Annals of Long Term Care

Adverse drug events (ADEs) are defined by the Institute of Medicine (IOM) as, “injuries resulting from a medical intervention related to a drug.”¹ Institutionalized elderly experience ADEs at a rate as high as 10.8 events per 100-patient months, often as a result of polypharmacy, multiple comorbid illnesses, and difficulty with monitoring prescribed medications.^2-4 This translates into approximately 135 ADEs each year in an average-size nursing home (NH; bed size of 105), or approximately 2 million events a year among all U.S. NH residents. ADEs represent the most clinically significant and costly medication-related problems in NHs, and are associated with 93,000 deaths a year and as much as $4 billion of excess healthcare expenditures.^5-6 Despite the consequences and costs associated with ADEs, the vast majority of these events go undetected using traditional methods, including comprehensive chart reviews, direct observation, and voluntary reporting. Therefore, alternative surveillance strategies are needed in NHs to supplement existing detection strategies and minimize the potential consequences of ADEs.

The trigger tool methodology, developed in part by the Institute of Healthcare Improvement (IHI), greatly simplifies the chart review process by allowing rapid and systematic examination of charts to extract relevant data for the detection of potential ADEs. The technique, which requires minimal training, appears to increase the rate of ADE detection 50-fold over traditional reporting methods.⁷ The triggers themselves represent specific events including the ordering of certain medications (eg, antidotes such as vitamin K), the results of certain laboratory studies (eg, supratherapeutic serum medication concentrations such as digoxin level), and change in clinical status or new sign or symptom (eg, drug-induced fall or drug-related rash). Since the triggers are likely to differ based on specific clinical setting, multiple IHI trigger tools have been developed including those for mental health settings, adult inpatients, adult outpatients, adult intensive care units, adult perioperative care units, pediatric inpatients, and neonatal intensive care units.⁸ Many of the clinical setting-specific trigger tools have been successfully used to demonstrate the benefits of low-cost error detection strategies that produce consistent, reliable, and relevant data.^9-13

Recently, a study was completed to develop a consensus list of agreed upon laboratory, pharmacy, and Minimum Data Set (MDS) 2.0 triggers to expand the use of the trigger tool methodology to the NH setting.¹⁴ The authors conducted a comprehensive literature search for potential ADE triggers, followed by an Internet-based, two-round, modified Delphi survey of physician, pharmacist, and advanced practitioner experts in geriatrics. Panelists reached consensus agreement on 40 triggers: 15 laboratory/medication combinations, 12 medication concentrations, ten antidotes, and three Resident Assessment Protocols (RAPs). Highest consensus scores (4.6; 95% CI, 4.4–4.9 or 4.4–4.8) were for: naloxone when taking opioid analgesics; phytonadione when taking warfarin; dextrose, glucagon, or liquid glucose when taking hypoglycemic agents; medication-induced hypoglycemia; supratherapeutic international normalized ratio when taking warfarin; and triggering the Falls RAP when taking certain medications.

The IHI formally adopted this set of 40 triggers as the “Nursing Home Adverse Drug Event Trigger Tool.”¹⁵ We suggest that this tool be incorporated into the consultant pharmacist medication regimen review (MRR) process. The State Operations Manual provides a definition for MRR (ie, F428) as a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences.