Transitions of Care III — Scarier than a horror movie: Medication errors

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We've been talking for a while about transitioning of our residents to and from the facility and some of the problems associated with it. We've even given a few tips (look back in the blog archive if you've missed them). But let's talk about just one huge problem, that big elephant in the room — medication reconciliation.

What we can do to make a difference and what we can try and advocate for? Let's get serious because this “stuff” is really scary! 

Studies show that in 86% of transfers (to or from SNF/hospital), medication errors occur. A study by Boockvar K., et. al. (Arch Intern Med. 2004;164:545-50) showed that at least one medication order was altered and out of that, 65% were caused by discontinuations, 19% were caused by dose changes, and 10% were caused by formulary substitutions.

That study also showed that half of adverse drug events (ADEs) attributed to medication changes were caused by discontinuations. A study from Wong JD, et. al. (Ann Pharmacother 2008;42:1373-9) showed that 30% of patients discharged from the hospital (to any location) have at least one medication discrepancy.

Why is this? Well, for one thing, you have formulary changes. Your resident goes into the hospital and if she or he is admitted, pretty much all of that person's medications are going to be switched to the hospital formulary. Now, I am not convinced there is 100% perfect therapeutic interchange.

With frail elders, the attending practitioners have often taken a great deal of time to titrate. An extended released opioid medication given every 24 hours that does not have a variation in peaks and troughs is not going to be matched by a generic opioid that needs to be given every four hours. An antidepressant or seizure medication that has taken months to titrate to get to a point to control symptoms with the least side effects just should not be messed with.

But we have no control over this. Cost control trumps patient safety. That's part A. Hold onto that for a moment. 

Enough to make heads spin

But let's move on to point B. Now get this: When I was a part of the expert panel of the Centers for Medicare & Medicaid Services' study for avoidable hospital transitions, all of the expert panel members noticed the same thing. We all were looking at records of residents who were transitioned to a hospital from a nursing home over a year period. Our charge was to see, using a survey instrument to take away subjectivity, if the hospital transfer was avoidable or potentially avoidable, and if so, what could have been in place to prevent the transition.

There was this glaring pattern that we could not ignore: Every resident who arrived at the hospital on a dementia drug had it discontinued by the ER doctor with a note “patient too demented to continue treatment.”

Wow, they could tell that in the few minutes they saw them, eh? Even if the resident was delirious? And I suppose it was no coincidence that those drugs were not on the hospital formulary?!

Now, there are times that medications are discontinued for the hospitalization for therapeutic purposes, such as taking a patient off of a basal/ basal-bolus insulin regime and moving to a sliding scale insulin regime because the blood glucose is all over the place due to a systemic infection. But my point is, once stable, they should be moved back to the standing regime.

So, what can we do and what do we advocate for with medication reconciliation? It's a bit easier with the resident who is returning because you have something to compare the transfer medication list with. So, yes, there will be formulary changes and, yes, the resident might have adverse consequences (proven by studies, not just my opinion) because of that.

That's the “Point A” to deal with.  Then, you have to deal with “Point B.” Look to see what has been discontinued. This is VERY important because you do not know the validity of the “why” it was stopped. And, remember, a great deal of physicians in hospitals have NO geriatric training.

Point of no return?

Maybe they didn't know that the studies prove that once off the dementia drug, the patient might never come back to baseline. Either way, it's up to us to make sure we reconcile.

So you and the resident's practitioner have to go over the old medication list and the new one along with the diagnoses that were given in the hospital (taking UTI and dehydration with skepticism — meaning you need to get the results of the labs to see if those diagnoses hold water). Hopefully, you'll have transfer notes on the course of the hospitalization and then reconcile the meds with the readmission orders.

What, of course, is much harder are the new admissions who are coming right from the hospital, because you know they have just had medication changes that their primary care practitioner (PCP) had them on. And then you and the brand new attending — who have never met this person — have to play detective.

But guess what Dr. Watson? There are clues. First, call the previous primary care physician to see if you can get a hold of pre-hospitalization medication orders. No matter what his or her office staff says, handing off this information does NOT violate HIPAA, and they have no right to charge for this service, either. This information belongs to the resident.

Your next tip is to look at the hospital records for clues within the diagnoses. For example, see if there is a diagnosis of dementia, and if they are not on dementia medications, ask the family members if they can recall if their loved one was on anything prior to the hospitalization. Also, call the previous PCP to see if you can get a hold of pre-hospitalization medication orders. (You have a short window on this one, so be aggressive about finding this out.)  If they are on sliding scale, find out what their insulin regime was at home. Trust me, no one is on a sliding scale at home. Get them off of that! 

What can we advocate for? Well the National Transitions of Care Coalition (look it up — at www.ntocc.org — they have great FREE tools and resources) advocates for the pharmacist to have a stronger role in medication reconciliation BEFORE the resident leaves the hospital.

Imagine that, having a licensed, trained, brilliant pharmacist go through the medical records and reconcile the med list prior to the patient leaving the hospital, instead of a first-year surgical resident. Man, makes your mouth water doesn't it?

But we can make a difference, we can be detectives, and we can reduce that elephant to a mouse.  Yup, just us nurses!

Just keeping it real,

 Nurse Jackie

The Real Nurse Jackie is written by Jacqueline Vance, RNC, CDONA/LTC — a real life long-term care nurse who is also the director of clinical affairs for the American Medical Directors Association. A nationally respected nurse educator and past national LTC Nurse Administrator of the Year, she also is an accomplished stand-up comedienne. She has not starred in her own national television series — yet. 

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The Real Nurse Jackie

The Real Nurse Jackie is written by Jacqueline Vance, RNC, CDONA/LTC, a 2012 APEX Award of Excellence winner for Blog Writing. Vance is a real life long-term care nurse. A nationally respected nurse educator and past national LTC Nurse Administrator of the Year, she also is an accomplished stand-up comedienne. The opinions supplied here are her own and do not necessarily reflect those of her employer or her professional affiliates.

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