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Serious Medication Errors and Hospital Admissions

Last month, we began a series of blog posts that cover patient scenarios that describe common challenges associated with medication management. Each provides the background and reasons for these and discusses the shortcomings of the technology used by many healthcare organizations today. We’ll then explain how Meds 360° helps solve these problems, and how it can improve quality of care, reduce risk, and improve clinician and patient satisfaction in the process.

Our first post began the series with a broader discussion about the shortcomings of the current solutions, primarily EMRs, relied upon to address suboptimal medication management.  

This post will be our first real scenario and focus on the potential downstream clinical impact on patients admitted to the emergency department (ED) or hospital without being able to provide an accurate list of medications they are taking. This widespread occurrence often results in poor outcomes and unnecessary costs.

According to various studies, error rates in medication reconciliation at hospital admission typically range from 30% - 40%. This study, for example, showed a baseline error rate of 34% at the time a Transition of Care Team was implemented. Although many medication inaccuracies at admission are inconsequential, 33% of them have the potential for serious harm.[1]

Joe’s Extended Hospital Stay

Meet Joe, a 70-year-old, white male with congestive heart failure, non-insulin dependent diabetes, hypertension, hyperlipidemia, and chronic lower back pain. After becoming lightheaded and short of breath one afternoon, Joe is transported by a neighbor to Our Lady of Lourdes emergency department (ED). Because multiple specialists across three different enterprises manage Joe’s usual care, the only medical record information that Our Lady of Lourdes has about Joe in its electronic health record (EHR) is from his endocrinologist. So, the medication list in the EHR at the time Joe rolls into the ED is incomplete: it contains only the medications prescribed by his endocrinologist.

Rushed for time, Jill, the ED triage nurse, records only the medications Joe can recall taking: Lasix, metformin, carvedilol, and occasionally Xanax. Joe tells Jill that there are two other pills that he takes, but doesn’t remember the names. He describes them as “one is white and round (it’s actually digoxin 250mcg),” and “the other one is also white/round (it’s actually Soma 350mg).”

Joe is admitted with a diagnosis of CHF exacerbation. Because his admitting physician, Dr. Xi, relies on Jill’s admission medication list, he unknowingly fails to include anticoagulants, antihypertensives, and statins in the medication orders. Joe is successfully diuresed with IV Lasix, after which time treatment efforts are focused on tuning up his pharmacologic regimen to prevent another exacerbation.

Eighteen hours after being admitted, Joe sustains a mild ischemic stroke. He is successfully treated with Tissue Plasminogen Activator (tPA), but his length of stay increases by six days. When finally discharged, Joe is taking ten medications: Lasix, digoxin, lisinopril, metformin, pravastatin, Eliquis, carvedilol, Plavix, Soma, and Dilaudid which was started for severe lower back pain that reemerged the day before discharge.

How Joe’s Hospital Stay Could Have Been Better

Our current system relies on patients knowing the names, dosages, and frequency of every pill they take. It’s an unrealistic and heavy burden and does not work most of the time, especially for elderly patients with complex medication regimens like Joe. The result is that, when patients can’t describe their medication regimen with 100% accuracy, incomplete and inaccurate information goes into their medical records. Combine that with the fact that an EHR in one hospital isn’t connected to an EHR in another or all the physician groups in town, and you can see how a patient’s medication history becomes fragmented and incomplete, all over town.

All of this changes with Meds 360° medication management software, which provides clinicians a streamlined view of actual prescription pick up and change data from pharmacies and PBMs, as opposed to the patient’s memory or an individual enterprise’s EHR. This data is far more accurate, and it’s presented in a one-screen view that consolidates all of a patient’s picked up prescriptions and dosage changes, from all providers, from any health system or physician organization.

Here’s how Joe’s story would have been different if Our Lady of Lourdes used Meds 360:

Before beginning her intake conversation with Joe, Jill the ED admissions nurse, pulls up his prescription data using Cureatr Meds 360° software on her desktop computer or handheld device.

medication mangaement screenshot

From Joe’s profile screen, Jill can see the list of all of his current medications and past medications (defined as those for which the last day supplied was exhausted more than 30 days ago) represented on Meds 360 °’s 12-month timeline view. By clicking the medication reconciliation view, she sees all of Joe’s prescribers and dispensing pharmacies over the last 12 months - which means she sees more medications than the ones that the Our Lady of Lourdes endocrinologist prescribed. She can also see three opioids Joe is taking for his back pain highlighted in red.

Jill reviews each of the medications on the list with Joe. Those two “white and round” pills? Jill clicks to open images of digoxin and Soma and asks Joe to verify whether these are the medications he is taking. Joe tells her, yes. So in addition to his self-reported medications, Joe becomes aware of the antihypertensive, anticoagulant, and anti-platelet aggregation agent and statin that have been a part of his prescribed regimen during the preceding 12 months. Since Jill has confirmed these medications with a visual match, she adds them to his medication list in the EHR. Remember that these pills were medications that Joe had failed to recall in the previous scenario.

Because all medications are now accounted for in the EHR, Dr. Xi does not add unnecessary medications to Joe’s admitting orders. Joe responds well to his IV furosemide, and a stroke is avoided because his inpatient medications included Eliquis, Plavix, and Cintapro. His inpatient stay is unremarkable, and Joe is discharged on day three instead of on day nine, improving Joe’s experience and lowering cost for Our Lady of Lourdes.

Healthcare organizations must capture a timely and accurate view of a patient’s current medication regimen. The current process of relying on patient memories and siloed EHRs is error-prone and results in poor outcomes and unnecessary costs such as the ones Joe experienced during his inpatient stay. The Meds 360° technology solution supports care teams in avoiding both of these by delivering a patient’s complete and accurate medication history in a streamlined view of actual prescription pick up and change data from pharmacies and PBMs.

Our next post in this series will be a continuation of Joe’s journey and lay out a likely post-acute care scenario of adverse health outcomes based on his original med rec errors.

[1] Medication Reconciliation: Patient Safety Primer, AHRQ, Updated January 2019. https://psnet.ahrq.gov/primers/primer/1

Whitepaper: Medication Management Challenges and Opportunities for Payers and Providers


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