Medication Reconciliation: Scarier Than All of Halloween's Horrors

Oct 30, 2020

Adverse drug events (ADE) are a leading cause of patient harm and death worldwide. Almost 70% of patients’ medication histories noted upon patient admission to hospital have at least one error, with 30 – 80% of patients having a discrepancy between the medicines ordered in hospital and those they take at home. Here is one patient example of the dangers and frustrations of poor medication reconciliation.

In preparation for an upcoming surgery, a patient & their carepartner followed up with all the patient’s care team and the patient’s primary care physician (PCP) to discuss the patient’s upcoming surgery & medications. The patient has multiple comorbidities with an extensive prescription history list that includes 30+ medications over their lifetime, with 20+ medications currently being actively taken on a routine basis. The carepartner accompanies the patient to help coordinate care and reduce friction due to language and health literacy barriers, hearing loss, and the complexity of navigating multiple comorbidities managed by numerous physicians across various health systems.

To prepare for these appointments and discussions, the patient and their carepartner printed out a copy of all the patient’s medications from their PCP’s patient portal. The patient and carepartner carefully reviewed the list of drugs and noted any discrepancies, such as over-the-counter (OTC) medications that were missing or prescriptions that were discontinued. Medications were discussed with each respective prescribing physician, including confirming their names, dosages, frequencies, their impact on surgical outcomes, and if any needed to be stopped in preparation for surgery. Upon completing all the follow-ups with the entire care team, this patient now had a comprehensive, up-to-date list of medications they deemed their Master Medication List.

The patient provided a copy of the Master Medication List with their new patient intake forms for their new patient surgery consultation appointment. The surgeon’s office was a private practice which currently does not have an EHR.

The following week, the patient & their carepartner went to a pre-admission testing appointment at the hospital for surgical clearance. An internist, who was not the patient’s regular PCP, reviewed all of the patient’s medications using pharmacy prescription records, not the copy of the Master Medication List that was provided by the patient that was also just given to the surgeon. This created a tense and frustrating situation as the patient felt ignored and not heard.

The internist also said she could not “see” the list of medications that was confirmed with the surgeon at the surgical consultation because they don’t send that information to the hospital even though the doctor is affiliated with the hospital and would be performing the surgery there. The patient and carepartner were bewildered and now even more concerned.

This is a significant workflow, interoperability, & patient safety concern.

In the days before surgery, the patient received numerous calls from the hospital and surgical team. Many of the calls reviewed prescriptions using the outdated prescription history files, not the patient’s curated master list. No one was willing to start with the patient’s Master Medication List or hear the patient’s concerns. At this juncture, the patient & carepartner were gravely concerned about safety & communication.

Upon being admitted into the pre-surgical unit on the day of surgery, the medication reconciliation chaos resumed.

A pre-operative nurse pulled up the medications, referring to the historical, outdated prescription history list.

The carepartner needed to frantically pull out notes while the patient was being prepared for surgery. Thankfully the carepartner had a copy of the patient’s Master Medication List on hand to help facilitate the process.

The nurse, patient, & carepartner were interrupted during the medication reconciliation process multiple times by PAs, surgical consent forms, a visit from anesthesiology, the surgeon, & security picking up the patient’s belongings for storage. The interruptions made it more difficult for the nurse, patient, & carepartner to correct all the information. An additional challenge was that the nurse referred to many drugs by a different name than the patient and carepartner understood. The nurse may have been referring to medications by their generic drug name while the patient and carepartner, in some cases, were accustomed to the brand or trade name. Now the carepartner was also trying to furiously Google drug names to be sure that they were correct.

In addition to working through the list, the nurse asked:

what medications the patient did and didn’t take the morning of surgery?
what time the patient took the drugs that they did take?
what medications were temporarily discontinued in preparation for surgery & when?
what medications was the patient no longer taking in general?

At this point, everyone at the pre-op bedside was incredibly frustrated.

The patient was overwhelmed & panicked that there would be a medication error, the anxiety was exacerbated by the fact that the carepartner could not be at the bedside post-operatively due to strict COVID19 protocols. All of this took place moments before the patient needed to be wheeled in for a complicated surgery with many potential risks and anticipated difficult recovery.

This level of chaos and disorganization can be substantially improved and harm reduced if patients and carepartners are:

coached about the importance of medication reconciliation
guided as to how to create their Master Medication List
recognized as essential contributors to their safe, well-coordinated care.

With the cultural shift from paternalistic to participatory medicine, patients and their carepartners want to brief their medical team and be active contributors to patient safety & outcomes, to reducing costs and improving communication.

Patients should not be given paperwork and information unidirectionally. Care teams need information from the patient & carepartner to be successful in delivering safe care.

Patients & carepartners need to be better prepared with updated, safer ways of confirming & reconciling medications, especially pre-operatively and during any care transitions. Identifying medication discrepancies between what may be listed in the hospital or care team’s EHR and the realities of what a patient IS taking is a serious matter of patient safety to ensure proper, safe care.

Patients can and should prepare their Master Medication List, whether in preparation for an upcoming surgery or for continuity of care. This list should detail what medications, prescription or OTC, a patient is or is no longer taking. Patients should request their medical records from each member of their care team and confirm their current treatment plans to make their master list. There are several resources that patients and carepartners can use to help guide the creation of their medication master list, including from the Agency for Healthcare Research and Quality (AHRQ), the American Society of Health System Pharmacists (ASHP), and the World Health Organization (WHO). Programs such as Vials of Life may also help patients and their carepartners with medication reconciliation efforts.

Let’s reduce the number of medication errors, adverse drug events, poor transitions of care, and emergency room visits due to medication discrepancies by empowering patients and their carepartners with their medical records and guiding them on advocating for their health and safety. Horror stories should be associated with Halloween, not healthcare.

Medication Reconciliation: Scarier Than All of Halloween's Horrors

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