Home Commentary Improving med rec: Let’s start a discussion

Improving med rec: Let’s start a discussion

When patients are transferred, meds are often omitted

A discussion concerning medication reconciliation
Getty Images: Cameravit

AFTER WORKING as a hospitalist for several years, I’ve spent the past 10-plus years as a medical director for a long-term acute care (LTAC) hospital, a job I love.

But that means all my patients are admitted from other acute care hospitals—usually from ICUs—with a lot of complications and a long list of transfer medications. I find I’m increasingly frustrated by the medication reconciliation that needs to take place when patients are being transferred to a long-term facility like mine.

I understand that hospitalists can likewise be frustrated with quality improvement efforts targeting issues like medication reconciliation. But discharge medications are of paramount importance. Getting med rec wrong not only makes the work of accepting physicians (like myself) more difficult, but it poses a huge safety risk for patients. An article in the December 2010 issue of Annals of Pharmacotherapy looked at how often medication-reconciliation errors occur in hospitals when patients are transferred between units.

Getting med rec wrong poses a huge safety risk for patients.

That research found that at least one error (typically, an omitted medication) occurred in 62% of internal transfers.
That result doesn’t sound far off from my own experience. That’s why we—and I’m writing this with my daughter, an inpatient pharmacist—want to start a discussion about what changes and initiatives might make sense to ensure safer handoffs.

Common problems
Over my career, I’ve witnessed an explosion of information technology that, I believe, has had a positive impact on my practice. But in terms of medication reconciliation, technology has also made it much easier for us to be less vigilant and to allow errors to occur. One common error I see is that hospital physicians have checked “select all” for medications when patients are being transferred, instead of going through the medication list one by one and weeding out therapies that patients no longer take or need.

I still occasionally moonlight as a hospitalist, so I know how easy it is to cut that corner and hit “select all.” But rarely do we need all the medications used at a hospital to be continued at another facility, and it takes a lot of time for myself and my facility pharmacist to go through the medication list of patients being admitted to figure out which among the “select all” medications should actually be continued.

My proposed solution: Eliminate the “select all” option, which is just too tempting to use, especially on a busy day. It takes thinking out of the equation and is simply too dangerous. Even selecting all medications one by one may not solve the problem, because it is still too easy to run down the list checking “yes” without giving each of them a second thought.

That raises another very common problem that crops up: patients’ home medications. Most of my patients come to my facility after two or three weeks (if not two or three months) in another hospital, so their list of home medications is largely irrelevant.

It’s good to know what patients were taking when they weren’t as sick, but home medications should be included only as a reference, if I choose to use any of them. But the medication lists we receive from hospitals are saturated with drugs that patients probably haven’t used in weeks.

Usually, that’s due to one of two scenarios: Hospitalists may click on “home medications to be continued” by accident, an easy mistake to make. Or what seems to happen more often is that doctors try to combine home medications with the list of drugs the patient is actually taking.

What I need to know is what the patient is taking on the day he or she is leaving your hospital; home medications should be no more than an FYI. If the discharging doctor believes that any or all home medications should really be continued, the safest option would be for that doctor to enter them manually.

Big risks
Then there’s this problem, and it’s the one I’m most concerned about. Many times, patients are transferred on IV medications that hospital pharmacists adjust the doses for daily. Because of that adjustment, these essential medications often drop off the medication administration record (MAR) and transfer sheet altogether when a new daily dose hasn’t yet been entered in the hospital EHR. Often, I’m not even aware of these medications if I don’t go through the progress notes—and sometimes, those notes aren’t available.

This happens with both IV antibiotics and warfarin, and both are potentially big problems. I’ve occasionally phoned the transferring physician to point out that the patient the day before was on IV vancomycin. Are we supposed to stop or continue it? The answer almost always is that it’s supposed to be continued but the item isn’t on the MAR because a daily dose hasn’t been adjusted.

Here’s my quick fix: Send the most current MAR, including antibiotic stop dates, to the new facility, and make sure such medications are on the MAR with a note saying, “New dose pending.” The long-term solution would entail changing software to ensure that drugs being adjusted daily don’t fall off medication lists. I’d also make this suggestion: I think it would be helpful to involve hospital pharmacists with medication reconciliation when patients are being admitted and discharged. They could clean up the MAR before consolidating it into a final discharge medication list and double-checking to make sure no medications have dropped off.

I’d also encourage hospital physicians to clean up their patients’ medication lists once they’re confirmed for discharge, and I’ll continue going through the progress notes on every admission and cross-matching any medications mentioned to the list I receive. I know hospitalists are acutely aware of these issues and understand the danger they pose to patients. We think it’s time we work together to improve the process.

Andrzej Dankowski, MD, is medical director of Kindred Hospital Denver South.



Magdalena Dankowska, PharmD, is a pharmacy resident at Northwestern Memorial Hospital in Chicago.



Published in the March 2019 issue of Today’s Hospitalist
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