Table 4 Potential clinical implications of medication discrepancies detected and resolved by the 15 intervention pharmacists at the geriatric center
Discrepancies identified | Description of medication discrepancy | Potential clinical implications of discrepancy | Step taken by pharmacist | Physician’s response to the query raised | n (%) | % Accuracy |
|---|---|---|---|---|---|---|
Unprescribed medications/Self-medication | Took Tab Prednisolone recommended by a friend for pain | Worsening of disease condition | Patients were advised to discontinue the specific unprescribed medications due to potential adverse events. | Not required | 1 (1.3) | |
Antibiotics | Disruption of normal microbial flora | Not required | 11 (14.7) | |||
Tab Ketoconazole | Possible liver impairment, stomach pain, skin rash, orthostatic hypotension | Not required | 1 (1.3) | |||
Tab Potassium | Risk for cardiac arrhythmias | Not required | 1 (1.3) | |||
Cap Omeprazole | Risk for pneumonia | Not required | 1 (1.3) | |||
Antihypertensive medications | Risk for hypotension | Not required | 4 (5.3) | |||
NSAIDs and other pain relief medications | Risk for end organ impairment especially the kidneys | Not required | 13 (17.3) | |||
Anxiolytics | Increased risk for falls | Not required | 1 (1.3) | |||
Took opioid pain relief medications | Dependence | Not required | 2 (2.7) | 100% | ||
Total | 35 (46.7) | |||||
Duplication | Two different Atorvastatin taken together | Increased risk for adverse medication reactions Risk for end organ impairment | Patients were advised to discontinue the duplicate medication due to potential adverse events. Referred to physician | Not required | 3 (4.0) | |
Two brands of Cap Doxycycline taken together | Not required | 1 (1.3) | ||||
Two NSAIDs taken together | Not required | 2 (2.7) | ||||
Two brands of Cap Omeprazole taken together | Not required | 1 (1.3) | ||||
Duplicates of antihypertensive medications | Hypotension risk | Not required | 8 (10.7) | |||
Duplicates of Tab Metformin taken together | Hypoglycemia risk | Not required | 3 (4.0) | |||
Aspirin and Clopidogrel taken together | Risk for bleeding | Not required | 2 (2.7) | |||
Tab Potassium and Tab Spironolactone taken together | Risk for cardiac arrhythmias | Tab Potassium withdrawn | 1 (1.3) | 80.8% | ||
Total | 21 (28.0) | |||||
Different dose/ frequency of administration | Tab Nifedipine 30mg bd vs daily | Hypotension risk | Patients were asked to take appropriate doses | Not required | 1 (1.3) | |
Higher dose of statins taken by patient | Risk for adverse effects | Not required | 2 (2.7) | |||
Higher dose of diabetes medications taken | Hypoglycemia risk | Not required | 2 (2.7) | |||
Tab Metformin 500mg bd vs tds | Suboptimal dose | Not required | 1 (1.3) | 100% | ||
Total | Not required | 6 (8.0) | ||||
Duration | Patient taking discontinued antibiotics | Disruption of normal microbial flora | Medications withdrawn | Not required | 2 (2.7) | |
Patient taking discontinued PPIs | Risk for pneumonia | 3 (4.0) | 83.3% | |||
Total | 5 (6.7) | |||||
Substitution | Tab Aspirin vs Tab Clopidogrel | Gastric ulceration risk | Referred to physician | Tab Clopidogrel retained and Aspirin discontinued | 1 (1.3) | |
Tab S-Amlodipine 5mg vs Tab Amlodipine 5mg | Hypotension | Referred to physician | Tab Amlodipine 5mg retained | 1 (1.3) | ||
Herbal remedies substituted for prescribed OHAs | Poorly controlled diabetes | Patient advised to reinstitute OHAs | Not required | 1 (1.3) | ||
Herbal remedies vs Antihypertensive medications | Poorly controlled hypertension | Not required | 1 (1.3) | |||
Tab Bisoprolol + Tab Ramipril substituted by patient for Tab Uperio® | Worsening heart failure | Referred to physician | Patient counseled on adherence; Bisoprolol + Ramipril discontinued | 1 (1.3) | ||
Tab Simvastatin 40mg vs Tab Atorvastatin 40mg | Suboptimal dose | Referred to physician | Tab Atorvastatin retained, Simvastatin discontinued | 1 (1.3) | 85.7% | |
Total | 6 (8.0) | |||||
Omission | Tab Atorvastatin | Increase risk for CVD | Referred to physician | Tab Atorvastatin prescribed | 1 (1.3) | |
Arthritis medication | Poor quality of patient’s life | Referred to physician | Diclofenac prescribed | 1 (1.3) | 40% | |
Total | 2 (2.7) |