Inpatient ART errors can cause long-term problems for HIV patients

Antiretroviral therapy is less complex than it used to be, but errors are still common.

Antiretroviral therapy (ART) for HIV is less complex than it was a decade ago, with regimens that are more tolerable, have fewer side effects, and require less frequent dosing. Even with this reduction in complexity, however, ART prescription errors still occur routinely when HIV-infected patients are hospitalized.

The consequences of ART errors can mean confusion for the patient and the patient's HIV specialist when the patient leaves the hospital, or worse, development of potentially life-threatening drug-drug interactions, viral rebound, or resistance, explained Uriel S. Sandkovsky, MD, MS, FACP, assistant professor of medicine at the University of Nebraska Medical Center's HIV Clinic in Omaha.

Photo by Thinkstock
Photo by Thinkstock

“Most important are the drug interactions and resistance, because it is not like missing a drug for hypertension, where you can go back on that medication and control your blood pressure. But if you develop resistance to a drug for HIV, that's a problem that you will carry for the rest of your life,” he said.

Common ART errors include omitting a drug during the hospital stay, prescribing the wrong drug, giving an incorrect dose, combining drugs that cause an adverse interaction, and not giving a medication on the correct schedule.

Oddly, one contributor to medication errors for hospitalized HIV patients is the success these therapies have had in controlling the infection, said Baligh Yehia, MD, FACP, assistant professor of medicine and an infectious disease specialist at the University of Pennsylvania in Philadelphia. HIV-infected people are living longer, and fewer are hospitalized specifically for HIV or AIDS. As a result, hospital staff may be less familiar with HIV-related medications.

Error rates

ART inpatient prescribing errors are fairly frequent, with recent studies finding that they occur in 26% to 72% of admissions of HIV patients, according to Dr. Sandkovsky.

His own study found that 35.1% of HIV patients on ART hospitalized at the University of Nebraska Medical Center between 2009 and 2011 had at least 1 error, with drug omission accounting for more than two-thirds. Half of the errors were never corrected while the patient was in the hospital, and 31% were corrected in the first 24 hours, according to results published in the January 2014 Journal of Antimicrobial Therapy.

At the time of the initial study, the institution implemented a unified electronic medical record (EMR) system for the hospital, and the HIV clinic initiated a medication reconciliation process led by an HIV pharmacist.

When they looked at the issue again, in patients hospitalized for more than 24 hours between 2013 and 2014, the researchers found that while the EMR system had decreased the error rate by more than 50%, the intervention by the HIV pharmacist was key to timely correction of errors that did occur. Their results were published in Antiviral Therapy in January.

The initial study also found that black patients were at increased risk of a medication error compared with white patients. But that increased risk had disappeared by the second review. “Although there is a big disparity for African Americans in terms of HIV in diagnosis, treatment, care, and outcome, we didn't find anything like that related to ART medication errors,” Dr. Sandkovsky said.

The close connections between the hospital and the clinic, which treats about 80% of HIV-infected patients in Nebraska, has been a factor in bringing down the number of errors, Dr. Sandkovsky said. Several pharmacists who specialize in HIV are allied with the clinic, and clinicians at the clinic are notified when any of their patients are hospitalized. Staff members at the HIV clinic are on call 24 hours a day and are available if the hospital clinicians have any questions about therapy.

At Johns Hopkins Hospital, researchers looked at ART errors in 2009 and found that they occurred in 29% of admissions on the first day and in 7% of admissions on the second day. Seventy percent of dosing errors occurred with protease inhibitors, which sometimes are dispensed twice daily and are available in different dosage forms and strengths; 30% involved nucleoside/nucleotide reverse-transcriptase inhibitors. The most common error was an incomplete regimen, followed by incorrect doses, incorrect scheduling, and drug-drug combinations that are not recommended. The study results were published in Clinical Infectious Diseases in 2012.

Ironically, systems that should be reducing medical errors may be responsible for also causing some errors, said Dr. Yehia, who was the lead author on the Johns Hopkins study. For example, a computerized provider order entry (CPOE) or EMR system can lead to errors if a medication is off formulary or does not appear when its name is entered into the system. “Some doctors are very reliant on the system and may use CPOE displays to determine the range of doses for infrequently used medications. Also, if the system is down, they have to be able to figure out the doses and scheduling themselves,” a task that can be further complicated by lack of experience with the medications, he said.

Preventing errors

Education, communication, and collaboration can make a significant impact on decreasing medication errors in hospitals. Education should include not only knowledge about HIV regimens but also knowing where or from whom to find more information. “Have a heightened awareness that this is a very important drug regimen and that if you miss a component, it could impact resistance,” said Dr. Yehia.

Experts to contact for more information might include a specialized HIV pharmacist, the primary care physician, an infectious disease physician, or another specialist taking care of the patient. Some hospital pharmacists have not received training in ARTs, so a call to an outpatient expert can be required for accuracy.

Good communication around this issue also involves talking to the patients. Ask what medications they are taking and when they take them. If patients don't know the name of a drug, have a chart for them to consult. Charts are available online (for example, Dr. Sandkovsky recommended this one ), and apps can be downloaded that include pictures of the drugs and dosing and scheduling information.

The experts also recommended that hospitalists make sure medication reconciliation is done early in the patient's stay, so that any errors can be corrected within the first 24 hours. Double-check the dosing schedule and the dose; ensure that the patient is getting the correct drug and at the right time.

If the CPOE system is down or doesn't list the drug the patient is currently on, or if the drug is off formulary, check with an expert. In general, work as a team. “Use more than one pair of eyes, hear from people who have different expertise or look at things in multiple ways so that you are able to find mistakes more quickly,” Dr. Sandkovsky recommended.

Remember that this is an area where specialized expertise can help avoid mistakes with long-lasting effects, the experts said. “The less experience you have with people on these medications, the more likely you are to make a mistake,” said Dr. Yehia. “People who have more experience, who have a larger patient volume, are more likely to get better outcomes. That level of experience is important in the chronic management of the disease.”