Missing Medications: A Case Study

M e d i c a t i o n R e c o n c i l i a t i o n : A K e y I s s u e i n M e a n i n g f u l U s e

Shortages of prescription drugs in the United States are a serious threat to our nation’s health and safety. At first blush, this problem appears fairly simple and straight forward to solve. In reality, there is a complex web of causation with a number of root causes contributing to drug shortages. The aim of this paper is to answer the question: How do we mitigate prescription drug shortages? This discussion is written from the standpoint of advising the current presidential administration how to address this crisis. This essay begins with a discussion regarding the background of the issue. Next, the landscape, including stakeholders in this matter is identified. Following, political, social, economic, and practical factors surrounding

On Friday, November 20, 2015, Investigator Clyde Wheat and I met with Nursing Manger John Wagoner and Lead Charger Nurse Rachel Tarpley on Division 8900, in regards to medication missing from the narcotic lockbox, located inside the 8900 Oncology Pyxis West Room. Wagoner stated the medication was stored in the lockbox Monday, September 21, 2015, at approximately 2345 hours. The medication belonged to Patient Ieremia Fualau. The medication contained approximately sixteen (16) Oxycodone and (17) OxyContin.

The physician and pharmacist must write a report to the state’s health services department if medication is dispensed.

Mrs. Carroll stated on today’s date, she noticed her husband, James Carroll, was missing some medication. She advised the medication that appeared to be missing was listed as Fentanyl Transdermal, methadone 10 MG, and Morphine Sulfate. She stated the last time she seen the medications was approximately 3 days ago. She continued to state only immediately family was inside the residence the last few days. She also stated she can’t pin point anyone because she did not see anyone take the medication.

I have chosen the research topic of medication non-compliance, specifically regarding high blood pressure medication. I see patients very often at my job who do not take their medication because they say they feel fine or they forgot. I do teach my patients that they need to take their medication every day and suggest to take it at the same time as something they already do daily such as eating breakfast but my words seem to fall on deaf ears. Some patients don’t like the way the medication makes them feel so they just stop taking it instead of going back to their doctor. I believe that more visual aids in teaching such as videos that show what is happening inside your body when your pressure is high in addition to meeting stroke patients

This journal talks about it takes failure to resolve medications across changes in care is an important cause of harm to patients. There is not a lot to known about medication discrepancies before patients are admitted to a skilled nursing facilities. To describe the prevalence of, type of medications involved in, and sources of medication discrepancies upon admission to the SNF setting. Cross-sectional study. Patients admitted to SNF for subacute care. Number of medication discrepancies upon admission to the SNF setting. Cross-sectional study. Patients admitted to SNF for subacute care. Number of medication discrepancies, defined as unexplained differences among documented medication regimens, including the hospital discharge summary, patient

As a critical care nurse the concern with medication shortages really hits home. In my current practice I have been asked by our hospital pharmacy to decrease the amount of Ativan given to a patient because the supply was low and they did not have any more to restock our omnicell. I am unsure the reason behind this particular shortage, but several other drugs we currently use are in low supply, most importantly epinephrine. Epinephrine is a life-saving medication, not only for supply on our code carts for cardiac arrest, but available in injection form for people with severe allergies. The shortage affects everyone, from oncology patients to cardiac patients. Recent policy changes have been made in order to correct the major shortages to help keep these life-saving drugs on the market and available to the people that need them.

The medication error involved an 85 year old female. She was discharged from the hospital after an open reduction and internal fixation surgery for a fractured hip. Upon her arrival to the nursing home facility, there were multiple opportunities to prevent the medication errors that eventually lead to her fatal cardiac arrest. There was a lack in communication between the patient’s medical team. After the patient was discharged there was no follow up from the hospital nor a nursing care plan at the patients’ nursing home. The individuals did not use any critical thinking skills in going beyond the five rights of medication administration. There may have been a lack of knowledge of the medication. Since the patient had a history of

HCS Med 360 is a software solution used to support medication reconciliation. This technology allows the consulting pharmacists to rapidly query over a dozen national databases and see the patient's prescription fill history as well as gaps in the fill history. Experience to date shows that this robust system captures all prescription medications in Hawai‘i except those filled at Kaiser or the VA and those paid 100% self pay. The consulting pharmacist then completes the reconciliation process and produces a current medication list, including OTC medications, herbals, and supplements. The fill history and complete medication list are being built so that this information can be included in the patient's HHIE Community Health Record. The HHIE

A Corrective Action Plan meeting was held on 8/3/15. Present during the meeting were Elena Briceno, Regional Director, People's Care, Dara Mikesell, Manager of Quality Assurance, Kristen Gener SG/PRC Service Coordinator, and Adriane Picazo, Manager of Client Services, RS1. Plan of Correction: A, Staff will dispense medications as prescribed by physician B, The Administrator arranged for staff to received medication training by a pharmacy on July 24, 1=2015, verification of this training was submitted on August 3, 2015. C, The Administrator will instruct the staff to continue following the present Medication Dispensing Protocol, which indicates that DSP A dispenses the medications and DSP B verifies the medications with the Medication Administration

During the site visit I was scheduled to do medication history with patients. In the morning of the site visit, I attended to the medication history lecture and this presentation was very beneficial, this lecture made me feel well prepared and apply these skills during actual patient medication history. In the afternoon of the site visit, I got an opportunity to do medication histories with actual patients. This visit helped me have a better understand the role of an institutional pharmacist relating to medication history and medication reconciliation and why medication reconciliation is very important for the pharmacists in institutional setting. Medication reconciliation is important for an institutional pharmacist because this is a process

Reporting party (RP) stated that she wishes to remain anonymous and is a social worker. RP overheard staff Patricia Salvo stated that there is not enough food to give the residents. RP stated that the staff and residents are afraid of the caregivers (Emma, Aziza and Lara). RP stated that staff is afraid to tell Emma that there is not enough food for the residents for fear of retaliation. RP stated that resident Fernanda and Cheryl are too afraid of Emma to file a complain on their own. RP stated that staff yell at the residents and tell them, "If you don't like it you can leave." It was also reported that Fernanda is forced to take her medication with a glass of wine. RP was also concerned that the facility has had 9 death within the past year

If I were to walk down the hallway and hear a fellow nurse making the statement that they are trying to administer medication, and the cannot complete the task because the medication administration program is telling them wrong patient my first action would be to ask that nurse if I could assist her is finding a solution. Hopefully that nurse would allow me to assist. Then I would be able to check the chart and the patient’s identification band manually. If it was not the correct due to patients having similar names such as James Stewart or Stewart James, then the problem would be easily solved by selecting the correct patient’s chart. However, if the patient’s identification bracelet is correct and matches the selected patient’s HER, then

Carrie Johnson (DOB 08/05/58) was readmitted to the facility on 07/27/15 after a hospitalization. Carrie came back to the facility with a prescription of Norco to be given every 6 hours for pain. The facility had a pill bottle with one Norco in it on hand prescribed prior to her hospitalization. Facility staff gave Carrie the pill that evening in front of RPs and Carrie's family. Licensee agreed to get the new presciption filled so Carrie could have another pill in six hours as prescribed. RPs arrived to the office the next morning to learn that Carrie called after hours (call taken by Mario Lomeli, intake specialist of CFS) stating that she was not provided her medication six hours later