Q & A: A Case Study

Be careful when administering medications where there is more than one patient on the unit with the same name.

The activity that I performed and relates to this outcome is medication reconciliation. I performed this activity in my IPPE-III class as a PS-III student. It was a mandatory activity, which I carried out in workshop in the group of 4 students. In this activity, we were given a patient case, which had list of all the medications that patient was taking and had patient’s demographic information. After reviewing patient’s given information, I had to interview a standardized patient and find out if the patient is taking all the medications as directed by prescriber or not. If patient is taking any other vitamins, herbal or OTC medications that is not on the list and also had to look out for if there is any discrepancy with the medications patient currently on for example, duplicate therapy, drug-drug interaction, incorrect frequency etc.

In the UK, there are more than 1 billion scripts prescribed and dispensed every year (HSCIC, 2013). There are over 12,000 pharmacies in the UK, and approximately 1.6 million people visit a pharmacy every day (HSCIC, 2013). It is therefore natural to assume that between these 1 billion prescriptions, an error or mistake will be made. Current studies suggest that of all the dispensed medicines, there are approximately 0.01-3.32% errors made in community pharmacy and 0.02-2.7% in hospital pharmacy (James et all, 2009).

The reconciliation should be used in every transition in care, where the new medication is prescribed and old mediations are rewritten. The accuracy of the list can prevent many drug effects and interactions; therefore it is important to ensure proper documentation and communication at all levels of care. Also, many errors occur when doctors fail to write out necessary orders such as, “resume pre-op medication.” The use of this “resume pre-op medication” has been prohibited by the Joint Commission due to the many complications it can produce including increasing the chances of adverse effects. Furthermore, it has been discovered that most discharged patients have been found to have insufficient knowledge regarding their medications upon returning home (Joint Commission, 2006). Medical reconciliation provides the patient with crucial information regarding the dosage, route, therapeutic effect, and reason for administration.

Due to the large number of consumers being prescribed multiple medications, and the complexity of managing those medications, it is of a major safety concern that systems are in place for clinicians to reconcile patients medications to resolve any discrepancies in what the patient is using, or should be using, and newly added ones.

The purpose of this paper is to bring forth awareness when it comes to patients and medication errors and further educates health care professionals on the importance of communication especially during transition of care. According to Williams and Ashrcoft (2013) “ An estimated median of 19.1 % of total opportunities for error in hospitals.” Although not all medication errors occur during transition it is the time most prevalent for these errors to occur. As per Johnson, Guirguis, and Grace (2015) “An estimated 60% of all medication errors occur during transition of care. The National Transitions of Care Coalition defines a transition of care as the movement of patients between healthcare locations, providers, or different levels of care within the same location as their conditions and care needs change, [and] frequently involves multiple persons, including the patient, the family member or other caregiver(s), nurse(s), social worker(s), case manager(s), pharmacist(s), physician(s), and other providers.”

Medication Reconciliation is defined by the Joint Commission as the process of checking and rechecking a patient’s current medication list to the patient’s orders. Within a MedRec program, three steps must be followed to ensure patients have the correct medications at admission and discharge: Verification, Clarification, and Reconciliation (Greenwald et al., 2010; Ruggiero et al,. 2015). MedRec should not occur once, but multiple times especially when a patient moves from department to department. The more a patient moves, the more liable they are for a medication error due to poor communication. MedRec is done for the simple reason of catching those medication errors and correcting them before they can do any harm (The Joint Commission, 2006). Medication errors effect nearly 1.5 million people who enter the hospital setting in the USA. At least every patient has one medication discrepancy between admission and discharge, which leads to rehospitalizations due to hospital-setting medication errors (Institute of Medicine as cited by Wilson et al,. 2015). With nurses at the forefront of a patient’s medication regime, pressure is put on them to provide the necessary education and safety to prevent medication related rehospitalizations. Included in the causes for medication errors is miscommunication between departments taking care of the same patient (Allison et al., 2015). Many medication errors are preventable by the implementation of electronic orders. The use of electronic

drugs can be potentially dangerous for a patient, particularly if they are receiving medications from different clinicians who are not communicating with each

There are many challenges during the process of medication reconciliation. Some patients are taking herbal supplements that they forgot to mention during the interview, some of them do not take all medications that are on their list for different reasons, and errors made during transfer of care reconciliation, are just a few examples how this problem is serious and can cause potential harm, even death in some cases.

Goal three by the National Patient Safety Goal for 2014 is to use medicines safely. Many errors occur regularly with medications which is why communication is so important with the doctors, nurses and patients. One process that Joint Commission requires in accredited HCO’s is medication reconciliation “creating the most accurate list possible off all medications a patient is taking, including drug name, dosage, frequency, and route, and comparing that list against the physician’s admission, transfer, and/or discharge orders with the goal of providing correct medications to the patients at all transition points within the hospital (Finkelman & Kenner, 2012, p. 388)”. Ensuring medication reconciliation to the patient, health providers and any new consults that are

Assign pharmacists that are responsible for medication reconciliation and making sure that there is a current and accurate medication list.

My previous pharmacy employment has trained me to pay attention to detail. I have been trained to check every label and medication multiple times to ensure accuracy.

High Alllert Medications (HAMs) are a special class of drugs that are highly risky and capable of causing harm even under proper use. Consequently, they necessitate the need for Independent Double-Checks (IDC). As such, the nurse verifies the dosage, drug, and route to match the directives of the physician as well as pharmacological requirements (Galbraith et al., 2015). Such drugs include sedatives, opioids, insulin and anticoagulants. IDC minimizes errors asserted to drug name confusion such as heparin/Hespan; lack of knowledge, and confusion from interruption or fatigue. My colleagues implement IDC in spite of the constraints experienced. However, some rare incidences of workarounds occur during weekends or emergencies when no verifier is

In addition to, reviewing the medication regime, including all over-the-counter medications during every face to face encounter. There is time set aside to discuss what the medications are, why they are taking them and how the are taken. the importance of carrying an up to date medication list with you at all times is also discussed as a safety moment. Upon discharge from each clinic visit, every patient is given a detailed written summary of diagnosis, treatment plan, medications and an allergy list.

Medication error is one of the biggest problems in the healthcare field. Patients are dying due to wrong drug or dosage. Medication error is any preventable incident that leads to inappropriate medication use or harms the patient while the medication is in the control of the health care professional,or patient (U.S. Food and Drug Administration, 2015). It is estimated about 44,000 inpatients die each year in the United States due to medication errors which were indeed preventable (Mahmood, Chaudhury, Gaumont & Rust, 2012). There are many factors that contribute to medication error. However, the most common that factors are human factors, right patient information, miscommunication of abbreviations, wrong dosage. Healthcare providers do not intend to make medication errors, but they happen anyways. Therefore, nursing should play a tremendous role to reduce medication error