Medication Reconcilliation Screwups

[sdn1977]

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You may all know I think this new medication reconcilliation paperwork is just that - paperwork & accomplishes NOTHING!

Well....I had actual experience with it from the pts perspective this last week when I was at my mom's discharge from acute ortho rehab after a broken hip.

Her discharge orders were 180 degrees from what she was taking 2 weeks prior. Her medication reconcilliation sheet was there - fully filled out when she went from ER to acute inpt to OR to PACU to post op acute ortho to acute ortho rehab. Along the way...orders changed...but MD's changed also.

The one MD who stayed the same was the surgeon who admitted he knows nothing about her antihypertensives & left all that up to the hospitalist who then passed it off to the PMR dude in the rehab. No one knows why doses were changed & drugs were stopped (I have friends/old classmates who work this hospital - they admitted, no one looks at this - the nurses just fill it out).

This is a HUGE hospital (btw...a teaching hospital for USC pharmacy school Zpak!). The reality...her discharge medication instructions took all of 2 minutes....the nurse read what was on the discharge order & asked if she had any questions. When she asked about her other medications, the answer was - that information might be in the acute chart...but that was filed in medical records a week ago when you came to rehab & to ask her primary about it.

The system is BROKEN (one reason why I left it full time). We really need to have pharmacists communicate directly with pts & their families during the course of their stay & do discharge instruction. (However - she was asked twice during her 2 week stay - acute & rehab - if she was pregnant - SHE'S 87!!!!!!)

The new medication she was prescribed - for pain...I dropped off at her retail pharmacy & I picked it up. Essentially, she was given NO discharge medication instruction - from the hospital staff or retail staff.

Is it any wonder why pts get readmitted for medication issues??????

As of now...we are following bp bid, checking ankles for edema (because both antihypertensives & diuretic were dc'd somewhere sometime....) & will start them slowly as her condition is stabilized in the home & try to get an appt w/ the primary next week....altho the surgeon doesn't want her to be in a car😱 .

So, Zpak.....as I said....it is paper - nothing more than paper!!!

OK - rant over! Whew - I feel better😛

 

[rxlynn]

It doesn't work well from the retail perspective either. I'm not even working that much right now, and I've had two experiences in the past two weeks when patients clearly had no idea why there were certain meds on the discharge form, or (and this seems to be more common) meds they were on had dosage changes from the hospital doc, and then the patient/patient's daughter/whoever and I stand at the in window of the pharmacy and try to figure out which ones need to be filled and which ones don't. Our local hospital likes to write all the OTCs on the same form(maybe that's what they are required to do??), so we get to explain to the patient that no, we cannot fill their iron supplement/stool softener/etc.

 

[Caverject]

soapbox anybody?

 

[sdn1977]

soapbox anybody?

thank you!!! do I hear applause?????

 

[DHG]

The system is BROKEN (one reason why I left it full time). We really need to have pharmacists communicate directly with pts & their families during the course of their stay & do discharge instruction.

Yes!

I've been through it with my dad several times in the last couple years and it is RIDICULOUS. I mean, it needs to be done right and discharge counseling should be done by someone who knows what's going on and can answer questions (AKA a pharmacist).

Maybe at least the documentation will provide data to show at a later date what works and what doesn't... what I mean is maybe even though it is "just paperwork" it will help things get better in the future. It can potentially show who does the job the best (I think pharmacists potentially would do this the best of any healthcare professional).

Obviously the reconciliation thing is a HUGE issue... an artifact of just how bad the communication breakdown gets when patient see so many different people in the system. I wonder how much money will be wasted and how many lives lost/impacted for NO REASON other than poor communication before things change. I think if more patients knew how big of a problem it was/how many mistakes are made that they would DEMAND a pharmacist's services in the hospital. They'd riot if they really knew the implications of what's (not) happening now.

 

[ZpackSux]

You may all know I think this new medication reconcilliation paperwork is just that - paperwork & accomplishes NOTHING!

Well....I had actual experience with it from the pts perspective this last week when I was at my mom's discharge from acute ortho rehab after a broken hip.

Her discharge orders were 180 degrees from what she was taking 2 weeks prior. Her medication reconcilliation sheet was there - fully filled out when she went from ER to acute inpt to OR to PACU to post op acute ortho to acute ortho rehab. Along the way...orders changed...but MD's changed also.

The one MD who stayed the same was the surgeon who admitted he knows nothing about her antihypertensives & left all that up to the hospitalist who then passed it off to the PMR dude in the rehab. No one knows why doses were changed & drugs were stopped (I have friends/old classmates who work this hospital - they admitted, no one looks at this - the nurses just fill it out).

This is a HUGE hospital (btw...a teaching hospital for USC pharmacy school Zpak!). The reality...her discharge medication instructions took all of 2 minutes....the nurse read what was on the discharge order & asked if she had any questions. When she asked about her other medications, the answer was - that information might be in the acute chart...but that was filed in medical records a week ago when you came to rehab & to ask her primary about it.

The system is BROKEN (one reason why I left it full time). We really need to have pharmacists communicate directly with pts & their families during the course of their stay & do discharge instruction. (However - she was asked twice during her 2 week stay - acute & rehab - if she was pregnant - SHE'S 87!!!!!!)

The new medication she was prescribed - for pain...I dropped off at her retail pharmacy & I picked it up. Essentially, she was given NO discharge medication instruction - from the hospital staff or retail staff.

Is it any wonder why pts get readmitted for medication issues??????

As of now...we are following bp bid, checking ankles for edema (because both antihypertensives & diuretic were dc'd somewhere sometime....) & will start them slowly as her condition is stabilized in the home & try to get an appt w/ the primary next week....altho the surgeon doesn't want her to be in a car😱 .

So, Zpak.....as I said....it is paper - nothing more than paper!!!

OK - rant over! Whew - I feel better😛

LAC-USC???? No you didn't let your mom go there???

Medication Reconciliation system and concept are sound and it will get better when everyone has a medical record ID. Current process and practice may be broken...does not mean we should abandon it... rather improve it. That's why we have CQI... I mean PI.

 

[bananaface]

One of the local big hospitals here does reconciliation and med counseling at discharge. Isn't it going to be required soon?

 

[sdn1977]

LAC-USC???? No you didn't let your mom go there???

Medication Reconciliation system and concept are sound and it will get better when everyone has a medical record ID. Current process and practice may be broken...does not mean we should abandon it... rather improve it. That's why we have CQI... I mean PI.

LAC - No! Absolutely not! Long Beach Memorial....USC students do some elective rotations there.

Yeah.....it shouldn't be abandoned...but, I disagree it should have ever been started. The system was in place where the medications were rewritten upon acuity level of care change & that could have been improved, but we started a completely new "form" which I don't feel does what it should from a pharmacists perspective & now I don't feel it does what it should from a patient's perspective. So...now that we have it....we need to fix it.

I'm curious...what encompasses your quality feedback with regards to this? Who do you survey - the pt, the family, the other providers of care, the primary or the admitting specialist? What would be the criteria for a "fix"?

 

[sdn1977]

One of the local big hospitals here does reconciliation and med counseling at discharge. Isn't it going to be required soon?

I'm not sure it is actually going to be a JCAHO criteria or standard, but I firmly believe it should be. I haven't seen the new set of standards which I think come out in 2007.

In the 1980's it was "standard of practice" (not JCAHO) that all pts discharge medications were counseled by a hospital pharmacist. We didn't have all these official "hoops" we had to jump through....we just found a need & filled it.

To me...it makes trememdous sense to counsel in the hospital, but it takes time & time means money & staff. However...if you've ever done an admit audit for your own hospital for readmits for medication issues, you'd be surprised at how many there are & how close they come to the national averages.

So....its a balance & now with MTM in the community, there will be less pressure put on the acute side & more on the community side. That's good too, but MTM will take decades to be in place for everyone.

Its not unique to our area of practice....again my own family's situation...before I left, my mom was visited by the home health nurse, OT & PT...all on the same day. Each one did their own hx of her illness & her previous level of activity - they took a copy & left a copy with her "home chart".....but did any of them read the other's? - no.....the same questions exactly were asked all 3 times & it was all covered in the discharge h&p which was sent by the physician, so had they read that...they would have seen clearly what her level of care was & what the tx goal is. (I know....I read the home chart). Oh - none of them had a copy of the medication reconcilliation sheet - another obvious set of folks who should have gotten it.

Unfortunately, I think healthcare has become more fragmented rather than cohesive as it should be & I fear we as pharmacists are a part...