SDS Accreditation Update

Don't forget patient literacy when evaluating med reconciliation process in outpatient surgery

Study shows patients don't know names of medications they take

Because medication reconciliation is recognized as a key factor to prevention of medication-related errors, accreditation organizations require outpatient surgery programs to take steps to improve this process. In addition to the challenges already faced in collecting information needed for an accurate list of patient medications, health literacy also may create obstacles to accuracy.

One recently published study looked at the impact of health literacy on the ability of patients to identify their medications.1

"We discovered that of the 119 participants in our study, 31% had inadequate health literacy," says Stephen D. Persell, MD, MPH, co-author of the study and assistant professor of medicine at Northwestern University in Chicago. Although the study focused only on patients treated for hypertension, the results have implications for all areas of health care, including outpatient surgery, he says.

Health literacy was defined as inadequate or adequate after administering a short version of the Test of Functional Health Literacy in Adults.2 "We defined inadequate health literacy as below sixth-grade level," explains Persell. Of the patients identified with inadequate health literacy, only 40.5% were able to name any of their hypertensive medications compared to 68.3% of the patients with marginal to adequate health literacy, he says.

When lists of hypertensive medications provided by the study participants were compared to their medical records, 64.9% of patients with inadequate and 37.8% of patients with adequate literacy had identified medications that were not reflected in the medical record, which was correct, says Persell. Although inadequate health literacy amplifies the problem, even patients who are health-literate are unable to accurately name medications, he adds.

Health literacy levels affect the gap between what the doctor says and what the patient hears, points out Persell. "I changed a medication that one of my patients was taking and instructed him to quit taking the previous medication. I got a call from the patient six months later asking for a refill of the medication I had instructed him to stop taking," he says. Even though he believed that he was very specific in his instructions, his patient never understood that the new medication replaced the previous medication, he explains.

Outpatient surgery programs face additional challenges because the patient is usually not seen in the facility until the day of surgery, admits Persell. "Even if you get a list of medications from the patient's surgeon or primary care doctor, many patients see multiple physicians who may have prescribed medication that are not on the list," he says. "You can pull medication lists from the patient's previous records in the health system, but you have no way of knowing how up to date it is," he adds.

Although these lists may not be complete or up to date, you can use them to prompt conversation with patients, suggests Persell. As patients tell you what they take, you can see if they've previously been diagnosed with a condition for which they should be on medication, he says. If the patient doesn't mention a cholesterol control medication but they've been diagnosed with high cholesterol in the past, ask about it, he adds.

Make list legible

The patients who he sees in his office surgery practice are generally young and on very few medications, but his practice does a use a standard form to compile the list, says Gary Burton, MD, a plastic surgeon in Bowie, MD.

"Our policy has changed in the past year as everyone has become more cautious about medication safety," he says. "We ask to see their medications, and we ask for a typed list of medications."

The typed list of medications prevents misunderstanding a medication's name due to illegible handwriting, but Burton points out that even typewritten, the list may be wrong. "Some patients don't know how to spell the medication name and, if there are two or more medications with similarly spelled names, you might incorrectly think they are being treated for one condition rather than the real condition," he says.

For that reason, Burton's office staff members ask to see the medication bottles and the medical history is reviewed against the medication list, he reports. For an office surgery practice, the medication reconciliation process can serve as an extra step in patient safety, he says. "If a patient is on more than two or three medications, I review the medical history to see if the patient should go to the hospital outpatient department for the procedure," he says.

Staff at HealthSouth Surgical Center of Elizabeth-town (KY) call patients several days prior to their surgery to review instructions and to obtain a list of medications, says Robin Boles, administrator. "We also tell patients to bring in all of their medications on the morning of surgery so we can double-check everything," she says. Nurses verify the name and dosage of all the medications by reading the labels, Boles adds.

"If we see that a patient is taking a beta-blocker but the medical history doesn't list a condition for which they should take a beta-blocker, we ask the patient why they are taking it and for how long they've taken it," she explains. "It's hard with older patients who may be taking many medications and don't always know why."

If there is a question, the nurse calls the prescribing doctor to find out more before the patient is prepared for surgery, Boles adds.

Form should simply process

Boles' center is developing a form to use for medication reconciliation that will contain the list of current medications as well as all medications administered during surgery and prescribed post-surgery, she says. "We don't want to create more work for staff, but we need a way to have all of the information in one place rather than in different parts of the chart," she explains. There are three forms used in different areas, so nurses have to look back and forth between forms to complete the form that is given to patient at discharge.

"We want to make it easy to add to the list as it travels from pre-op to the operating room to recovery to discharge," she says.

Although outpatient surgery programs do give patients an updated list of their medications, including medications received or prescribed on the day of surgery, Persell points out that the health literacy level of the patient must be kept in mind. "Give very specific verbal as well as written instructions, especially if previously discontinued medications must be restarted in a specific timeframe, and give patients a chance to ask questions," he suggests. "If the patient appears disoriented or cognitively impaired, be sure to give complete instructions to a family member or other caregiver."

References

  1. Persell SD, Osborn CY, Richard R, et al. Limited health literacy is a barrier to medication reconciliation in ambulatory care. J Gen Intern Med 2007; 22:1,523-1,526.
  2. Baker DW, Williams MV, Parker RM, et al. Development of a brief test to measure functional health literacy. Patient Educ Couns 1999; 14:267-273.

Sources/Resources

For more information about medication reconciliation and health literacy, contact:

  • Robin Boles, Administrator, HealthSouth Surgical Center of Elizabethtown, 108 Financial Drive, Elizabethtown, KY 42701. Telephone: (270) 737-5200. E-mail: robin.boles@healthsouth.com.
  • Gary Burton, MD, 4000 Mitchellville Road, Suite 302, Bowie, MD 20716. Telephone: (301) 441-3375.
  • Stephen D. Persell, MD, MPH. Assistant Professor, Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, 750 N. Lake Shore Drive, 10th Floor, Chicago, IL 60611. Telephone: (312) 503-6464. Fax: (312) 503-2755. E-mail: spersell@nmff.org.

The following resources are available to help organizations with medication reconciliation:

  • A free medication list that can be used to collect patient medication information is available on the Massachusetts Coalition for the Prevention of Medical Errors web site. Go to www.macoalition.org and select "Publications." Scroll to the section titled "Patient Med List," and click on the link to the form.
  • A Sentinel Event Alert published in 2006 addresses medication reconciliation and prevention of medication errors. To view the Sentinel Event Alert, go to: www.jointcommission.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."
  • Another free tool to improve communications with patients can be found at www.ihi.org. Select "topics," and then "patient safety." Choose "safety: general" and "tools." Scroll down to find "General Tools." A list of available tools includes "Tips for Safer Surgery," a tip sheet for surgical patients to use to improve communications with their health care providers.