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n 1999, the Institute of Medicine (IOM) reported that between 44,000 and 98,000 people die annually as a result of preventable medical errors in the hospital setting.1 Among the most commonly occurring errors are adverse drug events and mistaken patient identity.1 In the hospital setting alone, the IOM estimates the costs of preventable medical errors to range between $17 billion and $29 billion annually. Medical errors including medication errors and adverse drug events have been documented across the continuum of care as well.
       In an article by Kelly, the author defines a medication error as any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, the patient, or the consumer.2 Kelly proposes that elderly patients have a higher risk of experiencing adverse drug events that may be fatal, permanently disabling, or life threatening compared to younger patient populations.2 The author attributes this increased risk to the fact that many elderly patients take more medications than younger patients, and elderly patients have reduced renal and liver function.2
       In 1993, Hyde, et al., conducted a study of medication management in Massachusetts assisted living facilities.3 In 12 facilities with 102 enrolled patients, the authors studied quality of life related to medication assistance, appropriateness of medication regimens, and error rates of medication administration.3 Of the patients enrolled in the study, 93 percent were taking >= 10 medications. Central nervous system drugs, cardiovascular drugs, gastrointestinal drugs, and pain medications were among the most common medications taken by the patients in this study. Adapting the Health Care Financing Administration’s methodology used in nursing facilities, outcomes measured included errors in right person, right drug, right dose, right time, with or without food, and technique. The authors examined medication administration policies between the participating facilities and found that the policies ranged from extremely informal to a complete medication administration policy. In some facilities, this meant that caregivers were removing patient medications from the pharmacy-provided containers and placing the medications in daily or weekly distribution containers or souffle cups out of sight of the residents. The types of storage and security systems also varied from facility to facility. Some medications were stored in the original pharmacy-provided containers, while some were placed in weekly pillboxes that were filled by patients’ family members. Other facilities used unit-dose or compliance packaging.
       The statistics in this small study demonstrate that the rate of polypharmacy in the elderly, or the incidence of patients taking multiple medications, is high. In the near future, the elderly population will grow significantly as the baby-boom generation ages. As the population of baby-boomers ages and the foreseeable need for extended care increases, the need for effective medication management will also increase.
       Using a multidisciplinary team approach to managing or reducing polypharmacy is important regardless of healthcare setting. Among the factors to be determined prior to implementing a plan of action are the rate of polypharmacy, the rate of unnecessary medication, and the rate of potentially harmful drug interactions. Realistically, once a successful plan to manage or reduce polypharmacy has been implemented, there will still be residents on multiple medications and a need for an effective way to dispense medications to reduce errors.
       Medication carts, specifically a decentralized approach to medication distribution, are one approach to correcting problems associated with medication distribution. Cart systems are already utilized in some care settings. In the 2002 American Society of Health-System Pharmacists (ASHP) national survey of pharmacy practice in hospital settings, a sample of pharmacy directors in 1,101 general and children’s medical-surgical hospitals in the United States was surveyed by mail.4 The survey had a response rate of 46.7 percent. The results of the survey found that 80 percent of hospitals had a centralized inpatient dispensing system, but 44 percent were planning to become more decentralized. Automated dispensing cabinets were used by 58 percent of hospitals with decentralized drug distribution systems.
       An example of effective use of medication carts was outlined by Hand and Pang.5 The authors implemented a decentralized drug distribution system with master medication carts utilized by two roving pharmacists who worked closely with the nursing staff in the hospital. Within the medication cart were pharmacy medication profiles, and at each nursing unit the pharmacist reviewed patient medication profiles, filled new drug orders, resolved missing medications and discrepancies, and consulted with the nursing staff. Unit dose drawers were filled in the central pharmacy and exchanged once daily. Each medication cart held about 300 medications, which made up approximately 95 percent of the medications needed by the 340 patients served by the two carts.
       Along with a multidisciplinary approach to reducing or managing polypharmacy in the elderly population, an effective medication distribution system may not only organize the distribution process and reduce errors, it may also save caregiver time and costs to the facility. The approach a facility takes and system it implements will be unique to the facility and must accommodate the needs of patients, families, and caregivers alike.