EDs nurses are key to complying with new JCAHO medication goal

Surveyors will look very closely at this in 2006

Just as you’re about to give intravenous penicillin to treat a fungal infection of the lower extremity, the patient mentions being allergic to a certain antibiotic, but can’t recall which one.

Do you have a process in place to find out? And do you follow the procedure for every ED patient? If not, you’re out of compliance with the Joint Commission on Accreditation of Healthcare Organizations’ (JCAHO) National Patient Safety Goals requiring all patient medications to be reconciled.

In addition, the Joint Commission has issued a Sentinel Event Alert warning that dangerous drug errors are occurring because of lack of information about medications a patient is currently taking.

Surveyors are "absolutely looking very closely" at this for 2006 surveys, reports Richard J. Croteau, MD, the Joint Commission’s executive director for strategic initiatives. "We have ample evidence that a high percentage of medication errors are related to failure to know what a patient has been taking," he says. "If this is a problem in the ED, we’ll be looking to see if it is also a problem in other areas, and also explore why it is a problem."

According to data from the U.S. Pharmacopeia, about 100 errors were reported in 2005 involving the ED’s failure to reconcile a patient’s medications, including wrong doses, double dosages, and patients given drugs they were allergic to. As a result, one patient was hospitalized after a 10-fold dose of pain medications.

Joint Commission surveyors are finding that many hospitals lack a formal process for medication reconciliation, says Croteau. "This is particularly true in the ED, where there are obvious urgencies competing for the provider’s time and attention," he says. "But that doesn’t preclude the basic principle that you need to know what medications a patient is currently taking before prescribing new medications."

How to reconcile

To reconcile medications in your ED, do the following:

• Ask patients to show you their medications.

During an assessment of a woman complaining of dizziness, ED nurses at St. Rose Hospital in Hayward, CA, asked to see her prescription bottles — and found she was taking lorazepam, temazepam, and diazepam — all different versions of the same drug. "Each one of the bottles had a different prescribing doctor’s name and date of service," says Bridget Aube, BSN, RN, TNCC, interim nurse educator for the ED.

The patient told nurses she was taking one for "nerves," one for back pain, and one for sleeping. "I explained that all three medications are essentially the same and told her that this would probably explain her chief complaint — of bumping into objects at home with frequent falls," says Aube.

• Start the process at triage.

When Aube noticed elevated blood pressure in a patient being held waiting for a telemetry bed, she checked his medication list, realized the problem was probably due to missed doses of medications — and promptly got orders to continue the patient’s home medications. "Within a half an hour, the patient’s blood pressure was 115/82; he was smiling and no longer complaining of shortness of breath or a headache," says Aube.

This situation underscores the importance of starting medication reconciliation at triage — something the ED has implemented since then, says Aube. "If this process had occurred at the patient’s point of entry or at least when the admission orders were written, the patient’s care could have been more customized to his condition and history sooner," she says.

At University of Massachusetts-Memorial Health Care in Worcester, patients often missed doses while waiting to be seen or were given medications that could have interacted with something they already were taking, says June Ellis, RN, the ED’s nurse manager.

A form was created to obtain medication history at triage. "We start the medication reconciliation right at the point of entry now and that follows the patient through their entire visit," Ellis says. (See the ED’s Medication Reconciliation Order Form.)

Initially, nurses were resistant because they didn’t want to have to document medications twice, but this problem was solved by having nurses write "see attached" on the patient’s chart and stapling the form to the chart. "For patients who are taking multiple doses of cardiac medications, nurses can give then their next dose while they are still in the ED," Ellis explains.

• Make sure medication information goes with the patient.

ED nurses at Shore Health System in Cambridge, MD, complete a separate medication reconciliation form for all admitted patients to ensure information isn’t lost when the patient is "handed off." "If the staff is sure the patient will be admitted, the ED flow sheet is stamped, "See Med Rec Form," which is included in the inpatient record," says Gail McWilliams RN, MS, CCRN, CEN, clinical nurse specialist for the ED.

• Check for compliance with chart audits.

At St. Rose’s ED, chart audits are being implemented to check that current medications and dosages are documented. "Rather than punitive measures for those that do not fill them out, I will speak with the main offenders to see if they have suggestions for improving the process and go from there," says Aube.

To solve the problem of lack of space to record detailed information, one ED nurse suggested using stickers or stamps with two checkboxes, one saying "patient does not take any medications," and the other saying "see medication reconciliation sheet." "But, with the form being quadruplicate, we would be going through a lot of man-hours for each sheet," Aube says. Instead, nurses came up with the idea of using a separate form for medication reconciliation for lists that will not completely fit on the chart, she adds.

• Ask patients to carry their own lists.

The Joint Commission recommends instructing patients to bring a list of current medications to the ED. "We would like everybody to keep an up-to-date list," says Croteau. "Patients should be encouraged to do this."

At St. Rose’s, ED nurses give wallet-sized business cards to all patients at triage and ask them to write down their medications and primary care physician’s name. "If a nurse in the back end wants to give one to their patient, we encourage that as well," says Aube. "They are available to all nurses for distribution."

• Use outside resources.

ED nurses at University of Massachusetts-Memorial were able to find out which antibiotic a cellulitis patient was taking by calling the pharmacy, says Ellis. "We knew that one shouldn’t be ordered since it wasn’t working," she explains.

At Harney District Hospital in Burns, OR, the ED has an unwritten agreement with local pharmacies to obtain medication lists, refill histories, and allergies without a medical release of information, says Julie Burri, RN, ED clinical coordinator.

"I have never had a pharmacy tell me they would not release that information to me without a signed document," she says. EDs need to obtain the most current medication list possible for a patient, Burri notes. "This puzzle may have several pieces that we have to put together."

For example, a patient may have been prescribed 10 days of hydrocodone-acetaminophen, already gotten a refill, and also taken over-the-counter acetaminophen. "This would alert us that the patient may easily have a toxic acetaminophen level, and we would need to draw labs to see if this is influencing the patient’s current status," says Burri.

At Missouri Baptist Medical Center’s ED, nurses use the patient, the family, medication bottles, and area pharmacies as resources, and they update the list as new information becomes available, says Sharon Monical, RN, ED manager.

"When the patient doesn’t know their medications, we call their pharmacy or physician office," she says. This information has changed a patient’s treatment many times, as with patients taking sildenafil who can’t be given nitroglycerin to treat angina pain, says Monical.

In addition, all patients receive an allergy band at triage with either "NKDA" (no known drug allergies) or specific drug allergies listed, says Monical. "All nurses inquire as to allergies, check allergy bands and two patient identifiers prior to any medication administration," she says. "This is done so that staff is constantly checking potential allergies on every patient, every time."

Sources

For more information on reconciling medications in the ED, contact:

  • Bridget Aube, BSN, RN, TNCC, Interim Nurse Educator, Emergency Department, St. Rose Hospital, 27200 Calaroga Ave., Hayward, CA 94545. Telephone: (510) 264-4026. Fax: (510) 783-3576. E-mail: baube@strosehospital.org.
  • Julie Burri, RN, ED Clinical Coordinator, Harney District Hospital, 557 W. Washington, Burns, OR 97720. Telephone: (541) 573-8345. E-mail: jburri@harneydh.com.
  • June Ellis, RN, Nurse Manager, Emergency Department, University of Massachusetts Memorial Health Care, 119 Belmont St., Worcester, MA 01605. Telephone: (508) 334-8230. Fax: (508) 334-5670. E-mail: EllisJ@ummhc.org.
  • Gail McWilliams, RN, CCRN, CEN, Clinical Nurse Specialist, Emergency Department, Shore Health System, 300 Byrn St., Cambridge, MD 21613. Telephone: (410) 822-1000, ext. 8019. Fax: (410) 221-6213. E-mail: gmcwilliams@shorehealth.org.
  • Sharon Monical, RN, Emergency Department Manager, Missouri Baptist Medical Center, 3015 N. Ballas Road, St. Louis, MI 63131 Telephone: (314) 996-4596. E-mail: skm7693@bjc.org.