Fear and Medication Errors in the ER
What a blessing and a curse it must have been to practice medicine fifty years ago. Most internists had only about twenty or so medications that they used regularly. It was a curse not to have effective medications to treat many common ailments but somewhat of a blessing not to have the modern medical nightmare of having patients on 15-20 chronic medications with all the logistical problems of keeping track of them all and watching for any interactions and complications. The use of electronic medical records is helping more and more medical practices keep track of their patient’s medications.
Unfortunately, far too many emergency room departments believe that it is still 1960 when it comes to patient medications. And it used to be worse.
The accurate and consistent documentation of medications for patients admitted to the ER and the hospital was unregulated and of low priority until early the last decade when the Joint Commission for Hospital Accreditation starting requiring all member hospitals to keep track of their patient’s home medications and to reconcile these lists while in the hospital and on discharge. As of 2007, only 66% of hospitals actually documented a patient’s home medications though this seems to have improved. But from personal experience, the effort is often substandard.
The documentation forms for medication reconciliation are often confusing and poorly designed. Sometimes there are 2 or more lists which often contradict each other. Medications are frequently misspelled and dosages given in the wrong units or route. Yet, the single worst aspect is that these reconciliation lists are often jaw droppingly inaccurate to the point of being mostly fictional and this is despite the fact that this information is acquired by licensed medical professionals (mostly nurses and physicians).
The inaccuracy of this documentation appears to be a combination of two factors. 1. The medical staff appear to put forth much more of an effort to acquire a list (any list) than in maximizing the accuracy of such a list and 2. Many patients and their families have a very difficult time keeping track of their own medications.
The second problem is a universal headache for most health care workers. Patients either forget their medications or bring outdated lists or only some of their medications and family members are too infrequently involved in the patient’s medical care to help give information or the one member who knows the most is never available. These are considerable problems but short of a national electronic database to keep an accurate record of each patient’s medication list in real time (more on this in a future post) there is not much that can be done on the patient side. Yet, many patterns and common pitfalls can be seen and dealt with to significantly improve the accuracy of this information.
For example, patients often put all of their medications in one container to bring with them to the ER. However, this fact alone does not constitute an accurate list. Patients will put both medications that they have discontinued in addition to their current medications into the same bag. Or they will put their medications into the same container with their spouse’s medications. I frequently see this type of error. It’s as if the person recording these medications didn’t bother to read the name on the labels but simply assumed that every single medication in a specific container was currently being taken by the patient. In one case, a female patient’s medications were recorded to include doxazosin which is a medication taken to shrink the prostate in males. The doxazosin was the patient’s husband’s medication and the pill bottle label even stated “take nightly for prostate” and this line was included in the medication reconciliation list.
Patients frequently forget to include medications. They often do not mention medications that are not taken in pill form such as inhalers, injected insulin, home oxygen, topical patches, and eye drops. They frequently forget to mention non-prescription medications such as aspirin and the chronic use of such over the counter medications as non-steroidal anti-inflammatories which can have profound clinical consequences. Often, specific medications need to be asked about for patients with certain conditions, however, in my experience, if the the medication is not in the bag then it doesn’t go on the list.
This nit picking about the accuracy of medication lists is far more than cosmetic. There is a lot of data out there that medication side effects and complications result in a significant number of ER visits each year. A 2008 Canadian study found that 1 in 9 ER visits were related to medication problems; either adverse reactions, noncompliance, or wrong medication or wrong dosages. Obviously, the inability to get an accurate list of home medications can significantly impair the staff’s ability to recognize and treat for medication problems. Additionally, an accurate medication reconciliation list is important for discharge planning to ensure that patient don’t go home and start taking medications that they shouldn’t and that nobody asked them about.
The cynical reader would think that this lackluster effort to reconcile medication lists is mostly limited to big city public hospitals with mostly indigent patients but it’s actually a quite frequent occurrence in high dollar private hospitals belonging to huge national corporations. The priority in private hospitals is to move patients so as to facilitate higher volume and increased billing. The priority is not accuracy. It’s obvious that the ER staff is simply documenting to satisfy the regulations in the same way that public school teachers frequently “teach to the test”. In one incidence, the medication list appeared to be simply copied verbatim from the records for the patient’s previous ER visit about 3 months prior. This despite the fact that the patient was perfectly awake and alert and told me that her doctor had since discontinued those prior medications and started her on all different ones.
Patients need to be aware of this if and when they have to go to the emergency room. The best strategy is to double check the ER staff’s work. Try and make sure that you have all of the current medication bottles or an up-to-date and accurate list. Ask to see the medication reconciliation form after the staff have filled it out to verify to yourself or your family member that what is listed is accurate to the best of your knowledge. If you don’t know or are unable to get a full and accurate medication list then make sure that the staff are aware of this and that they document somewhere on the medication reconciliation that the list is not yet complete.