Category: Medication Safety

Hospitals & Health Networks: “Despite progress, medication reconciliation remains a bitter pill. Un-intended changes in medications occur in one-third of all patients transferred between hospital departments, and in 14 percent of patients at hospital discharge, according to the Agency for Healthcare Research and Quality.

Most medication inconsistencies could be avoided if reconciliation were performed at patient admission, transfer and discharge. Hospital information systems are helping some wired hospitals rdo this across the care continuum despite the lack of a universal solution.

Medication reconciliation was designated a 2005 National Patient Safety Goal by the Joint Commission, which recommended that organizations accurately and completely reconcile medications across the continuum of care. In 2009, however, the commission announced it would no longer score medication reconciliation during on-site accreditation surveys, because of difficulties with implementation strategies. Then, in December 2010, the commission announced a new version of the NPSG (08.01.01), to be effective July 1 of this year. According to the commission, the new streamlined version focuses on critical-risk points in the medication reconciliation process.

The Institute for Safe Medication Practices still is disappointed in the current status of medication reconciliation. “It’s not what we expected for a process that on the surface seems so simple,” says Stu Levine, an ISMP informatics specialist.”

I received a link to this article through the Healthcare IS – Pharmacy IT/Pharmacy Informatics CPOE Group on LinkedIn. The article is titled “Medication Reconciliation Only as Good as the IT Allows”. I find the title a little strange, and a bit misleading. Consider that the medication reconciliation process is best handled by diligence among healthcare providers, not IT. The technology to provide clinicians with medication lists is only a tool to make the process easier. Reconciling a patient’s medications is at best a difficult task. The “general public” knows surprisingly little about their own medications; including the simplest of things like names and doses. Getting physicians to reconcile a medication list isn’t much better. More often than not they simply sign the “transfer med list” without really scrutinizing what’s on it.

Unfortunately the article makes it sound like a simple process of looking at the medication list on admission, transfer and discharge. It really isn’t as simple as that. We utilized this process at my previous hospital and I can tell you that we were lucky to have a patient medication list that was accurate. Most were haphazard attempts that lead to confusion and lots of phone calls and clarification.

I was reading through the most recent issue of the ISMP Medication Safety Alert! and came across an incident where a CLINIMIX E solution was infused on a patient prior to being mixed, resulting in the patient receiving a concentrated dose of amino acids and electrolytes. Fortunately no harm was done.

CLINIMIX E is a dual chamber parenteral nutrition (PN) product consisting of two chambers separated by a seal. One chamber contains dextrose and calcium and the other chamber amino acids along with electrolytes. Simply bust the seal, mix the contents with some gentle agitation and hang it on the patient. Nothing could be easier. I loved these types of products when I used to work in the IV room. They don’t fit the bill for all patients, but when they do it sure makes life in the pharmacy simpler. Otherwise you have to make the PN from scratch which can be time consuming.

In the incident described in the ISMP article the CLINIMIX E bag was retrieved from the pharmacy after hours by nursing staff. This type of procedure is common in hospitals that don’t have a 24 hour pharmacy, i.e. small acute care hospitals. I think this type of system is dangerous, and certainly contributed to the mistake, but that’s not what stands out about this error.

The two things that really irritate me about this error are the physician’s directions and the nurses retrieving and starting a PN in the middle of the night. First and foremost, PN is never a life or death medication. Take a look at the ASPEN guidelines if you don’t believe me. PN is something that should only be used after serious consideration, and in a patient that has been NPO for several days. PN should never be used to adjust a patient’s electrolytes, temporarily augment a patients diet when they can eat solid food or to “stimulate appetite”. In this case if the patient needed PN it could have easily waited until morning. And second, the physician in this case wrote for the CLINIMIX E to be given “’if the patient does not eat at least 50% of breakfast.” For those of you that think this order is ok, raise your hand. Now everyone look around and find the people that raised their hands. Make a mental note to never allow them to treat you for anything serious. Again, PN is serious business and not something that should be started based on an “if, then” statement. Either start it or don’t, but don’t write orders for PN that may be interpreted more than one way depending on who’s looking at it.

Errors occur too frequently in hospitals now, we certainly don’t need to make committing them any easier.