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From the April 21, 2005 issue

What do all these medication errors have in common?

---A patient who was transferred from one hospital to another received a duplicate dose of insulin because the receiving nurse didn't know the medication had been given before transfer. The patient's medication history had not been provided to the receiving facility until several hours after the patient's arrival.

---Using the patient's handwritten list of medications taken at home, a physician misunderstood an entry for DESOGEN (ethinyl estradiol and desogestrel) and prescribed digoxin 0.25 mg daily. Later, a nurse discovered the error when she asked the patient why she was receiving digoxin.

---Shortly after admission, a patient became lightheaded and fell in the bathroom after a physician prescribed TOPROL XL (metoprolol extended-release) at a dose larger than she took at home. The patient required telemetry monitoring and hydration for 24 hours.

---A newly admitted patient with pulmonary hypertension had been receiving FLOLAN (epoprostenol) IV at home at 2.4 mL/hour. The physician prescribed Flolan at the same flow rate, but did not specify the concentration. The hospital used a concentration of 0.5 mg/100 mL, but the patient had been using a 0.3 mg/100 mL concentration at home. The error was discovered after the patient experienced symptoms common with higher doses.

---PAMELOR (nortriptyline) was prescribed for a newly admitted patient. While clarifying another order with the patient's pharmacy several days later, a pharmacist learned that the patient had been taking PANLOR (acetaminophen, caffeine, dihydrocodeine) at home, not Pamelor.

---A patient who had been transferred from an extended-care unit to a medical unit received extra doses of all her morning medications: warfarin, levothyroxine, metoprolol, amlodipine, and sertraline. The patient's extended-care medication administration record was not located until several hours after transfer.

---Enalapril 2.5 mg IV was administered to a patient after transfer from a critical care unit to a medical unit. The drug had been discontinued upon transfer, but the orders had not yet been transcribed.

---An emergency department patient with chest pain received a 7,000 unit heparin bolus prior to starting a heparin infusion. Upon admission to the critical care unit, the heparin bolus dose was repeated in error, delaying the patient's cardiac catheterization.

---Before surgery, a patient had been receiving daily doses of IV vancomycin. The drug was not reordered post-operatively, but it continued to be dispensed and administered for several days.

---Before discharge, LEXAPRO (escitalopram) was increased to 10 mg daily, but the patient's discharge instructions listed 5 mg daily. When the error was noticed, a pharmacist called the patient, who had been cutting in half the 10 mg tablets provided with her new prescription.

Each error is the direct result of failed communication about prescribed medications during vulnerable transition points in the continuum of healthcare: admission, transfers between care settings, and discharge. Another shared characteristic that might surprise you is that all of these errors, and so many more, were reported to ISMP within the past few months! (Some of these errors were reported through the PA Patient Safety Reporting System.) According to the Institute for Healthcare Improvement, experience from hundreds of organizations has shown that poor communication of medical information at transition points is responsible for as many as 50% of all medication errors and up to 20% of adverse drug events in hospitals. This is precisely why the Joint Commission has focused the nation's attention on reducing the risk of errors during these transition points through a process called medication reconciliation.

A 2005 Joint Commission National Patient Safety Goal (NPSG) requires hospitals to reconcile medications across the continuum of care. Below we have outlined the steps we suggest for implementing this process.

Obtain a medication history. Obtain the most accurate list possible of the patient's current medications upon admission to the organization before administering the first dose of medications (except in emergency or urgent situations). This includes prescription and over-the-counter medications (including herbals and dietary supplements), listing the dose, route, frequency, indication, and time of last dose. Most organizations use a specific form for this purpose, on which an assessment of patient compliance with drug therapy and the source of the medication history information can also be documented. Besides the patient and family, other sources of information may include visual inspection of the medications brought into the facility by the patient or family, previous medical records, as well as the patient's pharmacy and physician office.

Prescribe medications. As soon as the list is reasonably complete, have the prescriber review and act upon each medication on the list while prescribing the patient's admission medications.

Reconcile and resolve discrepancies. Require another person to compare the prescribed admission medications to those on the medication history list and resolve any discrepancies.

Reconcile again upon transfer and discharge. Each time a patient moves from one setting to another, review previous medication orders alongside new orders and plans for care, and resolve any discrepancies. When the patient is discharged, the reconciled list of admission medications must be compared against the physician's discharge orders along with the most recent medication administration record. Any differences must be fully reconciled before discharge.

Share the list. Communicate a complete list of the patient's medications to the next provider of service when transferring a patient to another setting, service, practitioner, or level of care within or outside the organization. This includes sending a list of medications prescribed upon discharge from the hospital to the patient's primary care physician, as well as encouraging patients to share the list with their pharmacy.

The Joint Commission requires hospitals to initiate this type of medication reconciliation process now. Full compliance is expected by January 2006. This new NPSG is not just for hospitals. The Joint Commission has also made medication reconciliation a NPSG in ambulatory care, assisted living, behavioral health, home care, and long-term care organizations. If all these healthcare settings are involved in the process, it will make obtaining an accurate medication history and reconciliation of prescribed therapy much easier. For more information on medication reconciliation, please visit this website . Audiotapes of our recent teleconferences on this subject (with discussions by the Joint Commission and hospitals that have implemented medication reconciliation) are also available for purchase.