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Go above and beyond with med reconciliation
When a young man came to an ED, he appeared to be developmentally delayed, but this was not the case.
"Come to find out, he was on 17 medications prescribed by eight different physicians," says Libby Raetz, RN, director of the ED at Saint Elizabeth Regional Medical Center in Lincoln, NE.
That determination was made by a case manager hired by the ED to closely investigate all the medications taken by patients who are frequent users of the ED, with three or more visits in a six-month period.
As a result of the ED's intervention, the number of medications the man was taking was reduced to four, "and his total functioning changed overnight," Raetz recalls. "He really regained his life. He was basically heavily sedated because he was on so many meds that act alike."
The program is used for any patient who meets this criteria: Patients with three or more visits in a six-month period, anyone under 16 without insurance, and anyone with a comorbidity — which, for 90% of patients, involves a mental health diagnosis.
The case managers contact pharmacies and physicians to determine exactly what they were prescribed and by whom, and they coordinate with the different doctors. "People aren't always the best historians and may not remember what they were prescribed," says Raetz. "After dissecting all this, the nurse may find the patient is taking three antidepressants and may just need one."
In the ED at Charlotte, NC-based Presbyterian Hospital, pharmacy technicians call community pharmacies and physician offices to ensure the most complete medication record possible for admitted patients, says Matt Lowery, RN, ED nurse manager. "The pharmacy techs also interview patients to ensure medication and allergy accuracy."
The ED-based technicians have found multiple instances of patients incorrectly reporting the medications they are taking, says Lowery. In some cases, they have found that patients with multiple providers have been on incompatible medications or multiple medications for the same problem, through failing to report their medications to their providers appropriately.
"Several of these instances have been why the patient presented to the ED for treatment," says Lowery. "The pharmacy technicians have prevented possible adverse reactions of several patients by identifying medication problems."
If the patient uses more than one pharmacy, no cross-check occurs through the community pharmacies to prevent those medication errors. "A busy ED nurse tends to take the patient information on the medications they take as correct. That has proven to not be the case for many patients," says Lowery.
At Advocate Illinois Masonic Medical Center in Chicago, it sometimes "takes a bit of detective work" to obtain all the pieces to a patient's medication history, says Emily Brooks, RN, BSN, an ED nurse.
"Using teamwork, we engage the hospital's social workers, who contact the patient's family members at home to physically look at prescription bottles for dosage information and medication names," she says. ED nurses also ask responding paramedics to bring all prescription medications to the ED with the patient. Occasionally, nurses have been able to determine the patient has been incorrectly taking medications at home or has the same prescription from two physicians.
Also, taking the patient's allergy history is an important part of the medication reconciliation process, says Brooks. At triage, ED nurses attach brightly colored wristbands to patients who identify medication allergies. "We also document medication allergies in the patient's electronic medical record, which can be easily reviewed on any future visits," says Brooks. "Therefore, the information is readily available, even if the patient isn't in a condition to tell us."