Overview

Iatrogenesis is defined as any injury or illness that occurs as a result of medical care (Taber’s Cyclopedic Medical Dictionary, 2013). An iatrogenic condition is a state of ill health or adverse effect caused by medical treatment; it usually results from a mistake made in diagnosis or treatment, and can also be the fault of any member of the healthcare team. The risk of iatrogenesis in individuals over the age of 65 is twice as high as that of a younger person (Gurwitz et al., 1994) and iatrogenic complications may be more severe in the elderly (Merck Manual, 2013). A sentinel report from the Institute of Medicine attributed most errors not to negligence or misconduct, but to system-related problems (Institute of Medicine, 1999).

From 2007 to 2009, 708 642 patient safety events were reported to have contributed to the deaths of 79 670 hospitalized Medicare beneficiaries in the United States of America (Healthgrades, 2011). Iatrogenic events have been estimated to affect 65% of nursing home residents annually and are likely to have negative impacts on older individuals residing in assisted living facilities as well (Mitty, 2010). Adverse drug reactions from prescription medications result from incorrect ordering and administration of dosages, and from polypharmacy in the elderly. Other problematic errors may be based on misreading test results, or on the ambiguous presentations of symptoms, a hallmark of aging (Lantz, 2002; Agency for Healthcare Research and Quality, 2004; Mitty, 2010). For 2011, 874 116 adverse event reports for drugs and therapeutic biologic products were received by the Food and Drug Administration, up from 370 240 reports in 2003 (FDA, 2012). It is estimated that 27% of adverse drug events in primary care and 42% in long-term care are preventable (American Geriatrics Society, 2012).

Hospitalization increases the risk for nosocomial infections, transfusion reactions, polypharmacy and immobility. Mobility is critical for well-being and quality of life in the elderly individual. Surgical and medical interventions may lead to complications because of anesthesia or fluid overload (Merck Manual, 2013). Older patients often arrive at hospital without medications or an appropriate list of prescribed drugs, meaning that scheduled doses may be missed for hours or days. Hospitalized older adults are especially at risk for ‘cascade iatrogenesis’, the development of multiple complications initiated by a seemingly innocuous initial event (Thomlow et al., 2009).

A host of factors augment the risk of the elderly suffering an iatrogenic condition. The presence of multiple chronic diseases increases the possibility that the treatment of one problem may have a negative impact on another. For example, the use of a nonsteroidal anti-inflammatory (NSAID) medication in the treatment of arthritis may exacerbate heart failure or chronic gastritis. Fragmentation of health delivery into many specialties may lead to changes being made in therapeutic interventions without adequate communication among caregivers.

A number of initiatives have been suggested to prevent iatrogenesis, especially in the frail elderly, including: use of case managers to coordinate services; judicious involvement of a geriatric interdisciplinary team for complex cases; consultation with a pharmacist; establishment of specific acute care units for the elderly; and preparation of advance directives, including designation of a proxy for medical decisions (Merck Manual, 2013). In an effort to promote safer healthcare, the Agency for Healthcare Research and Quality has published ‘20 Tips to Help Prevent Medical Errors’, presented in Box 56.1. This fact sheet informs patients and their family members about practical steps that they can take to prevent medical errors, thus ensuring safer healthcare.

An array of both voluntary and mandatory adverse event reporting systems in countries around the world has been summarized, and guidelines for reporting and learning systems have been drafted by the World Alliance for Patient Safety (2005). Not meant to be punitive (which likely would inhibit reporting), these systems are intended to enhance patient safety by facilitating learning from healthcare system failures and by taking action to make corrective changes.

This chapter focuses on iatrogenesis related to adverse drug reactions and immobility, and offers suggestions for proactively preventing these conditions.