹¹.

The process of identification, screening, eligibility and inclusion of studies for selection of the sample is shown in Figure 1. No back search based on the list of references of the selected studies was carried out and, thus, no additional articles were included.

Figure 1
Flow diagram of article search and selection process, adapted from PRISMA-ScR. Campina Grande (Paraiba state), Brazil, 2023.

RESULTS

In the present review, 121 studies were found on the different databases as follows: MEDLINE n=14 articles (11.57%), LILACS n=16 (13.22%), BDENF n=62 (51.23%), PUBMED n=33 (27.27%) and CAPES Periodicals n=47 (38.84%). The articles found had all been published and made available for study between 2018 and 2023. Of the total studies, 8 were selected for inclusion in the study sample. The settings of the respective studies ranged from long-term care facilities to hospitals. The studies were also conducted in various different States. The studies included in the review are outlined in Chart 1.

Chart 1
Studies included in scoping review on medication safety for hospitalized older adults. Campina Grande (Paraiba state), Brazil, 2023.

Identification	Author	Study design	Objective	Country	Quality of evidence**
A1	Martins et al.11,	Ecological study	To identify Adverse Drug Events (ADE) registered on the SIM, estimating rate and analyzing distribution by year, age group and event type.	Brazil	Level 4
A2	Santos et al.12,	Cross-sectional study	To asses potential drug-drug interactions in patients from a clinic at a university hospital	Brazil	Level 4
A3	Meireles et al.13,	Cross-sectional study	To estimate the prevalence rate of falls in the study setting.	Brazil	Level 4
A4	Moraes et al.14,	Cross-sectional study	To characterize the major potential interactions of drugs contraindicated in adult intensive care and determine their prevalence, medications and factors associated with exposure of these interactions.	Brazil	Level 4
A5	Eshetie et al.15,	Randomized study	To identify 4 example articles focusing on medication use quality and safety in 2020.	USA	Level 1
A6	Karapinar Çarkit et al.16,	Observational study	To assess the medication-related problems/errors reported to the Dutch medication incident registry and disseminated for information to pharmacists.	Holland	Level 4
A7	Leite et al.17,	Review	Determine the main health technologies used as tools for preventing medication errors in the hospital setting	Brazil	Level 5
A8	Costa et al.18,	Cross-sectional study	To describe the contributions of activities of resident pharmacists, under a multiprofessional program, to the safety of hospitalized older adults.	Brazil	Level 4

• Source: Authors, 2023. *A: article, followed by sequential number. ** According to categorization of the Agency for Healthcare Research and Quality (AHRQ)

Of the initial 172 studies retrieved, 8 studies met the inclusion criteria after reading of titles and abstracts. The remaining studies were excluded for being off-topic.

Overall, the results showed that participants of the studies were predominantly males, aged 65-75 years, and sought hospital level care for treatment of acute and chronic diseases. The results also revealed that the populations studied held medical prescriptions for use of Potentially Inappropriate Medications (PIMs)¹²,¹⁴,¹⁵.

With regard to publication language, six¹¹-¹⁴,¹⁷,¹⁸ (75%) articles were in Portuguese and two¹⁵,¹⁶ (25%) in English. In terms of study design, four¹³-¹⁵,¹⁹ were cross-sectional (50%), one¹¹ ecological (12.5%), one¹⁶ observational (12.5%), one¹⁵ randomized (12.5%) and one¹⁷ was a review study (12.5%). For country of study, most of the investigations took place in Brazil, accounting for six¹¹-¹⁴,¹⁷,¹⁸ articles (75%), plus one¹⁶ in Holland (12.5%) and one¹⁵ in North America (USA)(12.5%). Lastly, concerning the level of care provided by nurses, all eight¹¹-¹⁸ studies involved in-hospital care (100%).

DISCUSSION

Health teams, particularly nurses, face significant challenges dealing with the management of drug therapies in hospitalized geriatric patients, due to the particularities of the pharmacodynamic and pharmacokinetics in this age group. Furthermore, given the dearth of specific studies on medications in older adults, health teams must take actions to ensure a drug-therapy approach based on effectiveness, safety and need, taking into account the individual clinical context of the patient¹²,¹⁴.

Some of the studies reviewed reported incidents associated with drug-drug interactions as one of the factors compromising medication safety of the hospitalized older adults assessed. Drug-drug interactions occur when combinations of medications are used for different indications or treatments and can result in unintentional consequences with changes in pharmacokinetics and pharmacodynamic, resulting in a reduction in effectiveness or increase in toxicity of the drug. These reactions are considered preventable Adverse Drug Events (ADEs) that may result in serious or fatal outcomes and compromise the safety of patients in hospitals, occurring prior to admission or as an event resulting from hospitalization³,¹²-¹⁵.

These reactions can be classified according to severity: 1) Severe: life-threatening and requiring immediate intervention; 2) Moderate: when the clinical condition of the patients worsens and there is a need to change the drug therapy; 3) Mild: when the patient present shifts in their clinical condition, but not requiring changes in drug therapy; and 4) Contraindicated: when co-administration with other drugs is not recommended¹⁴.

With regard to use of PIMs for older adults, it is in this patient group that the risks of adverse events associated with their use can outweigh the therapeutic benefits, particularly when more effective alternatives are available. This highlights the importance of close control of the drug therapy with the proper medical prescription, so as to prevent drug interactions and intoxications, which tend to involve the gastrointestinal system of these individuals¹³-¹⁵.

A retrospective study reported that around half of adverse drug events required a higher level of care, of which 74% had the potential to cause temporary or permanent harm and 84% were preventable. The main drug classes involved in these events were antibiotics and antithrombotic agents¹⁹.

A host of risk factors can contribute to the occurrence of undesirable drug interactions, classified as factors related to patients, to medications and to medical prescriptions. Patient-related risk factors include age, comorbidity and polypharmacy. Risks associated with medications include enzyme inhibition or induction potential, and therapeutic margin and dose. Medical prescription-associated risks include high number of drugs prescribed, complexity of the clinical condition and prescriptions administered within and outside the hospital environment ¹².

Annually, an estimated 2.6 million deaths occur due to ADEs associated with healthcare in hospitals worldwide. Adverse events constitute one of the leading causes of death and disability in patients, constituting incidents which cause patients harm, especially hospitalized older adults²⁰.

A cross-sectional study involving medication-related problems/errors as reported to the Dutch medication incident registry, found that these cases are commonly related to confusing product characteristics, packaging issues such as the lack of a single unit package for an oncolytic product, or incorrect or incomplete user instructions¹⁶.

These findings underscore the importance of patient safety policies, such as the National Program for Patient Safety (PNSP), established in 2013 by the Brazilian Health Ministry, aimed at addressing the group of healthcare areas with quality and patient safety issues, including those related to medications. The program is intrinsically associated with care quality and has garnered international recognition, providing a valuable service for patients, families, managers and health professionals with the aim of safer care¹¹.

In a Dutch study, Karapinar-Çarkit et al.¹⁶ found that the care practice of professionals involved in providing care to hospitalized older adults was unpinned by valorization, conciliation of medications and advising patients on the safety of medications. Thus, at hospital discharge, the medication regimen is discussed with patients and information tailored to their needs.

Enhancing the quality of medication use and safety are priorities for prescribers working with older adults. As with all potential drug interactions identified in the present study, the importance of the role of nursing professionals is clear, as being best placed to contribute to the safety and effectiveness of drug therapy, critically assessing prescriptions and proactively identifying possible drug interactions. In addition, this prevents the occurrence of adverse events together with the multidisciplinary team²¹.

Based on the analyses of the publications, the results show that, in order to tackle the problems and challenges related to the safety of medications, as well as the high mortality rates, nursing professionals should seek to constantly improve their technical and scientific knowledge on patient safety.

These professionals should also establish knowledge and correct procedure in care provision as ethical principles, particularly with respect to the administering of medications¹¹-¹⁸.

CONCLUSION

The mapping of scientific output has provided an overview of a variety of different studies whose aim was to implement actions targeting medication safety of hospitalized older adults. The present review identified strategies for preventing medication errors in the hospital setting. Strategies should be devised to attend older adults swiftly and safely, given that the implementation of these measures in the hospital routine can reduce complications, such as adverse events, drug interactions and prolonged hospital stays.

Future studies to further discussions on medication safety of older adults in the hospital context are warranted. This subject should be further studied and preventive measures adopted for monitoring the use of medications.

Taken together, these results reaffirm the need for professionals to be informed and prepared with respect to “care aimed at medication safety”, in response to the growing incidence of drug interactions, ADEs and deaths associated with these errors, and that holding knowledge on patient safety is fundamental for resolutive quality health care.

• There was no funding for the execution of this work.
• DATA AVAILABILITY
  The complete dataset underpinning the results of the present study are available on Figshare and can be accessed at https://doi.org/10.6084/m9.figshare.25790502.

References

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Edited by

• Edited by: Camila Alves dos Santos

Data availability

The complete dataset underpinning the results of the present study are available on Figshare and can be accessed at https://doi.org/10.6084/m9.figshare.25790502.

Publication Dates

• Publication in this collection
  15 July 2024
• Date of issue
  2024

History

• Received
  03 Feb 2024
• Accepted
  24 Apr 2024