Patient Safety Tip of the Week
September 16, 2014
Focus on Home Care
We know some of our readers will read no further when the
see “home care” in the title. But the problems that take place in home care are
the result of errors and contributing factors that occur throughout the
healthcare system and usually not the result of errors by what we might
traditionally think of as “home care” providers. Particularly as the bulk of
medical care is being shifted to the home and ambulatory care side, we are
likely to see more and more adverse events occurring outside the hospital
setting.
A little over a year ago we did a column on adverse events
in home care (see our August 13, 2013
Patient Safety Tip of the Week “Adverse
Events in Home Care”) in which we reviewed several excellent studies done
in Canada. Well, our neighbors to the north have again made another excellent
contribution to our understanding of adverse events in home care. ISMP Canada
has done an analysis of medication incidents in home care (ISMP
Canada 2014).
ISMP Canada found
153 incidents over roughly 14 years in their database of voluntary medication
safety incidents and found there were three main themes:
- Medication Transition Failure
- Complex Communications
- Medication Handling Errors
Two-thirds of the incidents involved problems in the transition of patients from the hospital to home. That
obviously includes problems with medication reconciliation. The authors stress
that a discharge medication plan must not only focus on the medications
themselves. Rather there needs to be a comprehensive assessment of the patient
and his family or caregivers regarding financial issues, knowledge deficits,
physical challenges, etc. They note that a medication considered “appropriate”
may, in fact, be “inappropriate” if the patient cannot afford, manipulate or
swallow it.
But they take it a step further and point out that our
communication with community partners may be suboptimal. While home care
nursing is usually made aware of the discharge medication plan, the community
pharmacy seldom is. That can give rise to delays in treatment (eg. a pharmacy may not have a particular drug in routine
stock). We’ve previously also discussed another way the community pharmacy is
often cut out of the loop. In our May 27, 2014 Patient Safety Tip of the Week “A
Gap in ePrescribing: Stopping Medications” we
highlighted a critical issue: stopping a medication is often much different
than starting one. Starting a medication requires an active process – you
either write a prescription, enter one into a computer, or call the pharmacy. But
discontinuing a medication is often more passive – you may just tell the
patient to stop it. You don’t call the pharmacy to stop it. And, if there was
no associated office visit, you might forget to update the patient’s medication
list in your office EMR (or paper records) until the patient’s next office
visit. Thus, a patient may continue to get medications that you thought you had
stopped. A study done in a large multispecialty group practice in Massachusetts
(Allen 2012)
showed that among targeted medications that were electronically discontinued
(on the practice’s EMR) 1.5% were subsequently dispensed by a pharmacy at least
once. We suspect those discontinued at hospital discharge are equally likely to
continue to be dispensed when the community pharmacy is left out of the loop.
The second main theme in the ISMP Canada analysis, involved
in 14% of their incidents, was complex
communications. They point out examples where communication must take place
among multiple different providers, with each communication increasing the
likelihood of error. An example they provide was a patient suffering continued pain
despite a plan for use of a pain pump in the home. A pain pump had been
delivered to the home but no nursing visit was scheduled in advance so an undue
delay in pain management occurred. ISMP Canada points out that coordination
among home care providers can be very complex – involving electronic referrals,
faxes, phone calls, and manual documentation. They note that any change in the
care plan may affect multiple providers. The fact that our current systems are
poor at intercommunicating often leads to duplication of effort and an
increased likelihood of error. They note that a physician may need to write
orders on a home care order sheet but then also write new prescriptions.
The third ISMP Canada theme was medication handling. This theme, which involved in 22% of their
incidents, included errors in dispensing, administering, and repackaging
medications. They note that many patients on multiple medications do better
when their medications are repackaged into blister packs or dosettes.
They stress that systematic double checks need to take place when repackaging
and that the blister packs or dosettes must have the
patient name and list of contents clearly labelled. They note a fatal incident
where a patient’s dosette was filled with medications
intended for the patient’s spouse.
Also included in this theme are cases in which patients or
their caregivers misinterpret instructions for use of a medication. An example
was use of the abbreviation “tsp”, which was interpreted by some as “tablespoon”
rather than “teaspoon”. Also problematic is the instruction “take as directed”.
In our April 12, 2011 Patient Safety
Tip of the Week “Medication
Issues in the Ambulatory Setting” we noted how you tell patients to
take their meds (the “sig:” on your prescriptions) is also critical. A study (Wolf 2011)
gave well-educated volunteers prescriptions for seven drugs and watched them
try to figure out how and when to take them all. They could theoretically be
consolidated to be taken in 4 dosing sets per day. Yet only 15% were able to
consolidate the regimen to 4 times daily or less. Most ended up with regimens
taking medications 6 or 7 times daily. Even the instructions “twice daily” and
“every 12 hours” resulted in medications being taken at different times.
The drugs involved in the ISMP Canada study included high-alert
medications in a quarter of the incidents (opioids, anticoagulants,
hypoglycemic agents, immunosuppressants, and
pediatric liquids) so it’s not surprising that over a third of the reported
incidents resulted in harm to patients.
The ISMP Canada database relies on voluntary reporting. Undoubtedly,
the actual prevalence of medication errors in home care is much higher. But this
is an excellent article that draws attention to how care in multiple parts of
our complex medical system impacts on patients in their home setting.
We also suggerst that you read a
couple of our prior Patient Safety Tips
of the Week that have important considerations for medication safety in the
home care environment:
April 12, 2011 “Medication
Issues in the Ambulatory Setting”
August 13, 2013 “Adverse
Events in Home Care”
References:
ISMP Canada. Aggregate
Analysis of Medication Incidents in Home Care. ISMP Canada Safety Bulletin
2014; 14(8): 1-4
Allen AS, Sequist TD. Pharmacy
Dispensing of Electronically Discontinued Medications. Ann Intern Med 2012; 157(10): 700-705
http://annals.org/article.aspx?articleid=1391698
Wolf MS; Curtis LM, Waite K, et al. Helping Patients Simplify
and Safely Use Complex Prescription Regimens. Arch Intern Med. 2011; 171(4):
300-305
http://archinte.ama-assn.org/cgi/content/abstract/171/4/300
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