Did You, Do You, Can You

Oh so common in the ED…

Questions:

• Did you bring your medicines?
• Do you know the names of your medicines?
• Can you have someone bring them in?

Answers:

• The white one.
• The little one.
• The blood pressure one.
• Same as the last time, when you wrote them down.
• Call my doctor’s office (regardless of the fact it is 3 AM)
• Call the Walgren’s on 16th.
• I don’t know, they were stolen.
• Mine? Or the ones my sister gives me?

What Drugs Do You Take? | Hospitals Seek to Collect | Better Data and Prevent Errors | WSJ | 5.23.06

In the movie, “Something’s Gotta Give,” Jack Nicholson plays an aging Lothario, rushed to the emergency room after a heart attack, who won’t admit to taking Viagra in front of his young girlfriend. But then he yanks his IV tube out in a panic when the doctor warns of a potentially dangerous interaction between the erectile dysfunction drug and the nitroglycerin drip he just started.

The scene gets big laughs, but there’s nothing funny about the danger when hospitals have inaccurate or incomplete information about a patient’s medications. With drug errors responsible for killing more than 7,000 hospitalized patients a year, new national patient-safety standards, which went into effect in January, require hospitals to have formal processes known as “medication reconciliation.” This means hospitals must have a set routine for collecting complete drug and allergy histories and comparing them with new medications that doctors order. The aim is to avoid problems both while patients are in the hospital and when they are discharged with new drug regimens.

Joint Commission Issues Alert to Improve Medication Safety | JCAHO | 1.25.06

The Joint Commission on Accreditation of Healthcare Organizations today issued a new Sentinel Event Alert that urges intensified attention to the accuracy of medications given to patients as they transition from one care setting to another, or one practitioner to another. The failure to reconcile medications during these transitions can cause serious patient injuries and even death.

According to the Alert., medication reconciliation should occur whenever a patient moves from one location to another location in a health care facility (for example, from a critical care unit to a general medical unit); or from one health care facility to another or to home; and/or when there is a change in the caregivers responsible for the patient. When effective medication reconciliation does not occur, patients may receive duplicative medications, incompatible drugs, wrong dosages, or wrong dosage forms among the array of potential errors. The medication reconciliation process also provides an important opportunity to assure that the patient is receiving all medications necessary to his or her care and to eliminate any medications that are no longer needed by the patient

Using medication reconciliation to prevent errors | JCAHO | 1.25.06

Transitions in care include changes in setting, service, practitioner or level of care. This process comprises five steps:

1. develop a list of current medications;
2. develop a list of medications to be prescribed;
3. compare the medications on the two lists;
4. make clinical decisions based on the comparison; and
5. communicate the new list to appropriate caregivers and to the patient.

[T]he Joint Commission recommends that health care organizations consider:

1. Placing the medication list in a highly visible location in the patient’s chart and including dosage, drug schedules, immunizations, and allergies or drug intolerances on the list.
2. Creating a process for reconciling medications at all interfaces of care (admission, transfer, discharge) and determining reasonable time frames for reconciling medications. Patients, and responsible physicians, nurses and pharmacists should be involved in the medication reconciliation process.
3. On discharge from the facility, in addition to communicating an updated list to the next provider of care, provide the patient with the complete list of medications* that he or she will be taking after discharge from the facility, as well as instructions on how and how long to continue taking any newly prescribed medications. Encourage the patient to carry the list with him or her and to share the list with any providers of care, including primary care and specialist physicians, nurses, pharmacists and other caregivers.
4. When the patient is unable to actively or fully participate in the medication reconciliation process and has requested assistance from another person(s) (e.g., family member, significant other, surrogate decision maker), involve the authorized person(s) in the medication reconciliation process. This involvement should occur at all interfaces of care, and on admission to and discharge from the facility.

The Medication Reconciliation Process ( PDF) | JCAHO | 5.21.06

See PDF

This is a very important aspect of care, but fraught with so many obstacles and assumptions. If you can convince some family member or friend to go to the home and bring in the “BOM” (better yet, if EMS would only remember too; I can’t tell you how many times I hear “the captain got the meds”—poor cap’ always getting the blame… ) you will be shocked as to how many different medicines “the white one” really is. Not to mention polypharmacy is almost always accompanied by “polypractitioner” (too many chefs and too many kitchens). One patient I had seen once was reported by the California CURES program as seeing over 50 practitioners within 4 months. Of course this was for certain controlled substances and represents one extreme; but I have no doubt that we would find similar stats with antibiotics and many of the other common classes of drugs.

The typical MRF I see in the ED is:

• completely blank;
• says “see medication list”;
• lists “the white one” and “the blood pressure one”;
• the patient’s best guess at name;
• the patient’s best attempt at spelling;
• the nurse’s best guess at name;
• the nurse’s best attempt at spelling (of course this applies to the physician—that’s why we scrawl);
• name without dose;
• name without interval;
• etc.

And then, have you reviewed the medication list and acknowledge any changes… Right, review and acknowledge a two page list of over twenty medications all for a 10 minute visit for the treatment of an ingrown nail. The real-world need for the MRF does not jive with the realities of the ED and what the public commonly perceives to be emergencies. Where is this going—it has to go to a true universal EHR—anything short of this and we will be forever mired in documenting what a horrible health system we have. Lofty and needed goals, but the devil is in the execution. The ship will never be held fast as long as the predicate is BYOM and mandatory self-stringing of the weakest links—GIGO.

See here.