From the April 21, 2005
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
---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
---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
---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
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.