Case Study Medication Review and Transitions of Care: A Case Report of a DecadeOld Medication Error Rachel Comer, Mitsi Lizer A 69-year-old Caucasian male with a 25-year history of paranoid schizophrenia was brought to the emergency department because of violence toward the staff in his nursing facility. He was diagnosed with a urinary tract infection and was admitted to the behavioral health unit for medication stabilization. History included a five-year state psychiatric hospital admission and nursing facility placement. Because of poor cognitive function, the patient was unable to corroborate medication history, so the pharmacy student on rotation performed an in-depth chart review. The review revealed a transcription error in 2003 deleting amantadine 100 mg twice daily and adding amiodarone 100 mg twice daily. Subsequent hospitalization resulted in another transcription error increasing the amiodarone to 200 mg twice daily. All electrocardiograms conducted were negative for atrial fibrillation. Once detected, the consulted cardiologist discontinued the amiodarone, and the primary care provider was notified via letter and discharge papers. An admission four months later revealed that the nursing facility restarted the amiodarone. Amiodarone was discontinued and the facility was again notified. This case reviews how a 10-yearold medication error went undetected in the electronic medical records through numerous medication reconciliations, but was uncovered when a single comprehensive medication review was conducted. Key words: Behavioral health, Long-term care, Medication
error, Nursing facility, Transcription error, Transitions-of-care, Vulnerable populations. Abbreviations: ADE = Adverse drug event, A fib = Atrial fibrillation, BHU = Behavioral health unit, ED = Emergency department, EKG = Electrocardiogram, EMR = Electronic medical record, PCP = Primary care provider, TSH = Thyroid stimulating hormone, UTI = Urinary tract infection. Consult Pharm 2014;29:130-5.
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Introduction Unintended medication discrepancies may occur at any time in patient care, but patients are at especially high risk for these errors at transitions of care.1-5 Medication discrepancies occur in as many as 60.4% of hospital admissions, and up to half of these errors cause moderate to severe harm.1,2,6-8 Many of these errors are a result of incomplete medical histories and prescribing and transcribing errors.2,6 Medication errors and the risk of harm is such a problem that The Joint Commission added medication reconciliation to prevent errors to the 2005 National Patient Safety Goals.9 The elderly are more likely to incur medication errors, and though most studies do not include patients with poor cognition, there are those that do show that cognition and the inability to direct one’s own care are independent factors associated with transitions-of-care errors.2,4,5,10,11 Adverse drug events (ADEs) are more likely to occur in patients when medication changes are made transitioning from inpatient to long-term care or vice versa.12 Additionally, ADEs associated with inpatient changes most often appear after return to long-term care, and patients with more chronic comorbid conditions are more likely to experience these ADEs.12 A further complication is that nursing facility nurses report receiving unclear and sometimes incorrect information from hospitals, but they are not always able or willing to spend the time needed to decipher potential errors.13,14 Errors at transitions-of-care will not be eliminated by incorporating electronic tools such as computerized physician order entry as these do not substitute for a comprehensive medication history nor do they prevent transcribing errors.1,2,8,10 Inconsistencies between electronic medical records (EMRs) and actual patient use are common, and once an error has occurred and been incorporated into the patient record, the error is likely to be propagated.7,10,15 When communication is poor between hospitals and primary care providers and reluctance exists to question prescriptions written by other providers, the errors can snowball.13,16,17 A medication review gives a much more accurate picture of medication use and uncovers medication discrepancies not evident from a simple medication reconciliation.2,18,19
The Consultant Pharmacist MARCH 2015 Vol. 30, No. 3
A Case Report of a Decade-Old Medication Error
This case report describes a decade-old medication error in a nursing facility patient that was overlooked and snowballed into a second medication error during multiple transitions between the same hospital and nursing facility without detection by multiple health care providers at both facilities.
Case Presentation A 69-year-old Caucasian male, with more than a 25-year history of schizophrenia, was brought to the emergency department (ED) after threatening a nurse in his nursing facility with a coat-hanger. The staff at the facility reported that the patient was noncompliant with all medications and began exhibiting symptoms of paranoia and agitation. He was transferred to the behavioral health unit (BHU) under a temporary detention order for therapeutic stabilization. On admission to the BHU, physical findings included a weight of 76 kg and a height of 68 inches; and vitals included blood pressure of 105/67 mmHg laying down and heart rate of 69 beats/minute. Patient was experiencing orthostatic hypotension and found to have a urinary tract infection (UTI).
Past Medical History Past medical history for the patient included chronic obstructive pulmonary disease, hypothyroidism, hyperlipidemia, osteoporosis, gouty arthritis, and recurrent UTI. The patient had been hospitalized for both medical and psychiatric treatment many times in the past, including a five-year commitment to a state psychiatric facility, and subsequent placement in a nursing facility. The most recent psychiatric hospitalization was in 2009. Psychiatric diagnoses included paranoid-type schizophrenia, depressive disorder, and anxiety disorder. He had no known drug allergies. Laboratory values upon presentation to the ED are presented in Table 1. Home medication list upon presentation to the ED is presented in Table 2. Once admitted to the BHU, the student pharmacist on rotation obtained a medication history to reconcile inpatient medications with home medications. Since the patient was a poor historian, he was unable to corroborate current medications, and the student executed an extensive
chart review. It was noted that the patient did not have a current diagnosis of atrial fibrillation (A fib), nor any other diagnosis to justify the use of amiodarone 200 mg twice daily. All electrocardiograms (EKGs) performed during previous hospital admissions were unremarkable or normal, and none of the readers noted A fib. After reviewing admission, treatment, and discharge hospital records, it was determined that the patient was put on amiodarone 100 mg twice daily 10 years earlier because of a transcription error. After entering the hospital with chest pain, the admitting physician misspelled amantadine in the medication history and the nurse transcribed it as amiodarone. The EKG on admission showed normal sinus rhythm. The discharging physician noted that the patient had no arrhythmias in the discharge summary, but continued the “home med” amiodarone. Therefore, the patient entered the hospital in 2003 taking amantadine 100 mg twice daily and was discharged on amiodarone 100 mg twice daily. Seven years after this initial medication error, during a subsequent hospital admission, a second transcription error occurred. The medication administration record from the nursing facility listed amiodarone, one-half of a 200 mg tablet twice daily for the patient. Instead, amiodarone 200 mg twice daily was entered into the home medication list and the patient was discharged back to the nursing facility on the higher dose. The patient was continued on amiodarone 200 mg twice daily until the error was uncovered in 2013. Consultation with cardiology during a 2013 hospital admission resulted in confirmation that an error occurred and discontinuation of the amiodarone. The discharge note indicated the error and clearly stated that the patient had no history of A fib and should no longer receive amiodarone. A phone call was placed, and a letter was sent by the student pharmacist to the patient’s primary care provider (PCP) explaining the amiodarone error that occurred in the hospital and the discontinuation ordered by the cardiologist. The patient returned to the nursing facility after discharge and was readmitted to the hospital four months later in 2014 after falling and sustaining a hip fracture. The patient stated he was dizzy, as normally occurs when standing, and lost his balance while walking down the
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Case Study Table 1. Laboratory Results upon Admission to Emergency Department Specimen
Test
Blood
Glucose Sodium Potassium Chloride Carbon dioxide BUN Creatinine Calcium TSH Alcohol Salicylates Acetaminophen
Urine
Drug screen
UA
Leukocyte esterase WBC Bacteria Clarity
Urine
Culture
Result 119 mg/dL 140 mEq/L 4.5 mEq/L 106 mEq/L 19.2 mEq/L 23 mg/dL 2.01 mg/dL 10.5 mg/dL 0.14 mU/L Negative Negative Negative Negative 500 18 Rare Hazy > 100,000 CFU Klebsiella pneumoniae
Abbreviations: BUN = Blood urea nitrogen, CFU = Colony-forming units, TSH = Thyroid-stimulating hormone, UA = Urinalysis, WBC = White blood cells.
hallway. On this later admission it was discovered by the hospitalist that the nursing facility had resumed the amiodarone when the patient returned in 2013 despite the clear statements made in both the letter to the PCP and the discharge report that the patient did not have A fib and should no longer take amiodarone. The hospitalist wrote up the error in the consult and asked pharmacy to notify the nursing facility directly to remove amiodarone from the patient’s active medication list.
Discussion In this case report, the patient received amiodarone instead of amantadine because of a transcription error, which was compounded by a dose increase after a second transcription error over the course of 10 years before discovery. It is unknown if this error contributed to the
132
patient’s hypothyroidism, as this diagnosis predates the initial medication error. It is possible the bradycardia and orthostatic hypotension, which adds to fall risk, was related to the amiodarone since the half-life is 40 to 55 days.20 None of the health care providers involved in this patient’s care over the past decade noticed the medication error, and it was only uncovered via a complete medication review. The success of discovering and removing the erroneous medication was tempered by the reality that, upon discharge in 2013, the nursing facility resumed the inappropriate medication despite multiple efforts to communicate the error. Subsequently, four months later the patient fell, breaking a hip, in an event that may have been prevented.
The Consultant Pharmacist MARCH 2015 Vol. 30, No. 3
A Case Report of a Decade-Old Medication Error
Table 2. Patient’s Home Medication List upon Presentation to the Emergency Department Oral Medications
Strength/Dose
Frequency
Amiodarone Aspirin Bisacodyl Clonazepam Duloxetine Gabapentin Levothyroxine Multi-vitamin Olanzapine Pantoprazole Pravastatin Tamsulosin
200 mg 325 mg 10 mg 1 mg 20 mg 300 mg 250 mcg Unknown 10 mg 40 mg 40 mg 0.4 mg
1 tablet twice daily 1 tablet once daily 1 tablet at bedtime 1 tablet at bedtime 2 capsules once daily 2 capsules three times daily 1 tablet once daily 1 tablet once daily 1 tablet at bedtime 1 tablet once daily 1 tablet once daily 1 capsule once daily
Inhaled Medications Ipratropium/albuterol inhaler Albuterol nebulized
2 puffs twice daily Use with nebulizer every 6 hours as needed
Oral Medications, As Needed Lactulose Loperamide Acetaminophen
10 mg/15 mL 2 mg 325 mg
Medication errors at transitions-of-care is a topic of interest in the current literature, but the focus is generally on medication reconciliation alone to decrease errors and unintentional ADEs. A systematic review by Tam et al. points out that comprehensive medication histories that involve other resources (e.g., communication with community pharmacy or family physician) are more accurate than histories obtained from the patient.2 In a report of medication review practices of mental health admissions in the United Kingdom, Paton et al. reported an increased identification of medication discrepancies when more medication sources were referenced, specifically the PCP and the patient.19 Lizer and Brackbill found that a pharmacist-directed chart review, in addition to interviewing the patient, identified more medication
30 mL as needed 2 tablets every 6 hours as needed 2 tablets every 6 hours as needed
discrepancies on admission to an inpatient BHU than a patient history alone.18 The lack of research on medication errors in vulnerable patients, such as the elderly, the mentally ill, and the cognitively impaired, represents a significant gap in patient care. These patients are poor historians, and obtaining a patient history and/or conducting medication reconciliation is insufficient to detect medication discrepancies. This is compounded by poor communication between hospitals and long-term care facilities, which nurses note is the single largest barrier to providing a safe transition.13 In the current medical system, there is no single point of accountability when the patient is unable to assume responsibility of care for him or herself. Adding to this, the ineffective cross-organizational communication essentially guaranteed that the medication
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Case Study Summary
Take-Home Points • Medication reconciliation without a medication review that includes asking why a medication is present or absent may overlook medication errors at transitions-of-care. • Incorporation into an electronic medical record does not guarantee the accuracy of the medication list. • When continuity in care is lacking between nursing facilities and hospitals, there is an opportunity for the consultant pharmacist to create
In the case of our schizophrenic patient, a single comprehensive medication review uncovered a medication error that was undetected through 10 years of medication reconciliation. Although the error was discovered and communicated via discharge note and personal letter, the error was once again propagated at the nursing facility, illustrating the communication barrier that exists at transitions-of-care. Better methods of medication review and communication, as well as a focus on medication review upon return to long-term care, need to be addressed as significant means of decreasing medication errors for vulnerable populations.
that continuity.
error would persist despite the initial identification and intervention. There are two main questions this case brings to light: “Who is responsible?” and “How can we prevent these errors from happening or continuing?” While the ultimate responsibility falls to the PCP, there are other health care providers who can step in and close the gaps, and transitioning to and from nursing facilities represents one of these gaps. For example, a consultant pharmacist is uniquely poised to bridge this gap by broadening the scope of the monthly mandated medication chart review. Medication reconciliation is insufficient, and an extensive chart review that includes reading all hospital discharge summaries and ensuring all medications have appropriate indications is necessary. Pharmacists should not be afraid to ask “Why?” Why is this patient on this new medication? Why is this patient no longer taking this other medication? Simply because a medication is part of an electronic record does not make it correct, and the pharmacist just might be the only person asking “Why?”
134
Rachel Comer, PharmD, MS, is geriatrics pharmacy fellow, Shenandoah University Bernard J. Dunn School of Pharmacy, Winchester, Virginia. Mitsi Lizer, PharmD, BCPP, is clinical pharmacy specialist in psychiatry, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa. For correspondence: Rachel Comer, PharmD, MS, Shenandoah University Bernard J. Dunn School of Pharmacy, 1775 North Sector Court, Winchester, VA 22601; E-mail: [email protected]. Disclosure: No funding was received for the development of this manuscript. The authors have no potential conflicts of interest. © 2015 American Society of Consultant Pharmacists, Inc. All rights reserved. Doi:10.4140/TCP.n.2015.130.
The Consultant Pharmacist MARCH 2015 Vol. 30, No. 3
A Case Report of a Decade-Old Medication Error
References 1. Cornish PL, Knowles SR, Marchesano R et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med 2005;165:424-9. 2. Tam VC, Knowles SR, Cornish PL et al. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. CMAJ 2005;173:510-5. 3. Wong JD, Bajcar JM, Wong GG et al. Medication reconciliation at hospital discharge: evaluating discrepancies. Ann Pharmacother 2008;42:1373-9. 4. Unroe KT, Pfeiffenberger T, Riegelhaupt S et al. Inpatient medication reconciliation at admission and discharge: a retrospective cohort study of age and other risk factors for medication discrepancies. Am J Geriatr Pharmacother 2010;8:115-26. 5. Climente-Marti M, Garcia-Manon ER, Artero-Mora A et al. Potential risk of medication discrepancies and reconciliation errors at admission and discharge from an inpatient medical service. Ann Pharmacother 2010;44:1747-54. 6. van Doormaal JE, van den Bemt PMLA, Mol PGM et al. Medication errors: the impact of prescribing and transcribing errors on preventable harm in hospitalised patients. Qual Saf Health Care 2009;18:22-7. 7. Stueurbaut S, Leemans L, Leysen T et al. Medication history reconciliation by clinical pharmacists in elderly inpatients admitted from home or a nursing home. Ann Pharmacother 2010;44:1596-603. 8. Zoni AC, Duran Garcia ME, Jimenez Munoz AB et al. The impact of medication reconciliation program at admission in an internal medicine department. Eur J Intern Med 2012;23:696-700. 9. The Joint Commission. Medication reconciliation. Sentinel event alert. 2006. Available at http://www.jointcommission.org/ SentinelEvents/SentinelEvents Alert/sea_35.htm. Accessed March 13, 2014. 10. Desai R, Williams CE, Greene SB et al. Medicaton errors during patient transition into nursing homes: characteristics and association with patient harm. Am J Geriatr Pharmacother 2011;9:413-22.
11. Garcia-Aparicio J, Herrero-Herrero JI. Medication errors detected in elderly patients admitted to an internal medicine service. Int J Clin Pract 2013;67:282-9. 12. Boockvar K, Fishman E, Kyriacou CK et al. Adverse events due to discontinuations in drug use and dose changes in patients transferred between acute and long-term care facilities. Arch Intern Med 2004;164:545-50. 13. King BJ, Gilmore-Bykovskyi AL, Roiland RA et al. The consequences of poor communication during transitions from hospital to skilled nursing facility: a qualitative study. J Am Geriatr Soc 2013;61:1095-102. 14. Vogelsmeier A. Identifying medication order discrepancies during medication reconciliation: perceptions of nursing home leaders and staff. J Nurs Manag 2014;22:362-72. 15. Kalb K, Shalansky S, Legal M et al. Unintended medication discrepancies associated with reliance on prescription databases for medication reconciliation on admission to a general medical ward. Can J Hosp Pharm 2009;62:284-9. 16. Duran-Garcia E, Fernandez-Llamazares CM, Calleja-Hernandez MA. Medication reconciliation: passing phase or real need? Int J Clin Pharm 2012;34:797-802. 17. Cumbler E, Carter J, Kutner J. Failure at the transition of care: challenges in the discharge of the vulnerable elderly patient. J Hosp Med 2008;3:349-52. 18. Lizer MH, Brackbill ML. Medication history reconciliation by pharmacists in an inpatient behavioral health unit. Am J Health Syst Pharm 2007;64:1087-91. 19. Paton C, McIntyre S, Bhatti SF et al. Medicines reconciliation on admission to inpatient psychiatric care: findings from a UK quality improvement programme. Ther Adv Psychopharmacol 2011;1:101-10. 20. Lexi-Drugs. Amiodarone. Available at http://online.lexi.com. Accessed May 3, 2014.
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error, Nursing facility, Transcription error, Transitions-of-care, Vulnerable populations. Abbreviations: ADE = Adverse drug event, A fib = Atrial fibrillation, BHU = Behavioral health unit, ED = Emergency department, EKG = Electrocardiogram, EMR = Electronic medical record, PCP = Primary care provider, TSH = Thyroid stimulating hormone, UTI = Urinary tract infection. Consult Pharm 2014;29:130-5.
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Introduction Unintended medication discrepancies may occur at any time in patient care, but patients are at especially high risk for these errors at transitions of care.1-5 Medication discrepancies occur in as many as 60.4% of hospital admissions, and up to half of these errors cause moderate to severe harm.1,2,6-8 Many of these errors are a result of incomplete medical histories and prescribing and transcribing errors.2,6 Medication errors and the risk of harm is such a problem that The Joint Commission added medication reconciliation to prevent errors to the 2005 National Patient Safety Goals.9 The elderly are more likely to incur medication errors, and though most studies do not include patients with poor cognition, there are those that do show that cognition and the inability to direct one’s own care are independent factors associated with transitions-of-care errors.2,4,5,10,11 Adverse drug events (ADEs) are more likely to occur in patients when medication changes are made transitioning from inpatient to long-term care or vice versa.12 Additionally, ADEs associated with inpatient changes most often appear after return to long-term care, and patients with more chronic comorbid conditions are more likely to experience these ADEs.12 A further complication is that nursing facility nurses report receiving unclear and sometimes incorrect information from hospitals, but they are not always able or willing to spend the time needed to decipher potential errors.13,14 Errors at transitions-of-care will not be eliminated by incorporating electronic tools such as computerized physician order entry as these do not substitute for a comprehensive medication history nor do they prevent transcribing errors.1,2,8,10 Inconsistencies between electronic medical records (EMRs) and actual patient use are common, and once an error has occurred and been incorporated into the patient record, the error is likely to be propagated.7,10,15 When communication is poor between hospitals and primary care providers and reluctance exists to question prescriptions written by other providers, the errors can snowball.13,16,17 A medication review gives a much more accurate picture of medication use and uncovers medication discrepancies not evident from a simple medication reconciliation.2,18,19
The Consultant Pharmacist MARCH 2015 Vol. 30, No. 3
A Case Report of a Decade-Old Medication Error
This case report describes a decade-old medication error in a nursing facility patient that was overlooked and snowballed into a second medication error during multiple transitions between the same hospital and nursing facility without detection by multiple health care providers at both facilities.
Case Presentation A 69-year-old Caucasian male, with more than a 25-year history of schizophrenia, was brought to the emergency department (ED) after threatening a nurse in his nursing facility with a coat-hanger. The staff at the facility reported that the patient was noncompliant with all medications and began exhibiting symptoms of paranoia and agitation. He was transferred to the behavioral health unit (BHU) under a temporary detention order for therapeutic stabilization. On admission to the BHU, physical findings included a weight of 76 kg and a height of 68 inches; and vitals included blood pressure of 105/67 mmHg laying down and heart rate of 69 beats/minute. Patient was experiencing orthostatic hypotension and found to have a urinary tract infection (UTI).
Past Medical History Past medical history for the patient included chronic obstructive pulmonary disease, hypothyroidism, hyperlipidemia, osteoporosis, gouty arthritis, and recurrent UTI. The patient had been hospitalized for both medical and psychiatric treatment many times in the past, including a five-year commitment to a state psychiatric facility, and subsequent placement in a nursing facility. The most recent psychiatric hospitalization was in 2009. Psychiatric diagnoses included paranoid-type schizophrenia, depressive disorder, and anxiety disorder. He had no known drug allergies. Laboratory values upon presentation to the ED are presented in Table 1. Home medication list upon presentation to the ED is presented in Table 2. Once admitted to the BHU, the student pharmacist on rotation obtained a medication history to reconcile inpatient medications with home medications. Since the patient was a poor historian, he was unable to corroborate current medications, and the student executed an extensive
chart review. It was noted that the patient did not have a current diagnosis of atrial fibrillation (A fib), nor any other diagnosis to justify the use of amiodarone 200 mg twice daily. All electrocardiograms (EKGs) performed during previous hospital admissions were unremarkable or normal, and none of the readers noted A fib. After reviewing admission, treatment, and discharge hospital records, it was determined that the patient was put on amiodarone 100 mg twice daily 10 years earlier because of a transcription error. After entering the hospital with chest pain, the admitting physician misspelled amantadine in the medication history and the nurse transcribed it as amiodarone. The EKG on admission showed normal sinus rhythm. The discharging physician noted that the patient had no arrhythmias in the discharge summary, but continued the “home med” amiodarone. Therefore, the patient entered the hospital in 2003 taking amantadine 100 mg twice daily and was discharged on amiodarone 100 mg twice daily. Seven years after this initial medication error, during a subsequent hospital admission, a second transcription error occurred. The medication administration record from the nursing facility listed amiodarone, one-half of a 200 mg tablet twice daily for the patient. Instead, amiodarone 200 mg twice daily was entered into the home medication list and the patient was discharged back to the nursing facility on the higher dose. The patient was continued on amiodarone 200 mg twice daily until the error was uncovered in 2013. Consultation with cardiology during a 2013 hospital admission resulted in confirmation that an error occurred and discontinuation of the amiodarone. The discharge note indicated the error and clearly stated that the patient had no history of A fib and should no longer receive amiodarone. A phone call was placed, and a letter was sent by the student pharmacist to the patient’s primary care provider (PCP) explaining the amiodarone error that occurred in the hospital and the discontinuation ordered by the cardiologist. The patient returned to the nursing facility after discharge and was readmitted to the hospital four months later in 2014 after falling and sustaining a hip fracture. The patient stated he was dizzy, as normally occurs when standing, and lost his balance while walking down the
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Case Study Table 1. Laboratory Results upon Admission to Emergency Department Specimen
Test
Blood
Glucose Sodium Potassium Chloride Carbon dioxide BUN Creatinine Calcium TSH Alcohol Salicylates Acetaminophen
Urine
Drug screen
UA
Leukocyte esterase WBC Bacteria Clarity
Urine
Culture
Result 119 mg/dL 140 mEq/L 4.5 mEq/L 106 mEq/L 19.2 mEq/L 23 mg/dL 2.01 mg/dL 10.5 mg/dL 0.14 mU/L Negative Negative Negative Negative 500 18 Rare Hazy > 100,000 CFU Klebsiella pneumoniae
Abbreviations: BUN = Blood urea nitrogen, CFU = Colony-forming units, TSH = Thyroid-stimulating hormone, UA = Urinalysis, WBC = White blood cells.
hallway. On this later admission it was discovered by the hospitalist that the nursing facility had resumed the amiodarone when the patient returned in 2013 despite the clear statements made in both the letter to the PCP and the discharge report that the patient did not have A fib and should no longer take amiodarone. The hospitalist wrote up the error in the consult and asked pharmacy to notify the nursing facility directly to remove amiodarone from the patient’s active medication list.
Discussion In this case report, the patient received amiodarone instead of amantadine because of a transcription error, which was compounded by a dose increase after a second transcription error over the course of 10 years before discovery. It is unknown if this error contributed to the
132
patient’s hypothyroidism, as this diagnosis predates the initial medication error. It is possible the bradycardia and orthostatic hypotension, which adds to fall risk, was related to the amiodarone since the half-life is 40 to 55 days.20 None of the health care providers involved in this patient’s care over the past decade noticed the medication error, and it was only uncovered via a complete medication review. The success of discovering and removing the erroneous medication was tempered by the reality that, upon discharge in 2013, the nursing facility resumed the inappropriate medication despite multiple efforts to communicate the error. Subsequently, four months later the patient fell, breaking a hip, in an event that may have been prevented.
The Consultant Pharmacist MARCH 2015 Vol. 30, No. 3
A Case Report of a Decade-Old Medication Error
Table 2. Patient’s Home Medication List upon Presentation to the Emergency Department Oral Medications
Strength/Dose
Frequency
Amiodarone Aspirin Bisacodyl Clonazepam Duloxetine Gabapentin Levothyroxine Multi-vitamin Olanzapine Pantoprazole Pravastatin Tamsulosin
200 mg 325 mg 10 mg 1 mg 20 mg 300 mg 250 mcg Unknown 10 mg 40 mg 40 mg 0.4 mg
1 tablet twice daily 1 tablet once daily 1 tablet at bedtime 1 tablet at bedtime 2 capsules once daily 2 capsules three times daily 1 tablet once daily 1 tablet once daily 1 tablet at bedtime 1 tablet once daily 1 tablet once daily 1 capsule once daily
Inhaled Medications Ipratropium/albuterol inhaler Albuterol nebulized
2 puffs twice daily Use with nebulizer every 6 hours as needed
Oral Medications, As Needed Lactulose Loperamide Acetaminophen
10 mg/15 mL 2 mg 325 mg
Medication errors at transitions-of-care is a topic of interest in the current literature, but the focus is generally on medication reconciliation alone to decrease errors and unintentional ADEs. A systematic review by Tam et al. points out that comprehensive medication histories that involve other resources (e.g., communication with community pharmacy or family physician) are more accurate than histories obtained from the patient.2 In a report of medication review practices of mental health admissions in the United Kingdom, Paton et al. reported an increased identification of medication discrepancies when more medication sources were referenced, specifically the PCP and the patient.19 Lizer and Brackbill found that a pharmacist-directed chart review, in addition to interviewing the patient, identified more medication
30 mL as needed 2 tablets every 6 hours as needed 2 tablets every 6 hours as needed
discrepancies on admission to an inpatient BHU than a patient history alone.18 The lack of research on medication errors in vulnerable patients, such as the elderly, the mentally ill, and the cognitively impaired, represents a significant gap in patient care. These patients are poor historians, and obtaining a patient history and/or conducting medication reconciliation is insufficient to detect medication discrepancies. This is compounded by poor communication between hospitals and long-term care facilities, which nurses note is the single largest barrier to providing a safe transition.13 In the current medical system, there is no single point of accountability when the patient is unable to assume responsibility of care for him or herself. Adding to this, the ineffective cross-organizational communication essentially guaranteed that the medication
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Case Study Summary
Take-Home Points • Medication reconciliation without a medication review that includes asking why a medication is present or absent may overlook medication errors at transitions-of-care. • Incorporation into an electronic medical record does not guarantee the accuracy of the medication list. • When continuity in care is lacking between nursing facilities and hospitals, there is an opportunity for the consultant pharmacist to create
In the case of our schizophrenic patient, a single comprehensive medication review uncovered a medication error that was undetected through 10 years of medication reconciliation. Although the error was discovered and communicated via discharge note and personal letter, the error was once again propagated at the nursing facility, illustrating the communication barrier that exists at transitions-of-care. Better methods of medication review and communication, as well as a focus on medication review upon return to long-term care, need to be addressed as significant means of decreasing medication errors for vulnerable populations.
that continuity.
error would persist despite the initial identification and intervention. There are two main questions this case brings to light: “Who is responsible?” and “How can we prevent these errors from happening or continuing?” While the ultimate responsibility falls to the PCP, there are other health care providers who can step in and close the gaps, and transitioning to and from nursing facilities represents one of these gaps. For example, a consultant pharmacist is uniquely poised to bridge this gap by broadening the scope of the monthly mandated medication chart review. Medication reconciliation is insufficient, and an extensive chart review that includes reading all hospital discharge summaries and ensuring all medications have appropriate indications is necessary. Pharmacists should not be afraid to ask “Why?” Why is this patient on this new medication? Why is this patient no longer taking this other medication? Simply because a medication is part of an electronic record does not make it correct, and the pharmacist just might be the only person asking “Why?”
134
Rachel Comer, PharmD, MS, is geriatrics pharmacy fellow, Shenandoah University Bernard J. Dunn School of Pharmacy, Winchester, Virginia. Mitsi Lizer, PharmD, BCPP, is clinical pharmacy specialist in psychiatry, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa. For correspondence: Rachel Comer, PharmD, MS, Shenandoah University Bernard J. Dunn School of Pharmacy, 1775 North Sector Court, Winchester, VA 22601; E-mail: [email protected]. Disclosure: No funding was received for the development of this manuscript. The authors have no potential conflicts of interest. © 2015 American Society of Consultant Pharmacists, Inc. All rights reserved. Doi:10.4140/TCP.n.2015.130.
The Consultant Pharmacist MARCH 2015 Vol. 30, No. 3
A Case Report of a Decade-Old Medication Error
References 1. Cornish PL, Knowles SR, Marchesano R et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med 2005;165:424-9. 2. Tam VC, Knowles SR, Cornish PL et al. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. CMAJ 2005;173:510-5. 3. Wong JD, Bajcar JM, Wong GG et al. Medication reconciliation at hospital discharge: evaluating discrepancies. Ann Pharmacother 2008;42:1373-9. 4. Unroe KT, Pfeiffenberger T, Riegelhaupt S et al. Inpatient medication reconciliation at admission and discharge: a retrospective cohort study of age and other risk factors for medication discrepancies. Am J Geriatr Pharmacother 2010;8:115-26. 5. Climente-Marti M, Garcia-Manon ER, Artero-Mora A et al. Potential risk of medication discrepancies and reconciliation errors at admission and discharge from an inpatient medical service. Ann Pharmacother 2010;44:1747-54. 6. van Doormaal JE, van den Bemt PMLA, Mol PGM et al. Medication errors: the impact of prescribing and transcribing errors on preventable harm in hospitalised patients. Qual Saf Health Care 2009;18:22-7. 7. Stueurbaut S, Leemans L, Leysen T et al. Medication history reconciliation by clinical pharmacists in elderly inpatients admitted from home or a nursing home. Ann Pharmacother 2010;44:1596-603. 8. Zoni AC, Duran Garcia ME, Jimenez Munoz AB et al. The impact of medication reconciliation program at admission in an internal medicine department. Eur J Intern Med 2012;23:696-700. 9. The Joint Commission. Medication reconciliation. Sentinel event alert. 2006. Available at http://www.jointcommission.org/ SentinelEvents/SentinelEvents Alert/sea_35.htm. Accessed March 13, 2014. 10. Desai R, Williams CE, Greene SB et al. Medicaton errors during patient transition into nursing homes: characteristics and association with patient harm. Am J Geriatr Pharmacother 2011;9:413-22.
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