Rx for Patient Safety
Those little plastic rectangles divided into seven squares, one for each day of the week, are lifesavers for many people, particularly the elderly, who take a bewildering number and variety of pills each day. Prescription drugs, over-the-counter remedies, herbal preparations—all factor into the mix of meds many patients are taking when admitted to the hospital.
It is precisely this mix that holds the potential for life-threatening errors, for each step of the way in a hospital stay, medications can be mistakenly continued, discontinued, changed or duplicated. That is why, with the coming of the new year, Hopkins Hospital will roll out a new “medication reconciliation” initiative, one that is expected to improve communication between care teams, as well as between patients and their providers inside and outside the hospital.
How will it work? Pharmacy’s Bob Feroli, medication safety officer, Stephanie Poe, program coordinator in the Department of Nursing, and Beryl Rosenstein, vice president for medical affairs, recently sat down with Dome to explain.
Q: Why is “medication reconciliation” necessary?
Rosenstein: Let’s say a 14-year-old girl comes into the hospital with a broken arm. Maybe she was on seizure medication at home. Somehow that information wasn’t picked up while she was being treated here, and she misses a couple of doses. The consequence? She has a seizure while in the hospital.
Feroli: Or, take the 57-year-old man on Lipitor for high cholesterol. That’s recorded on the admissions form when he comes in to be treated for an acute illness. When he’s discharged a couple of weeks later, the doctor knows he’s supposed to be on medication to reduce cholesterol, so he prescribes Zocor. The patient goes home. He now has the new Zocor prescription and the leftover Lipitor. He doesn’t know that they are the same kind of medicine, so he winds up taking both.
Q: It seems like the need for reconciliation is greatest when a patient is admitted and discharged.
Feroli: Actually, errors are most likely to occur at all times of transition, not only admissions and discharge, but also whenever the patient changes services, like going in or out of an ICU.
Q: So how will you minimize the opportunity for errors?
Poe: We’re creating a new form—the “home” medication list—that is the list of medicines that the patient is taking before coming to the hospital. The list will be attached to every medical record, probably on the top page just behind the history tab. This form will be reviewed and signed by a physician accepting care of the patient, who will certify that he or she has considered the medications on the list when writing the admission order.
Then, whenever a patient changes services or level of care during the hospital stay, there will be another round of reconciliation. The doctor will review the home list as well as the medication list active at the time of transfer, once again certifying, “I have considered the medicines the patient was on prior to transfer while writing my transfer orders.”
Q: Will herbal preparations be included on the pre-admission medication list?
Feroli: Yes. We’re interested in prescription drugs, over-the-counter drugs and herbals. Each one has pharmacological action and they interact. Many herbal medicines interact with prescription medicines. That’s why we want as complete a list as possible.
Q: But won’t the new system be cumbersome for physicians?
Rosenstein: Basically, doctors will be just formally documenting what they are already doing. The system will be automated on the floors that have already implemented P.O.E. (Provider Order Entry). The docs will have a nice computer print-out of all meds that are active just before the transfer, and everything that’s been discontinued within the previous 24 hours. On floors without P.O.E., they will have to go through the chart manually and review the medication history before signing the document. Eventually, the entire process will be done electronically.
Q: It sounds like doctors will be the only employees affected by the change.
Poe: Not really. This is going to affect the entire care team. It’s important that we have the support of prescribers—physicians, nurse practitioners, physician assistants—as they are the ones who will sign the reconciliation forms. But nurses and pharmacists will help by gathering home medication information. Still, it is very clearly the doctors who have to do the reconciliation. They are the ones writing orders and signing the form certifying that they’ve reviewed the medication history.
Q: What about when the patient goes home?
Rosenstein: The physician will consider the meds the patient is taking just prior to discharge, but it will also be important to review the meds the patient came in on, knowing full well that there are prescriptions or refills for those prescriptions at home.
Poe: Patients need very clear instructions on which to continue, stop or change. And they need to pass that information along to their care providers outside the hospital. The discharge paperwork will include all this information, signed by the physician.
Q: When will you be up and running?
Poe: We’re doing some pilot testing of the system right now in nine units of the hospital. By Jan. 1, the program will be implemented hospital-wide.