The "Top 10" Drug Errors and How to Prevent Them
Introduction
More than 7000 pharmacists gathered in Atlanta, Georgia, for the American Pharmacists
Association (APhA) 2007 Annual Meeting to explore new challenges and the latest advances in
pharmacy. Among the more than 80 programs presented were several sessions that dealt with
reducing medication errors and adverse events, a topic that has received widespread media
attention.
In addition, the author of a critically acclaimed book on drug errors was on-site to discuss his
book and to autograph copies for attendees. Michael R. Cohen, RPh, MS, ScD, DPS, is President
of the Institute for Safe Medication Practices (ISMP) and author of Medication Errors, which was
published by the APhA.
Conference participants learned about common medication errors, steps to avoid or eliminate
them, strategies to communicate effectively with prescribers, and ways to recognize and reduce
stressful situations in the pharmacy workplace that may contribute to medication errors.
"Top 10" Medications Involved in Adverse Events
The Institute of Medicine (IOM) published findings in 1999 on the quality of healthcare in
America. That report, "To Err Is Human: Building a Safer Health System," concluded that as many
as 7000 Americans die from medication errors each year.[1] In July 2006, the IOM released a new
report, "Preventing Medication Errors," stating that the frequency of medication errors and
related injuries was still a serious concern.[2]
A common question that arises is: "What drugs are most often involved in medication errors?"
Matthew Grissinger, RPh, FASCP, is a medication safety analyst with ISMP, the nation's oldest
voluntary drug error reporting program, located in Huntingdon, Pennsylvania. His session on
"The Top 10 Adverse Drug Reactions and Medication Errors" drew an audience that filled the
meeting hall.[3]
Grissinger first referred to a study that identified the 10 drugs most commonly implicated in
adverse events requiring treatment in a hospital emergency department (ED).[4] The study also
documented the frequency with which each of the 10 drugs was involved:
1. Insulin (8%);
2. Anticoagulants (6.2%);
3. Amoxicillin (s) (4.3%);
4. Aspirin (2.5%);
5. Trimethoprim-sulfamethoxazole (2.2%);
6. Hydrocodone/acetaminophen (2.2%);
7. Ibuprofen (2.1%);
8. Acetaminophen (1.8%);
9. Cephalexin (1.6%); and
10. Penicillin (1.3%).
Unintentional overdoses made up 40% of these ED visits, representing the most prevalent
mechanism of injury by far. Other mechanisms included side effects and allergic reactions. Some
of the drugs on this list are especially common (eg, hydrocodone and amoxicillin), so the sheer
volume of prescriptions written is a major factor.
The elderly also play a key role in this issue, as they account for 34% of all written prescriptions.
The average number of prescriptions for an elderly person in the United States in 2000 was 28.5
per year. That number is estimated to reach 38.5 by the year 2010. Almost a quarter million
seniors are hospitalized every year due to reactions between prescription and over-the-counter
(OTC) medications.
Common misuses that lead to adverse drug events are taking incorrect doses, taking doses at
the wrong times, forgetting to take doses, or stopping the medication too soon (all
nonadherence issues). An example of commonly misused medications can be seen with arthritis
therapies. Seventy million Americans suffer from arthritis and joint pain, which translates into
30 million people taking nonsteroidal anti-inflammatory drugs, either prescription or OTC.
Misuse of these drugs leads to 103,000 hospitalizations and 16,000 deaths per year.
Unnecessary use of nonsteroidal anti-inflammatory drugs also increases avoidable side effects,
such as dyspepsia, peptic ulcer, and gastrointestinal bleeding.
Another high-volume prescription class is the antibiotics. This group represents significant
inappropriate prescribing: Twenty-three million antibiotic prescriptions are written for colds,
bronchitis, and upper respiratory infections each year, Grissinger said, despite the fact that
antibiotics don't kill viruses.
Top 10 Medications Involved in Drug Errors
A somewhat different top 10 list identifies medications that are most commonly misused or
mishandled in some way by healthcare professionals. This list is based on information from the
United States Pharmacopoeia (USP), which maintains a database of medication errors that are
reported anonymously. The figures represent drug errors associated with acute hospital care[5]:
1. Insulin (4% of all medication errors in 2005);
2. Morphine (2.3%);
3. Potassium chloride (2.2%);
4. Albuterol (1.8%);
5. Heparin (1.7%);
6. Vancomycin (1.6%);
7. Cefazolin (1.6%);
8. Acetaminophen (1.6%);
9. Warfarin (1.4%); and
10. Furosemide (1.4%).
Hospitals and healthcare systems use the USP database to track medication errors and identify
trends. Drug errors are defined as unintentional acts committed by healthcare providers
involving medications. Grissinger noted that comparable data are unavailable for outpatient
care.
The number 1 error-prone medication is insulin. In fact, a 1998 ISMP study found that 11% of all
serious medication errors involve insulin misadministration.[6] Errors include mixing up products
with similar packaging (look-alike products); confusing generic listings on computer databases;
similarity in names (eg, Humalog and Humulin); and most importantly, confusing the
abbreviation "u" for units with the number 0. ISMP reports that these errors have been
occurring for over 30 years.
The second drug on this list is morphine, which can be extrapolated to include all opioids,
Grissinger said. Similar names for some of these drugs often cause confusion, such as:

Avinza and Evista;

Morphine and hydromorphone;

Oxycontin and MS Contin;

Hydrocodone and oxycodone; and

Oxycodone and codeine.
In the community pharmacy, these drugs often are stacked close together in a locked area, and
many have similar packaging, making it easy to grab the wrong one when dispensing. Another
common mistake is mixing up oxycodone with oxycodone ER (extended release), especially in
handheld device order entry.
Morphine oral solutions cause many problems because of the multiple concentrations that are
available, all stored close to each other. For example, it would be easy to confuse "mL" with
"mg"; using 5 mL of morphine 20 mg/mL (100 mg) instead of the prescribed 5 mg (0.25 mL)
would lead to overdosing the patient. Alternatively, an intended dose of 1 mL of morphine 20
mg/mL (20 mg) might be given as 1 mL of 10 mg/5 mL (2 mg), thus underdosing the patient.
Grissinger also reported a case in which Avinza (morphine ER caps) 30 mg was misinterpreted
and dispensed as "qid" (4 times daily) instead of "qd" (once daily), causing a near-fatal overdose.
Acetaminophen is another drug on the error list that causes many problems. It is available in
many different strengths, and various measuring devices are available for dispensing it. In
addition, it is found in many combination medications, both prescription and OTC. Prescription
labels of combination products with acetaminophen can be very confusing for the patient. For
example, hydrocodone 10/650 has 650 mg of acetaminophen, but many patients would not
know how to interpret that.
Grissinger reminded the audience that acetaminophen can be toxic, even though it is sold OTC.
A recent study showed that acetaminophen-induced liver toxicity accounts for more than 40%
of US cases of acute liver failure.[7]
Antibiotics are the next big group of drugs associated with medication errors. As with opioids,
the liquid dose concentrations increase the risk for mistakes. Confusion over measurements in
"mL" vs "tsp" (teaspoons) can cause a 5-fold overdose or underdose if undetected. In one case,
for example, azithromycin suspension was dispensed with directions to take 2.5 tsp daily
(equivalent to 12.5 mL) instead of the intended 2.5 mL daily, Grissinger reported. The entire
contents of the bottle were administered according to the labeled instructions, and the child
developed diarrhea.
Reconstituting antibiotics can also be problematic. Pharmacists have mistakenly reconstituted
antibiotic suspensions with alcohol instead of distilled water.
System Errors May Interfere With Individual Efforts
Most healthcare professionals have learned the "5 rights" of safe medication use: the right
patient, the right drug, the right time, the right dose, and the right route of administration.
However, in his book Medication Errors, Michael Cohen wrote that these "rights" focus on
individual performance and can overlook system errors. Examples of system errors are poor
lighting, inadequate staffing, handwritten orders, doses with trailing zeros, and ambiguous drug
labels. All of these can prevent healthcare professionals from verifying the 5 rights.[8]
Experts at ISMP have identified 10 key "system" elements that most influence medication use,
reported Donna Horn, RPh, DPh, ISMP Director, Patient Safety - Community Pharmacy. Systems
factors play a major role in increasing the likelihood that an individual will make an error.
Deficiencies in any of these system elements can lead to medication errors[9]:
1. Patient information (age, weight, allergies, diagnoses, and pregnancy status);
2. Drug information (up-to-date information readily available);
3. Communication (collaborative teamwork between all healthcare members and the
patient);
4. Drug labeling, packaging, and nomenclature (limit look-alike and sound-alike drug
names, confusing packaging);
5. Drug standardization, storage, and distribution (restricting access to high-alert drugs);
6. Medication delivery device acquisition, use, and monitoring;
7. Environmental factors (poor lighting, cluttered work spaces, noise, interruptions,
nonstop activity, and deficient staffing);
8. Staff competency and education;
9. Patient education; and
10. Quality processes and risk management (systems are needed for identifying, reporting,
analyzing, and reducing the risk for medication errors with a nonpunitive culture of
safety).
When an error occurs, it is tempting to blame individuals, Horn said. A "systems approach,"
however, looks at the whole system rather than individual errors. For instance, failures in the
design or implementation of systems can lead to excessive reliance on memory, lack of
standardization, inadequate access to information, and poor work schedules. Thus, with a
systems approach, accountability is expanded to include anyone who had any influence over the
error, setting the stage for broader solutions.
How Can We Prevent Medication Errors?
Nearly half of all adverse drug events have some form of "preventability," and many do not
represent errors of commission but, rather, errors of omission. This implies a failure on the part
of someone (pharmacist, physician, patient, or the interactions between these groups) to detect
certain factors that most likely led to the adverse event. These factors include:
1. Failure to detect a disease state contraindication to the drug therapy;
2. Failure to detect a significant drug interaction;
3. Failure to detect a significant drug allergy;
4. Failure to prescribe the correct dose for a specific patient;
5. Failure to monitor drugs with narrow therapeutic indexes; and
6. Patient knowledge deficits.
Many of these can be avoided by spending a few minutes counseling the prescriber and/or the
patient. Communication is key, Horn said. Barriers to effective communication include illegible
handwriting, abbreviations, verbal orders, ambiguous orders, and fax or ePrescribing problems.
When communicating with prescribers, pharmacists should identify the issues clearly and
concisely, said Marialice Bennett, RPh, FAPhA, Professor and Pharmacy Director of the
University Health Connection at Ohio State University in Columbus, Ohio.[10] She offered these
suggestions for such discussions:

Outline the specifics of the problem;

Keep focused on the patient;

Provide possible solutions;

Ask for prescriber feedback; and

Document the final decision.
Conflict can lead to poor communication, which can hinder the discovery of medication errors,
she said. Conflicting opinions about patient care should be handled objectively and
professionally. The ISMP recommends that healthcare organizations create a code of conduct
that encourages behaviors supportive of team cohesion, staff morale, and sense of self-worth
and safety.
Managing Stress in a Workplace Full of Risks
Pharmacy work can be highly stressful, and pharmacists who are under extreme stress are at
risk for more errors, said Henry Cobb, PhD, MD, BS, CDM, Clinical Associate Professor, University
of Georgia College of Pharmacy, Athens, Georgia.[11] Pharmacists need to identify their own
personal stress triggers and anticipate their responses to stress. He presented 5 questions that
could be used for such self-analysis:

How do you know whether stress is a problem for you?

What is causing most of your stress?

Is your supervisor aware of the problem?

How do you deal with stress?

What can you do to reduce the impact of stress?
Cobb described 3 ways that most workers deal with stress on the job. The active-cognitive
person draws on past experience, taking one thing at a time. He or she considers several
alternatives, looking for the positive side, and is able to step back and be objective. The activebehavioral person finds out more about the situation and takes positive action. He or she may
talk with a friend or spouse, exercise more, or talk with a professional in order to find a solution.
The person who practices avoidance keeps feelings to himself or herself, prepares for the worst,
takes out frustrations on others, and eats or smokes more to reduce tension.
Identifying the phases of stress can be helpful. Phase 1, or the warning phase, includes vague
anxiety, depression, and apathy. Phase 2, or mild stress, includes sleep disturbances, muscle
aches, and irritability. Entrenched stress, or phase 3, includes alcohol abuse, depression, ulcers,
withdrawal, and marital discord. Phase 4, or severe stress, includes asthma, heart problems,
severe depression, violence (or suicide), paranoia, and uncontrolled anger. It is important to
note that professional help is needed for phases 3 and 4.
To reduce stress on the job, Cobb presented this list of quick strategies:
1. Discontinue caffeine;
2. Engage in regular exercise (30 minutes 3 times weekly);
3. Practice relaxation-breathing exercises (20 minutes 2 times weekly);
4. Get adequate sleep (try going to bed 30 minutes earlier than usual);
5. Nurture your leisure time, engage in hobbies;
6. Set realistic expectations and avoid perfection;
7. Reframe your outlook to be optimistic, not pessimistic;
8. Eat right;
9. Maintain a sense of humor;
10. Talk and vent;
11. Write down your thoughts;
12. Avoid unhealthy habits (such as alcohol);
13. Set limits (learn to say "no"); and
14. Get help from a professional.
In some cases, however, a person who is in a job that does not match his or her personality and
preferences may need to switch to another role or job, Cobb added. That may be a much better
stress-reduction technique than any other.
References
[ CLOSE WINDOW ]
References
1. Kohn K, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System.
Washington, DC: National Academy of Sciences, National Academy Press; 2000.
2. Committee on Identifying and Preventing Medication Errors. Board on Health Care
Services. Institute of Medicine of the National Academies. In: Aspden P, Wolcott J,
Bootman JL, Cronenwett LR, eds. Preventing Medication Errors: Quality Chasm Series.
Washington, DC: The National Academies Press; 2006.
3. Grissinger M. Top 10 adverse drug reactions and medication errors. Program and
abstracts of the American Pharmacists Association 2007 Annual Meeting; March 16-19,
2007; Atlanta, Georgia.
4. Budnitz DS, Pollock DA, Weidenbach KN, Mendelsohn AB, Schroeder TJ, Annest JL.
National surveillance of emergency department visits for outpatient adverse drug
events. JAMA. 2006;296:1858-1866.
5. United States Pharmacopeia Web site. Available at: http://www.usp.org/ Accessed April
27, 2007.
6. Institute for Safe Medication Practices (ISMP). ISMP action agenda: Oct-Dec 1998. ISMP
Medication Safety Alert! Available at: http://www.ismp.org/Newsletters/default.asp
Accessed April 1, 2007.
7. Larson AM, Polson J, Fontana RJ, et al; Acute Liver Failure Study Group. Acetaminopheninduced acute liver failure: results of a United States multicenter, prospective study.
Hepatology. 2005;42:1364-1372.
8. Cohen M, ed. Medication Errors. 2nd ed. Washington, DC: American Pharmacists
Association; 2007:5-36.
9. Horn D. Top 10 adverse drug reactions and medication errors. Program and abstracts of
the American Pharmacists Association 2007 Annual Meeting; March 16-19, 2007;
Atlanta, Georgia.
10. Bennett M. Communicating drug therapy recommendations to prescribers. Program and
abstracts of the American Pharmacists Association 2007 Annual Meeting; March 16-19,
2007; Atlanta, Georgia.
11. Cobb H. Dealing with stress: decompression strategies for pharmacists. Program and
abstracts of the American Pharmacists Association 2007 Annual Meeting; March 16-19,
2007; Atlanta, Georgia.
New Opportunities in Medication Therapy Management
Introduction
As part of Medicare's new prescription drug coverage, pharmacists now have more
opportunities to develop patient-centered programs and to get paid for their efforts. A variety
of services qualify under Medicare's definition of "medication therapy management" (MTM),
and their goal is to optimize therapeutic outcomes for Medicare beneficiaries.
Various aspects of MTM services were discussed in sessions at the American Pharmacists
Association (APhA) 2007 Annual Meeting, held March 16-19, 2007, in Atlanta, Georgia. Pain
management and diabetes care are 2 key areas in which pharmacist involvement can improve
health outcomes. Speakers also addressed related business issues, such as marketing new MTM
programs and learning to communicate effectively with prescribers.
Participants attending MTM sessions also shared their own experiences in practice, and almost
everyone agreed that MTM represents a significant positive opportunity for the pharmacy
profession.
Emerging Dynamics in Pain Management
Why should pharmacists get involved in pain management?
The reasons are many: In the community setting, a pain management service could benefit up to
80% of the walk-in public and likely would generate strong customer loyalty.[1] Many doctors
would be eager to work with a pharmacist-run pain management service. It would also offer
financial rewards, due to the sheer volume of patients with chronic or acute pain, and to
reimbursement formulas under Medicare's MTM program.
Another important incentive is the potential to reduce an enormous amount of unnecessary
suffering. The scope of the problem is huge: One hundred five million Americans are dealing
with some type of chronic pain; 10% of them experience pain more than 100 days per year; and
50 million Americans are disabled due to chronic pain.[1]
In fact, pain is the leading reason for people to seek medical care. Unfortunately, pain treatment
is often inadequate, particularly in the elderly and minority populations, according to Kathryn
Hahn, PharmD, Affiliate Faculty, College of Pharmacy, Oregon State University, Corvallis,
Oregon, and Pharmacy Manager, Bi-Mart Pharmacy, Springfield, Oregon.
Various barriers prevent patients from receiving adequate pain treatment. In many cases, pain
cannot be managed properly by just 1 type of healthcare provider alone, Dr. Hahn explained.
Most patients with chronic pain require a multifaceted approach. Physicians and pharmacists
may need to involve psychologists, spiritual advisors, acupuncturists, or other caregivers.
However, basic education in pain treatment is lacking in many healthcare professions. Among
physicians, 88% have reported that the pain education that they received in medical school was
poor, and that residency training did not improve the situation. Pharmacists are also illprepared; 25% say that they are unable to address complex pain management concerns.
Drug diversion and abuse also are concerns among healthcare providers, Dr. Hahn said.
However, pharmacists should not let the fear of opioid diversion scare them away from
advocating for the proper use of such medications in patients who need them. In fact, many
patients who need opioids are not using them. Other patients are using short-acting
combination drugs, such as hydrocodone with acetaminophen, when a long-acting agent would
be more effective in avoiding peaks and troughs in drug levels, as well as associated anxiety and
pain.
Opioids are often underdosed, and patients may contribute to the problem by self-limiting these
medications out of fear of addiction or social stigma. Only a minority of patients overuse pain
medications for illegitimate reasons (10% to 15%), whereas the majority of pain patients are
undertreated.
The pharmacy profession is in the right place at the right time to help fix this tremendous
problem, Dr. Hahn said. The pharmacy is an accessible setting, and MTM makes it practical now
that reimbursement is available.
Different types of pain, including somatic, visceral, and neuropathic pain, must be treated with
different agents, and multiple agents are often required. For instance, when inflammation is
involved, an agent with anti-inflammatory properties should be used. For more information
about specific pain medications, Dr. Hahn recommended a collection of resources available
online in the APhA pain management library.[2]
The World Health Organization's analgesic ladder can be used to classify the pain as mild,
moderate, or severe.[3] This guide incorporates the use of opioids for moderate-to-severe pain,
and recommendations are based on pain severity, not on whether the patient is classified as
terminal. It is worth nothing that, although this approach is more than 25 years old, many
people still erroneously consider opioids appropriate only at the end of life.
MTM is separate from dispensing, although there can be some overlap, Dr. Hahn said. She
identified 5 core elements of an MTM service:

Review of a patient's medications.

Creation of a portable personal medication record (PMR) for the patient. Several
organizations have created useful PMR templates.

Development of a medication action plan identifying necessary steps to improve the
patient's health, including nonmedication aspects, such as physical activity and diet.

Intervention and/or referral: Pharmacists may make informal referrals to a physician,
pain psychologist, or other healthcare professionals; this is different from a formal
referral used by insurance companies.

Documentation and follow-up: Pharmacists should collect and record appropriate lab
values, track patients' progress, and record charges and billing. Over-the-counter
medications and complementary or alternative therapies also should be documented, as
these may represent a large component of a pain management routine.
To illustrate this process, Dr. Hahn reviewed the case of a patient who had previously led an
active life as a custom furniture maker. After experiencing a fall that caused multiple lumbar
fractures, the patient had untreated chronic pain, depression, anxiety, nausea, confusion,
insomnia, and a 50-pound weight gain. The patient described having severe pain "all the time"
that ranged from 7 to 10 on a 10-point pain scale. The pain was described as "stabbing and
aching" in the lumbar region and "burning" in the lower extremities.
When the patient first presented to the pharmacy, he was receiving methadone 3 times daily,
citalopram, quinapril, and a short-acting combination drug for breakthrough pain taken about 6
times daily. He had failed fentanyl patches, primarily because they wouldn't stay on.
Methadone was an ineffective agent for this patient and was poorly tolerated. In general, most
side effects of opioids and analogs are transient, except for constipation. However, patients
have individual responses to different agents, and this gentleman was suffering from persistent
nausea and confusion.
Dr. Hahn worked with the patient's physician to change the pain medicines to morphine
(titrated to effective dose) and duloxetine, for nerve pain and depression. The patient began to
work with a pain psychologist and was referred for physical therapy. He was also found to have
low testosterone levels, a complication from long-term opioid therapy, which was then
corrected.
In a video presentation, the pain psychologist described the consequences of physically active
people who experience industrial accidents and become disabled. Their prior level of activity
was part of their normal coping mechanism, which they lost in the accident. They also lost their
way of making a living and contributing to society. They are under suspicion for using opioids to
control their pain. The psychologist reported that it sometimes takes several sessions to
convince a patient to accept the use of opioids to reduce pain and regain function. Taking
multiple medications is another area of patient resistance; however, different mechanisms of
action may be required.
Dr. Hahn also discussed billing codes for MTM and appropriate follow-up; in the case that she
had described, the follow-up involved addressing adverse reactions and a testosterone injection
technique. She reported that the patient has improved (with pain at about 4 on a 10-point
scale), is sleeping better, is working with a physical therapist, and has lost weight; his depression
also has lifted.
The session inspired audience members to get involved in pain management. Because of the
new reimbursement potential, it is likely that new training and certification courses will be
developed to enable more pharmacists to provide pain management services.
Diabetes Care Represents Golden Opportunity for MTM
Another clinical area that is particularly suited for MTM is diabetes. Nonadherence is a
significant problem, and the costs of poor treatment are substantial for the patient and for
society. Half of patients with diabetes stay on their medications for 6 months or less, said Pam
Marquess, PharmD, East Marietta Drugs, Marietta, Georgia.[4] Most patients have significant
knowledge deficits and simply do not know how dangerous it is to let their blood glucose run
high. Correcting the knowledge deficit can increase medication adherence and help reach
therapeutic goals.
For each dollar spent on pharmacist-provided education for patients with diabetes, there is a
$2-$3 cost savings, primarily by reducing complications and hospitalizations, Marquess said.
Employers can be lobbied to save money by using pharmacist-provided MTM services.
Another speaker addressed this issue from the employer's perspective. Jim Astuto, Consultant,
formerly of Regional Healthcare Manager, Verizon Communications, Inc., Atlanta, explained why
that company enlisted a pharmacist-managed diabetes program to improve employees'
health.[4]
The huge costs associated with mismanaged chronic disease are a major motivation for
companies, Astuto said. Verizon's employee healthcare costs rose 7% to 12% annually at a time
when revenues were increasing only 3% to 4% a year. Half of those healthcare dollars go to
treatment and complications associated with diabetes, heart disease, and kidney disease, he
said.
Diabetes is a great example of how proper care can result in huge cost savings. Currently,
diabetes accounts for $135 billion annually in direct costs and another $65 billion in indirect
costs, he said. The average annual cost for 1 patient is over $15,000.
What is the cost difference between a well-controlled patient with a glycated hemoglobin (A1C)
level less than 7% vs a patient with an A1C level over 9%? The uncontrolled patient (which is
most patients) costs between $15,000 and $20,000. The patient with controlled diabetes may
have a higher prescription drug cost, but has a total treatment cost of about $7000. That means
a company saves about $10,000 per person per year if the disease is controlled. In addition, the
uncontrolled patient has a higher risk for complications, which result in even higher costs. From
the employer's side, managing diabetes well makes financial sense.
Why is diabetes so difficult to control? It depends on whom you ask. Some doctors blame the
patient, saying that they told the patient what to do and the patient just didn't do it. Most
doctors understand, however, that they can't educate or treat a patient with a complex disease
properly in the short amount of time they have with that patient. Pharmacists know that most
patients with diabetes don't know the basics about their condition or how to manage it. A
patient may need multiple oral medications or require insulin therapy; however, many choose
to start with only a single medication, and they may view insulin as a "punishment" for bad
behavior. Pharmacists should promote insulin as a valuable tool, rather than as a desperate lastditch measure.
Pharmacists providing MTM services can help change this picture, as they are the ones who see
the patients most often. When pharmacists are involved in diabetes care, they improve health
outcomes and cut costs.[5] The Asheville Project, an APhA-sponsored program that used
pharmacists to educate and monitor patients' drug therapies, found that participants with
diabetes had improved A1C levels, lower total healthcare costs, fewer days of missed work, and
increased satisfaction with pharmacist services.[6]
Thus, research has demonstrated that pharmacists can improve the health of patients with
diabetes and also cut costs; MTM programs now offer a way for them to get paid for that
involvement. Another motivation to involve pharmacists in diabetes management is the
expanding array of oral and injectable (noninsulin) medications used to treat type 2 diabetes.
These new medications are raising patients' overall drug costs, even though the risks and
benefits are not yet well defined. In some cases, prescribers are adding 2, 3, or 4 new
medications to a patient's regimen, often due to a lack of knowledge about proper insulin use.
Pharmacist-run clinics and MTM programs can help patients titrate to goal without unnecessary
hypoglycemia, a common concern of patients and prescribers. This will benefit both the patient
and society overall, through lower short-term costs as well as long-term costs associated with
complications. Thus, diabetes, MTM, and pharmacy can be a winning combination for all.
Creating Demand for MTM Services
Medicare guidelines require prescription drug plans to offer some kind of MTM services for
certain beneficiaries who take multiple medications. According to federal guidelines, however,
any "qualified healthcare provider" may provide and be reimbursed for MTM services. This
challenges the pharmacy profession to demonstrate that pharmacists have the specialized
knowledge to deliver the most beneficial MTM programs, said Marquess.[4]
In order to qualify for MTM services, Medicare beneficiaries must spend at least $4000 in annual
prescription drug costs. MTM programs are charged with serving patients who have "multiple
chronic" conditions, but drug plans may decide which particular conditions to target. They also
can determine the minimum number of medicines that each member must use to qualify for
their MTM program. Billing procedures initially were not defined, and reimbursement rates
reportedly varied significantly, but those discrepancies are beginning to normalize, Marquess
said.
How can pharmacies "get the word out" about their MTM programs? A good place to start is by
informing local doctors and nurses. Marquess offered a sample conversation between a
pharmacist and a nurse during a routine call to authorize a prescription refill:
Pharmacist: Did you know that our pharmacy is offering something called medication
management services?
Nurse: No, what is that?
Pharmacist: We call it MTM. We actually sit down with patients like Mrs. Jones who are taking
10 or more medications and have 4 or more disease states, and help resolve their drug
problems. We help them manage side effects. We help them with cost savings and formulary
issues, and things of that nature. If we are resolving these issues, they are going to stop calling
your office. The patient will be feeling better and doing better.
The staff in a doctor's office are likely to support a proposition that gets patients to stop calling
and "bugging" them.
Pharmacists in rural areas and small communities may be able to simply spread the word
informally to local doctors and nurses. That may be more challenging in urban areas, but
pharmacists there can also use their professional and social networks to advance their MTM
programs. A successful MTM program is based on relationships built with patients and
prescribers.
Although word of mouth is essential, pharmacists may also want to distribute brochures and use
other marketing tools. Some pharmacies are giving referral cards to area medical offices for
their patients who could benefit from MTM. One idea that works well, Marquess said, is to ask
doctors to refer their "trouble" patients with particular medical conditions. For instance, a
pharmacy that wants to build an MTM program for patients with diabetes may tell doctors to
refer their patients who have high A1C levels, and then offer to demonstrate improved
outcomes. Many doctors will welcome help with their difficult patients, especially when it's
offered at no cost to them.
Another way to promote an MTM program is to advertise it or write about it in a local
newspaper. For instance, some pharmacists write a drug therapy column or "Q&A" for their
local newspaper.
Effective communication with patients is also vital to building an MTM program, Marquess said.
After all, each patient may refer many others, so ensuring their satisfaction is essential.
A review of basic communication "do's and don't's" can be useful, especially for pharmacists
who are used to standing behind a counter:

Organize your thoughts before speaking to the patient.

Have the key points in front of you, which can be written as notes or as part of the
medication action plan.

Eliminate unnecessary information so that you don't overwhelm the patient.

Focus on the patient, using eye contact. Turning away from the patient gives a negative
impression. It is impossible to provide MTM services while answering the phones or
looking down the aisles.

Practice listening, and remember that it's okay to occasionally keep silent.

Relax and smile when appropriate.
When dealing with physicians, it's best to use terms, such as, "It is my opinion." For example: "It
is my opinion that this patient could benefit from saving money by switching to generics."
Follow up by asking, "What do you think?"
When you solve patients' medication problems and improve their lives, you have a patient for
life. They will be so excited about what you did for them that they'll tell their friends and
neighbors and help build your business. Patients rarely get to sit and talk with their doctors, so
this will be a unique experience for them.
In fact, Marquess said that she has yet to find a patient who hasn't loved receiving MTM, and
that sentiment was widely shared by those in the audience who are providing MTM services.
References
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References
1. Hahn K. Pain management and medication therapy management (MTM) services.
Program and abstracts of the American Pharmacists Association 2007 Annual Meeting;
March 16-19, 2007; Atlanta, Georgia.
2. American Pharmacists Association. Pain management library. Available at:
http://www.pharmacist.com/pain_management/pmp.cfm Accessed March 18, 2007.
3. World Health Organization. WHO's analgesic ladder. Available at:
http://www.who.int/cancer/palliative/painladder/en/ Accessed March 18, 2007.
4. Marquess P, Astuto J. Creating public and provider demand for MTM services. Program
and abstracts of the American Pharmacists Association 2007 Annual Meeting; March 1619, 2007; Atlanta, Georgia.
5. Kaveh G, Shojania KG, Sumant R, et al. Effects of quality improvement strategies for type
2 diabetes on glycemic control. A meta-regression analysis. JAMA. 2006;296:427-440.
6. Cranor CW, Bunting BA, Christensen DB. The Asheville Project: long-term clinical and
economic outcomes of a community pharmacy diabetes care program. J Am Pharm
Assoc. 2003;43:173-184.
Authors and Disclosures
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Author
Kathryn L. Hahn, PharmD
Affiliate Faculty, College of Pharmacy, Oregon State University, Corvallis, Oregon;
Pharmacy Manager, Bi-Mart Pharmacy, Springfield, Oregon
Disclosure: Kathryn L. Hahn, PharmD, has disclosed no relevant financial relationships.
Karen B. Shapiro, PharmD, BCPS
Clinical Pharmacist, Arcadian Health Plan, San Dimas, California
Disclosure: Karen B. Shapiro, PharmD, BCPS, has disclosed no
relevant financial relationships.
Editor
Christine Wiebe, MA
Editorial Director, Medscape Med Students, Medscape Pharmacists
Disclosure: Christine Wiebe has disclosed no relevant financial relationships.