Leaving the hospital — what meds to take?

medlistHospital medication errors are very frequent.  A commonly quoted figure is one error every day of a hospitalization.  Meaning: wrong drug or wrong dose or wrong time or missing dose.

Consequently, it should not come as a surprise  the instructions patients are given when they are sent home have frequent errors.  Patients may be taking medications before they are hospitalized, so in addition to new medications those pre-existing medications need to be considered (a process called “medication reconciliation”).

You may ask:  how can this be goofed up?  A person has medications at home, the doctor writes a new prescription just before going home, the prescription is filled by the local pharmacy, and the prescription is taken in addition to the same medications as before.  What could be more simple?

The answer is: there is plenty of room for error!  What if:

  • the new medication is actually a generic duplicate of a brand name home medication
  • the new medication has severe interactions with a home medication
  • the home medication dose is listed incorrectly
  • the new medication prescription and the discharge instructions don’t match
  • a new medication prescription was omitted
  • a doctor outside the hospital is unaware of the new medication and prescribes something that interacts badly
  • the patient get an allergic reaction to the new medication but the prescriber is not available to help
  • the patient forgot to mention some of the home medications
  • unnecessary brand name drugs are prescribed that are not covered under the outpatient insurance plan
  • the prescriber forgot to tell the patient to stop some of the home medications that were causing symptoms prior to hospitalization

NOT SIMPLE AT ALL.

Yet, hospitals and prescribers often don’t take much time to get the medications right at discharge (there is a big push to get the patient out the door as soon as possible).  Here is an actual example from 2 weeks ago:

A patient was admitted from a care center with an accurate list of medications.  The admitting nurse transcribed the list into the medical record but made a mistake on one dose.  The physician’s plan was to reduce the does of another medication which seemed too strong but the patient was not taking any medications by mouth at that point so no medication orders were written.  A few days later the patient was ready to leave the hospital.

Unfortunately, a different physician discharged the patient rather than the one that admitted the patient.  The nurse’s list of home medications was used to generate the discharge medication instructions — no new medications were ordered.  But, the transcription error of the nurse was included with the instructions and the plan to reduce the dose of another medications was forgotten.  Two major errors.  The family actually realized the errors but the nurse the family informed forgot to call the doctor so no change to the list was made so the care center followed the flawed instructions.

So what went wrong?

  1. Duplicate lists of home medications were collected but the transcription error was not detected because the lists were not compared.
  2. The list of medications used during the hospital stay was not marked as equal to or changed from home medications.
  3. The planned change in home medications was not made because there was no place to put such a reminder for discharge in the hospital chart.
  4. The prescriber did not review the medications with the patient or family personally.

Worse yet, although errors happened there was no plan to change the system to prevent similar errors in the future.

So, as a patient or family member what can you do?

  1. ALWAYS bring multiple copies of an accurate list of home medications to the hospital — give a list to anyone that asks to review the medications.
  2. Expect the attending physician to review the discharge instructions with the patient or appropriate family member — if this does not happen immediately complain and make that expectation known.  Good physicians plan ahead and sometimes do this review the day before discharge!
  3. Use one of the copies of the home medication list to compare to the discharge instructions.  Make sure to understand ANY changes.  And ask — does the new medication, if any, interact with home medications?
  4. Find out who to call if questions or problems with the medications arise after getting home — get a name and phone number.  Often the discharging nursing unit will take the call and find the right person.

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