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Avoiding use of contraindicated medications


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After reading this article, you will be able to:

  • Identify the standards that apply to contraindicated medications
  • Describe methods by which team members can help avoid contraindications

Why is review of "other contraindications" important and what are some examples? Who is required to check for them? What tools can make identifying them easier, increasing the likelihood of both patients' safe use of medications and compliance with applicable elements of performance (EP)?

Requirements

The Joint Commission has three standards containing EPs that address medication contraindications.

The Joint Commission assigns direct impact requirements to EPs that are "likely to create immediate risks to patient safety." Two EPs have direct impact requirements: Medication Management standard MM.05.01.01, EP 9, and MM.06.01.01, EP 6. Organizations that are found by The Joint Commission to be noncompliant with direct impact EPs are subject to more intensive review and potentially a recommendation for an adverse accreditation decision. EPs for MM.05.01.01 require pharmacists to review medication orders for ­appropriateness.

Previously, EP 5 of former Medication Management standard 4.10 had lumped together a substantial list of items to be reviewed, from "appropriateness of the drug, dose, frequency, and route of administration" to "other relevant medication-related issues or concerns." The Joint Commission split the items from MM.4.10's EP 5 in 2008, renumbered the standard MM.05.01.01, and expanded the number of EPs from one to 11.

In package inserts, medication contraindications typically include the following verbiage: " is contraindicated in any patient who has shown a hypersensitivity to or any of its other ingredients."

Regarding MM.05.01.01, EP 4's review of the profile for "patient allergies or potential sensitivities" is separate from EP 9's review of "other contraindications." So, the term "other contraindications" excludes allergies and sensitivities.

Tools

Administering a medication that is contraindicated may harm the patient. To avoid dispensing and administering contraindicated medications, the interdisciplinary team works together using patient safety tools and professional judgment. The Joint Commission's Medication Management standards require both pharmacist review for order appropriateness (including but not limited to contraindications) plus verification that the medication isn't contraindicated.

The practitioner who is to administer the medication also performs verification. The interdisciplinary team members' combined efforts reduce the likelihood that a patient will receive contraindicated medications. Current computerized physician order entry (CPOE) systems are often unable to alert users when there are contraindications, also referred to as "drug-disease interactions." Thus, team members for the most part perform this action without the assistance of computer alerts. Below are some examples of various team members' efforts:

  • The nurse or other practitioner enters an admission assessment at the time of admission. The assessment includes documentation that the patient is pregnant.
  • Entry of the assessment enables team members involved in the patient's care to be aware of the patient's health conditions and to safeguard the patient.
  • Expanding on this example, the pharmacist might receive a programmed computer system alert if anastrozole (contraindicated in women who are or may become pregnant) is ordered for a patient documented as pregnant; the pharmacist should contact the prescriber for authorization to discontinue the order.
  • The prescriber avoids prescribing medications that are contraindicated for the patient. An example of a tool used to assist prescribers with avoiding a contraindicated medication is a mini order set in which a medication's contraindications appear preceding the CPOE order check box for the medication.
  • The pharmacy and therapeutics committee could review its formulary for medications that are more likely to be contraindicated in its patient population.
  • Mini order sets for selected medications could be built in CPOE to include a listing of contraindications beyond the typical "hypersensitivity to or any of its other ingredients." This would remind prescribers to consider all contraindications.
  • The pharmacist reviews medication orders for appropriateness. The review includes but is not limited to contraindications. Tools to avoid common clinical contraindications may include programmed alerts, (such as those that access electronic values for the patient's demographics), lab results, and admission assessment. Alerts may be used to force or require an entry into the record by the team member before proceeding is possible.
  • The respiratory therapist, nurse, or another practitioner authorized to administer medications serves as a final patient safety check, verifying that no contraindications exist before administering the medication.
  • To check for contraindications, the practitioner might access some tools, such as online links to the package insert or to Micromedex®, especially when the practitioner is not familiar with the medication ordered. Conveniently, such tools might be directly accessible from the electronic medical record.

In conclusion: Practitioners can safeguard the patient's health by reviewing and verifying that each medication ordered for the patient is not contraindicated. By doing so, they will also demonstrate compliance with applicable Joint Commission standards.

Prescribing: A mini order set addressing a single medication could be developed to reduce the likelihood of ordering of a contraindicated medication.

  • Known or suspected pregnancy or as a diagnostic test for pregnancy
  • Undiagnosed vaginal bleeding
  • Known or suspected malignancy of breast
  • Active thrombophlebitis, or current or past history of thromboembolic disorders, or cerebral vascular disease
  • Significant liver disease
  • Known hypersensitivity to Depo-Provera CI (medroxyprogesterone acetate or any of its other ingredients)