Breakdown in Medication Reconciliation Leads to Inpatient Dose 16 Times Higher Than Home Dose

January 2016

When a patient is admitted to the hospital, the clinical team must complete medication reconciliation—the process of creating the most accurate list of all medications and corresponding doses a patient is taking at the time. We do this to prevent medication errors. Most of the time, one or more home medications for chronic diseases, such as diabetes or high blood pressure, may be administered while the patient is in the hospital.

In the case we review below, the dosage of a patient’s blood pressure medication was not verified during the medication reconciliation process, and the wrong dose was entered into the computer and given to the patient while she was in the hospital.

We are making a number of improvements to ensure this error is not repeated. What can you as a patient do to partner with us in your care? Carry a written, up-to-date medication list when you come to the hospital.

Thank you for reading,

Allen Kachalia, MD, JD
Chief Quality Officer, Brigham and Women’s Hospital

What Happened
A patient was admitted to BWH for a planned cardiac catheterization. On several occasions, she told staff members that she was taking lisinopril, a drug that lowers blood pressure, and that she was taking 40 mg daily.

Before the procedure, the physician saw the lisinopril in the patient’s profile and ordered 40 mg of the medication. After receiving the medication, the patient began experiencing lightheadedness, low blood pressure and right-sided abdominal pain.

The attending physician asked the patient about her medications, and the patient said she wasn’t sure if 40mg was the correct dose, as she had originally stated. The patient’s medications were then reviewed with her primary cardiologist’s office, and it was discovered that the actual dose was 2.5 mg. Fortunately, the patient did not suffer any long-term consequences from receiving a high dose of lisinopril.

What Went Wrong
During the admission medication reconciliation process, whenever possible, the medication list should always be verified with the patient’s primary care physician’s office or the community pharmacy where the patient fills prescriptions, as patients may not always know the dosage. Time constraints can make this challenging for providers, and in this case, multiple providers did not confirm the dosage before entering it into the computer.

The medication dosage had already been marked as reviewed by several staff, so the provider who ordered the dose believed it had been verified.

What We Are Doing

Staff education: The Consolidated Medication List Viewer (CMLV), available in Partners eCare, electronically accepts retail pharmacy information, including the name and dose of medications dispensed from the pharmacy. Providers should always use this to see what prescriptions were most recently picked up by the patient.

System Improvements: The Partners eCare Medication Reconciliation Task Force is working to enhance eCare to make it easier to navigate and to include educational materials for staff on medication reconciliation.

Department-specific Efforts: Some departments are taking additional steps. The Department of Medicine’s Medication Conversion Team is updating electronic medication lists for clinic patients before scheduled visits. They are downloading information from the CMLV, calling pharmacies for clarification when there are discrepancies and going over the list when patients arrive for their appointments. BWH has established an Emergency Department Medication Reconciliation Support Team, with pharmacy students, certified pharmacy technicians and a supervising senior clinical pharmacist. The team members have been trained to conduct a thorough medication history through patient interviews and other measures prior to admission to help ensure that patients admitted to BWH via the Emergency Department have accurate medication lists.

Patient Education: Patients can play an important role in medication reconciliation by carrying a written, up-to-date medication list. Care providers should encourage patients to bring their current medication bottles to the hospital and clinic visits, including herbs, supplements and over the counter therapies. A new patient safety brochure includes information on this and other important topics.

Just Culture Corner: Is the Customer Always Right?
BWH is committed to adopting the principles of a Just Culture and creating an environment where we feel safe and supported when speaking up about risks we see. Safety Matters will highlight a new concept or learning around this important culture change in each issue.

The two biggest Just Culture principles at play in the above story are at-risk choices and system design.  An at-risk choice is a choice in which risks are deemed to be insignificant or justified.  At-risk choices are often driven by competing priorities, such as safety versus productivity. Our system design can sometimes magnify competing priorities. For example, if the system makes it time consuming and difficult to complete safety steps, it is more likely that staff will skip these steps in an effort to meet productivity goals.

At the time of the above story, the process in place was for the admitting provider to confirm correct dosing by steps such as checking electronic medication records, by contacting the community pharmacy, or verifying doses with pill bottles or a patient medication list. But because there wasn’t a streamlined system to support providers in completing these steps, these verifications were commonly skipped. The provider documenting this information likely had competing priorities with a busy workload, and chose to enter the dose provided by the patient without verifying it. This at-risk choice was seen by the provider as justified (especially since the dose provided by the patient was a common one), but the choice increased the risk of a medication error.

The Just Culture response in this case is to change the system design to minimize the conflict between competing priorities. eCare changes and Medication Conversion Team are systems design improvements that make medication reconciliation faster and more accurate. The Just Culture response is also to support and coach the provider on how to prioritize the safety step of medication verification while still managing workload (peers must also be coached, since all face the same challenge of balancing these competing priorities). Educating providers on use of the CMLV is part of this. Through system changes and effective coaching, we create safer and more reliable processes for patient care.

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10 thoughts on “Breakdown in Medication Reconciliation Leads to Inpatient Dose 16 Times Higher Than Home Dose

  1. Colleen Wilson

    there are many free apps for smart phones that will keep a list of medications with all the doses, pharmacy, etc. The one my family and I use is Carezone. You just take a picture of the bottle and it records the information, but as I stated there are many.

  2. Ronald Hirsch, MD

    Why do you not have a RSS feed? This is so valuable and I will never remember to check back for new cases.

    1. Karen Fiumara, Director, Patient Safety BWH

      Thank you for the suggestion, Ronald. We have just added a “Follow” button to blog. You’ll spot it in the lower right corner. Best, Karen

  3. wz

    Instead of laying this on the patient, why aren’t reconciliations being asked for from the PCPs who have EMRs with current med lists (also pre-op testing results)? If patient histories don’t agree, someone looks into it? Where is the coordination? The root cause should not be laid on patients who are a spectrum of accurate to completely inaccurate at the whim of a slight or not so slight confusion that lay historians are prone to. Why are PCPs so uninvolved with their patients?

    1. Karen Fiumara, Director, Patient Safety BWH

      Dear WZ,
      Thank you for your comment. I completely agree with your statement. It is so important that we clarify our intent. We indeed believe that it is our responsibility to ensure accurate medication reconciliation. Patient education is just one component of our improvement plan. We believe that empowering patients to ask questions and be active participants is an important way to do this. For example, if a provider notes a discrepancy in the medication list, it becomes important for the provider to verify with the patient what the patient is taking.

      We also recognize that the best way to prevent these types of mistakes is to focus on improving our system. We are working hard to leverage our electronic healthcare record to prevent these errors in the future. The power of an integrated electronic health record is that accurate information should be readily available lessening the risk of human errors that everyone (including providers that are indeed invested in and working their hardest to make sure patients get the best care) is prone to making.

      Thank you again, Karen

  4. Irene Jankowski

    What about the involvement of the RN? Medication administration by nurses sho include a verification of dosage and conversation with the patient that will promote patient education

    1. Karen Fiumara, Director, Patient Safety BWH

      Thank you for your comment, Irene.
      In this case, the nurse did attempt to reconcile the dose by asking the patient. Unfortunately, the patient (who did not have a list) did not provide the correct dose.This serves as a good reminder for all providers to also, when possible, verify doses with the patient’s pharmacy records and for patients to always carry up to date medication lists with them to help prevent medication errors.

  5. Diane

    As a nationally certified RN case manager in a major city hospital, I see a number of patients and families who do not know the meds they are on, the doses, the name and number of their pharmacy, the names and contact numbers of the visiting nurse agencies that have been providing RNs and aides that are coming inside their homes, and sometimes even their primary care MD’s name and number. I always take the opportunity to recommend to patients and family members to keep a small index card with this information in their wallet, or keep this information in one place on their cell phones.
    Patients and their families need to take more responsibility for their own lives and health information.
    In an emergency situation, RNs, MDs and pharmacists can be called upon to search out this information, but the primary responsibility rests with the patient and family. A system that does all this for patients and families creates learned helplessness, and it’s a need that professionals cannot keep up with meeting on a regular basis.

    1. Karen Fiumara, Director, Patient Safety BWH

      Dear Diane,
      I agree that empowering patients to partner with us in their healthcare is a fundamental patient safety strategy. Nevertheless, it is also critical that our systems are designed to support patients, families and providers to facilitate getting medication information at the point of care. Much of the medication information needed to perform medication reconciliation is available electronically and therefore automating the process will ensure that our healthcare providers and patients can focus their attention elsewhere. Thank you so much for your thoughtful comments.

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