ED Accreditation Update: Sentinel event issued on med reconciliation
ED Accreditation Update
Sentinel event issued on med reconciliation
Imagine that a patient with a chronic disease and taking multiple medications has an acute deterioration at home. The patient calls 911, and an ambulance arrives. The emergency technicians aren’t able to obtain all of the patient’s medication information from family members, and the patient is unable to communicate. The patient is transported to the ED, where he receives emergency management. The patient survives and is transferred to the intensive care unit.
"There’s already been multiple handoffs, and at no point has there been any reconciliation or gauge of what the patient has been taking for pre-existing situations," says Peter Angood, MD, vice president and chief patient safety officer at the Joint Commission on Accreditation of Healthcare Organizations and co-director of the Joint Commission International Center for Patient Safety. "The opportunity for error is very high," he adds.
Because of concerns about errors involving medication reconciliation, the Joint Commission has issued a Sentinel Event Alert on the issue.
At Luther Midelfort Mayo Health System, in Eau Claire, WI, a medication reconciliation form can’t be fully completed on every emergency patient, says Marcie Talbott, MSN, RN, CNA-BC, director of emergency services. ED staff realize that gathering information from patients can be difficult if a patient isn’t in a state to give accurate info or if relatives are not there, "but we initiate it and complete as much of it as possible," she says.
If the patient ever has been treated in the Luther Midelfort Mayo system, there is a repository of the patient’s previous medications, she says. "We have some indication of what medications the patient has been taking, and then we verify it later with a relative or with the transferring facility," Talbott says.
If the patient is admitted, the inpatient staff continued to complete the medication reconciliation form, "but every effort is made to get the information as soon as possible," she explains.
4 tips from Joint Commission
To reduce the risk of errors related to medication reconciliation, the Alert recommends that health care organizations do the following:
- Put the list of medications in a highly visible place in the chart and include essential information about dosages, frequency, immunizations, and allergies.
- Reconcile medications at each interface of care, including admission, transfer, and discharge. The patient, physicians, nurses, and pharmacists should be involved.
- Provide each patient with a list of medications that he or she will take after being discharged, as well as instructions on how and how long to take any new medications.
- Encourage the patient to carry this list and share it with caregivers who provide follow-up care.
Resource
To view the Sentinel Event Alert, go to: www.jcaho.org. Highlight the "Sentinel Event" tab, and click on "Sentinel Event Alert." Then click on "Issue 35 — Jan. 25, 2006: Using medication reconciliation to prevent errors."
Imagine that a patient with a chronic disease and taking multiple medications has an acute deterioration at home. The patient calls 911, and an ambulance arrives. The emergency technicians arent able to obtain all of the patients medication information from family members, and the patient is unable to communicate.Subscribe Now for Access
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