Archive for category Prescription management

Deprescribe — too many medications

bottle_of_medsMany patients take too many medications which leads to unnecessary side effects, drug interactions and high cost.  Yet physicians sometimes fight just to get patients to take necessary medications.  Two examples:

  1. Provider:  How many medications are you taking?
    Patient:  Including vitamins I think fifteen.
    Provider:  What? I only have two medications on my list.
    Patient:  I restarted all the medications I was taking before you hospitalized me plus all the new prescriptions from when I left the hospital and I added some vitamins.
  2. Patient:  I stopped that medication because I thought it was causing my hair to fall out.
    Provider:  Your heart medication does not cause hair to fall out.  And, even if it did you could die without it.

The medications you take should be reviewed at each visit so you and the provider consider which are truly needed and why.  The provider who gives the patient a prescription is responsible to make sure there is no interaction or duplication with ongoing treatment.  Yes, that means cardiologists and dentists also.  A proactive patient should simply ask, “Is that new medication compatible with all of my existing medications and does it replace one of the existing medications?

The highest risk situation for evaluation of medications happens when alternate providers become involved.  Like a hospital doctor, an ER doctor or a specialist.  They tend to add medications without fully considering the existing medications, often thinking the primary provider will resolve any drug issues — too bad when a fill-in primary provider steps into the mix.

An article in the Washington Post January 28, 2017 by Dr. Ranit Mishori advises the following questions for providers and patients to consider together about medications:

● What is this medication, and why am I taking it?
● Are there non-pharmacologic options to treat this condition?
● How long do I need to be on it?
● What are the benefits of continuing to take it?
● What are the possible harms of using that medication?
● Do any of my medications interact with any another?
● Can I lower the doses of any of these medications?
● Which of my medications are more likely to be nonbeneficial considering my age, my other medical conditions and my life expectancy?
● Are there any medications I can get off completely?

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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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Prescriptions — the missing manual

samplerx

The above prescription example comes from Medical School Headquarters intended as an example of what doctors should NOT do — that is to issue handwritten prescriptions.  There are just so many possibilities for error mostly coming from illegibility.  Also, errors from inadequate information provided to the pharmacist and the patient.

Electronic prescribing is unquestionably the best solution.  Patients should choose prescribers who use computer software to send prescriptions to the pharmacy.  In fact, prescribers who don’t use computers to do this are dinosaurs soon to be extinct — perhaps it would be a good time to leave that office practice and find something more modern.

You might think electronic prescribing solves all the problems, NOT SO.  Just ask any patient taking a few medications on a regular basis!  Here is what they say:

  • My office appointments never match when prescriptions expire –so I either have to change appointment times or hope the office will renew the prescription early — always involves a phone call and wastes my time.
  • I had no idea the doctor prescribed a brand name drug instead of a generic and I got hit with an unnecessary huge bill.
  • The doctor has no idea how much medications cost.
  • I need 90 day prescriptions for some things and 30 day prescriptions for other things but they can’t get it straight.
  • My doctor’s computer system can’t send things to my mail order pharmacy
  • I have to send prescriptions to my mail order pharmacy myself — usually they are the handwritten type and sometimes the pharmacy can’t read them.
  • If my doctor issues a duplicate prescription so it will last until my next visit sometimes I get more medication (and cost) than I need.
  • Often generic medications are less expensive if I purchase them without involving insurance — the pharmacist sure does not tell me that!

Here are some prescription suggestions for PATIENTS:

  • ALWAYS take a list of prescriptions with you to health care appointments (or just take the bottles, but there is a risk of loosing expensive medications in the process).
    • Your record should include the name of the medication (brand name if appropriate) and generic name
    • Dose — that means the size (mg) of the pills and number taken, or amount of liquid (ml) or strength (%) of a cream or ointment
    • How often taken and whether scheduled or as needed
    • Why the medication is taken
    • Number of doses of medication prescribed AND exactly how many days that covers (like 30 day supply)
    • When that medication will expire and need refill
    • The pharmacy phone number and FAX number (the latter is very important for mail order pharmacies)
  • ASK if a new medication is generic and if not if a suitable generic is available.  Or, if a suitable generic in the same drug family is available.
  • ASK if the medication is short term or long term.  If it is long term usually ask for 90 day supply with 3 refills (if insurance will approve).  And, use mail order services advised by the insurance company since they are usually less expensive.
  • BEFORE leaving the prescribers presence ask if the number of refills on a new prescription will last until next appointment?  And, ask for an extension of refills for older prescriptions that will expire before the next scheduled visit (otherwise you get the fun of calling the nurse for refills)
  • If a specialist prescribes a medication ASK if the specialist plans on long term follow-up and providing refills — if not what communication with primary care will convey the needed prescription information.  But, if the specialist plans on managing the medication expect a full review of all medications to avoid duplicate prescribing and adverse drug interactions.

Here are some prescription suggestions for PRESCRIBERS:

  • Consider the cost of medications — you can’t do that if you don’t find out how much they cost, especially the brand name drugs
  • Prescribe the lowest cost alternative.  Before prescribing a brand name drug ask if you are sure there is a real cost benefit over an older generic.  If you don’t know, find out.
  • Don’t prescribe antibiotics for viral infections
  • Think about refills, don’t just write some arbitrary number.  Make sure the patient has enough refills and will not have to call your nurse to get them.  Contrary to popular belief patients do not like to go the the pharmacy — give 90 day prescriptions where possible.
  • Have a patient Internet portal to deal with medication refill issues.
  • Although it’s nice to compute the number of pills a patient will need it is sometimes better for insurance reasons to say the number of days of medication is needed ( 7 days, 90 days etc.)
  • To avoid duplicate prescriptions when the patients prescription will not last until the next scheduled visit the following statement is helpful “extend existing active prescription so refills last until ____ “(e.g. a year from today).  Sometimes: “stop refills on current active prescription.  This is a replacement so note the changes.”
  • Most mail-order pharmacies will take either electronic prescriptions or faxed prescriptions — it is not rocket science to get those numbers into the electronic prescribing system — make it happen.

Finally, sloppy prescribing causes patient injuries, provider law suits, extra time, and extra costs for both the patient and the prescriber.  Electronic prescriptions are a step in the right direction but they are now mostly geared for pharmacists and not the real-world problems of patients.  The integration of pharmacies within care delivery systems (e.g. an ACO) is an urgent need.

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