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MATCHING MEDICATIONS Med Rec for medical staff

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MATCHING MEDICATIONS Med Rec for medical staff

Best Possible Medication History

Why do we need to take a medication history on admission? “ An accurate and complete medication history

should be obtained and documented at the time of presentation or admission, or as early as possible in the episode of care”

“This information will form the basis for future decisions about therapy…”

Reference : Australian Pharmaceutical Advisory Council’s: guiding principles to achieve continuity in medication management. Canberra, 2005

What can go wrong??

St Vincent’s Hospital in Sydney: Conducted study where doctors were interviewed if an error was found in their medication history

Reasons for errors – from Doctors

Acknowledgement: St Vincent’s Hospital Sydney

Reasons for Error:

Include: – Old notes unavailable – Patient being moved (eg. to diagnostic unit areas)

before medication history completed – Not planning on admitting patient but then

decision changes – Called to attend to resus - distraction

Environment factors n = Workplace

Interruptions Chaotic environment Noisy Embarrassed for pt time waiting/reviewed in chair

2 1 1 1

Workload High workload, busy Long working hours (n> 40hr/week) Pressure of workload Working out of hours/weekend

Similar pts in quick succession MH in retrospect Doing multiple things at once Need to prioritise Drained because of previous case

14 8 7 4 2 2 1 1 1

Staffing levels Short staffed (incl. when only 1 registrar present)

4

Error producing conditions

Error producing conditions Team factors n = Communication

GP unavailable (incl. OS) Own Meds/list unavailable CP unavailable (incl. OS) Look-a-like, sound-a-like (exac. by Brand vs generic usage) Carer unavailable (incl. OS) GP letter not clear Test results unavailable Pt for D/C but stayed (so MH not completed)

8 4 4 3 2 1 1 1

Responsiblility Leave details to Medical Registrar Before Intern started: “didn't realise how much Rxing to do thought senior did it”. Interns are thrown in the deep end, (Rxing)

2 1 1

Obtaining medication history from patient: – unconscious, NESB, cognitive function – changed meds cf list/previous admission – use brand names/ don't know doses – webster packs confusing/ print under plastic – no list/ OM – Pt injured/ Sick pt

• make sure pt safe then MH later

Verifying medication history with 2nd source – after hours – GP/Community Pharmacy not available – ED pressures makes you prioritise duties,

• not always call GP – Dr shopping - list incomplete

Other problems:

Case Study

Mr L 85 yr old man Brought into ED chest pain SOB

Case Study

Mr L is asked about his medications – No idea; son looks after them – Has not brought own meds into hospital – Hands over the list below…

Questions…

Can med list be relied on as full/accurate list of current meds?

ANSWER: No. Handwritten list may not be accurate – May not be updated with recent changes

•may have been ceased/started/new doses etc

Questions…

Pt’s son would be useful source of information re Mr L’s current medications?

ANSWER: YES – Pt says son looks after meds should be able to provide up to date/relevant info. Pt/carer interview should form part of med hx taking process wherever possible

NO OTHER SOURCE CAN EXPRESS WHAT PATIENT ACTUALLY TAKING

Questions…

As well as interviewing son, other sources of info should be used to confirm med hx?

ANSWER: YES Pts/carers often remember limited info. Helpful to use other sources to ensure you obtain relevant info. Other sources??

Sources available for med rec:

Patient interview (or family / carer) Patient’s Own Medications Dose Administration aids (eg. Webster

packs) GP lists/letters NH transfer letters or profiles Discharge summaries from previous hospital

admissions

Patient interview Use patient as a source Interview – use systematic approach

– Be proactive – Prompt questions – Open ended questions – Medical conditions as a trigger – Can use Med Rec form – Assess for compliance OBTAIN COMPLETE AND ACCURATE INFO: – Drug name, dose, freq, ROA, SR/normal release

Patient’s Own Medicines Don’t assume labelled directions correct Don’t assume all meds brought in are current Don’t assume meds contained in a bottle are what

they should be Don’t assume these are all the meds they are

taking Check dates on label Use labels to get details about pt’s pharmacy Double check pt’s name on label

Example label:

Dose Administration aids

Careful interpreting backings Check pt takes all medications

– “I don’t take the blue tablet in the morning as it makes me sick, but I don’t want to upset my GP. Please don’t tell him”

Check for additional medications – Eg. puffers, fridge items, eye drops,

sprays, patches, cytotoxic medications, injections etc

Check for additional Webster packs – Eg. Pack 1 of 2 – where is pack 2 ?

GP lists/letters – CAUTION High error rate

– Meds pt no longer taking; Often a “running list” – More obvious ones:

» may show patient on multiple medications from same class (eg. ramipril and perindopril) when one was meant to replace the other

– Less obvious ones: » Parkinson meds may have been changed and list may

have multiple products which are no longer current

– Wrong doses/frequencies • Not always most up to date list especially if changes made

elsewhere (eg. specialist, hospital admission) – Does not contain entire medication history

• May be missing meds

Nursing home lists/profiles

Check you have all pages of profile

Check date of profile

Check for medications with cease dates

Check entire profile – especially “regular non-packed medications”

Assess prn medications

Other Previous admissions

– Check DATE to assess if current – Confirm with patient

Brand name generics – If unsure, check (MIMS, AMH etc) – PPIs/statins are major offender

• Nexium® – esomeprazole • Zoton ® – lansoprazole • Acimax ® /Losec ® – omeprazole • Somac ® - pantoprazole

Still no luck?

Treat admitting condition Document what has been tried Document “medication history to be

confirmed” on chart AND notes Page ward pharmacist to further investigate

Lillian’s Story: BIBA: fell over, ? broken arm Med Hx: T2DM, HTN, Hyperactive thyroid (recently

commenced PTU) Pt slightly confused, nurse took med hx using pt med list

– metformin 500mg tds, daonil 5mg tds, karvea 150mg od, temaze 10mg prn, panamax 2 prn

ED busy, RMO used nurse’s list to write med chart 48 hrs later, Lillian agitated & confused, ↑ HR, ↑ temp

– suspected sepsis, blood cultures, commenced flucloxacillin IV 1g qid

48 hrs later, sx worsened bloods taken ↑ T4 Unresponsive, thyrotoxic coma, recommenced PTU

– passed away 12 hours later

Back to Mr L ….

Med hx interview Mr L’s son arrives at hospital with pt’s own meds from home. Using these and an interview, his med hx is taken…

Med hx interview

Omissions… Consider patient’s medication hx in context of med hx

WHAT MIGHT BE MISSING??

Investigating…

Investigating…

asdf

Consequences…

Mr L’s ECG/blood test result suggest second MI – cardiac catheterisation; found to have

thrombosis in recently placed stent which has caused second MI

Stent thrombosis and subsequent MI directly attributed to lack of antiplatelet therapy

Learning from this case study Importance of med rec at all transitions of

care Effective Med Rec is a team process

– Prescriber considers pt’s admission meds, clinical presentation, plan for ongoing care etc

– Pharmacist reconciles script against chart – Nurse to check discharge meds/discharge

checklists

Tips to remember:

Always use at least 2 sources for BPMH Always check dates for most current list Don’t assume patient takes meds as listed

on GP list, patient’s own list etc Leave a follow-up trail Use your pharmacist’s help to do admission

& discharge reconciliation

Questions...