Sometimes during the course of a person’s hospitalization their medication regimen is changed. Sometimes however, there are oversights, errors or as in this case, printer problems.
So many times one problem compounds another and the end result is a dangerous mess of mixed up medications that goes unnoticed until a person becomes unwell or experiences a crisis. A prescription review can identify issues before they become problems.
Here is a story about a prescription review from our practice today:
Today we were organizing a client’s medications.There were multiple vials of medications strewn throughout the apartment. Some were years old. The client had a dangerous habit of pouring medications from one vial to another vial. The printed directions on the medication vials were not necessarily the most recent instructions and some dosages had, in fact, changed. The client confided to us that she has difficulty opening the vials. We introduced a medication dossette.
Although this client had a recent history of low hemoglobin and she had iron tablets at home by order of her family doctor, the discharge note from the hospital did not mention anemia as one of her pre-existing conditions. Nor did it mention the iron therapy or any follow up that might be required by a person with anemia. We called the Nurse Practitioner at the hospital who revealed that the client had had a transfusion while in hospital, related to low hemoglobin but that they had been unaware of any history of iron therapy.
An oversight.
This particular client also has diabetes. She is newly diagnosed and is insulin dependent. She has been directed to take her blood sugar readings four times daily and adjust her insulin dose based on the reading. She does not have a chart to reference. She is unsure of what foods she should eat in order to maintain good blood sugar control. She is uncertain as to what she would do if her blood sugar reading was low. She lives alone and is frail.
Another oversight?
The Client received a referral to a dietitian but the period of time between her discharge from hospital and the appointment for the dietitian is 5 months….
During our home assessment we found, candies, white bread and other items that would not normally be found on a diabetic diet. The client’s family said that visitors are bringing all kinds of foods to the house when they visit…
Finally, in reviewing the medication in the discharge note we found a discrepancy.The family doctor ordered a medication to be taken three times daily. The hospital discharge prescription noted that it was only to be taken once per day. We could not see any reason for the discrepancy.
Once again we called the Nurse Practioner to help clarify the prescription. In assisting us, she discovered that the medication dosage should have been one tablet, three times a day and that it was due to a printer error that the order had been cut off (instead of reading that the meds should be taken with breakfast, with lunch and with dinner, it read only that the drugs should be taken with breakfast. The rest of the message was not included.)
True story. One of many.
What you can do:
The next time you or someone you care about is leaving the hospital, take the time to do a thorough prescription review. Always ask questions if there seems to be a discrepancy, never assume anything.
Printer problems, errors and oversights happen, but no one should have to suffer as a result.
Health Council of Canada report on CCAC hours and our experience…
