Practical guide for caregivers helps avoid medication errors

By Micha Shalev

During an episode of illness, older patients may receive care in multiple settings, putting them at risk for fragmented care and poorly-executed care transitions.

In the course of illness, a patient may interact with nurses, therapists and physicians in a hospital, skilled nursing facility, assisted living, rest home or home setting with home care. And finally, in an ambulatory clinic setting.

Such care is often fragmented without coordination. The negative consequences may include the duplication of services, inappropriate or conflicting care recommendations, medication errors, patient and caregiver confusion and distress. Higher costs can occur due to re-hospitalization or use of the emergency department. These events might have been prevented if there was a smooth transition from hospital to home. But, many times information gets lost during transfer from the emergency room to the hospital admitting floor.

Make sure that the facility has a system to collect and document information about all current medications for each patient and that the list of all medications is available during admission, transfer, discharge and outpatient visits.

Suggested information to be collected includes:

•Prescription and non-prescription (over-the-counter) medications, vitamins, nutritional supplements, potentially interactive food items, herbal preparations, and recreational drugs.

•The dose, frequency, route and timing of last dose. Whenever possible, validate the home medication list with the patient and determine the patient’s actual level of compliance with prescribed dosing.

The source(s) of the patient’s medications. As appropriate, involve the patient’s community pharmacist(s) or primary care provider(s) in collecting and validating the home medication information.

•A comparison of the patient’s medication list with the medications being ordered to identify omissions, duplications, inconsistencies between the patient’s medications and clinical conditions, dosing errors and potential interactions.

•A process for updating the list — as new orders are written — to reflect all of the patient’s current medications, including any self-administered medications brought into the organization by the patient.

•A process for ensuring that, at discharge, the patient’s medication list is updated to include all medications the patient is to be taking following discharge — including new and continuing medications and previously discontinued ‘home’ medications that are to be resumed. The list should be communicated to the next provider(s) of care and also be provided to the patient as part of the discharge instructions. Medications not to be continued should ideally be discarded by patients.

•Clear assignment of roles and responsibilities for all steps in the medication reconciliation process to qualified individuals, within a context of shared accountability. Those may include the patient’s primary care provider, other physicians, nurses, pharmacists and other clinicians as well as the primary caregiver(s).

•Access to relevant information and to pharmacist advice at each step in the reconciliation process.