PERIOPERATIVE GRAND ROUNDS
Discontinued Medications: Are They Really Discontinued? THE CASE
A 69-year-old man with chronic atrial fibrillation and a past cerebrovascular accident treated with warfarin and aspirin presented to the emergency department with a severe headache. A STAT computed tomography (CT) scan revealed bilateral subdural hematomas. His international normalized ratio (INR) was supratherapeutic at 4.9. He was admitted to the intensive care unit, and the warfarin was stopped. After resolution of the condition, warfarin was restarted because of the high risk associated with the patient’s previous cerebrovascular accident. One day after reinitiation of warfarin, the patient experienced a recurrence of subdural hematomas. Medical personnel discontinued the warfarin, and the patient stabilized clinically and was discharged. Warfarin was not on the patient’s discharge medication list, but a few days after returning home, the patient received a mail renewal from his outpatient pharmacy. Confused, he thought he should restart warfarin. At his followup appointment, he had an elevated INR again. A CT scan was, fortunately, negative for hemorrhage. To prevent a recurrence of subdural hematomas, warfarin was added to his allergy list with the comment “Never to be resumed.” Still, when the primary care provider contacted the pharmacy weeks later, warfarin remained on the patient’s active medication list with available refills. The primary care provider had it removed from this list.
DISCUSSION Transitions of care represent a period of vulnerability for patients. A reduction of transition-related errors is a priority for performance improvement efforts. Approximately half of adults experience a medical error after hospital discharge, with 19% to 23% experiencing an adverse event.1 A review of medication records for patients older than 65 years of age who are discharged from hospitals revealed that 86.2% had at least one medication discrepancy.2 Medication reconciliation prevents adverse drug events and has been a requirement of The Joint Commission since 2006.3 This includes documentation of a patient’s current medications at hospital admission and discharge. A study by Salemi and Singleton looked at medication
reconciliation as a method to decrease errors and adverse drug events.3 Discharge medication reconciliation could provide collaboration with community partners, important in payment models, such as bundling and accountable care organizations. In this case, the delivery of discontinued warfarin was an error. Although this type of error has not been well documented, it probably is common.4 A retrospective cohort study of electronically discontinued medications found that 1.5% of medications were dispensed during the 12-month followup.4 Also, a 27% rate of represcription after an adverse drug reaction during the first six months following discharge has been observed.5 A prescription becomes part of the pharmacy database upon receipt of a medication order, but there is no process to notify pharmacies when medications have been discontinued. When a medication is removed from the patient’s active medication list, patients and family members must be instructed about the change. However, the change is unlikely to be communicated to the pharmacist. Consequently, automatic refills of discontinued medications still occur. To prevent errors, pharmacies should get up-to-date medication lists, including discontinued medications, so the continued on page 358 This content is adapted from AHRQ WebM&M (Morbidity & Mortality Rounds on the Web) with permission from the Agency for Healthcare Research and Quality. The original commentary was written by Celina Garza Mankey, MD, and Prathibha Varkey, MD, MPH, MBA, and was adapted for this article by Nancy J. Girard, PhD, RN, FAAN, consultant/ owner, Nurse Collaborations, Boerne, TX. (Citation: Mankey CG, Prathibha V. Discontinued medications: are they really discontinued? AHRQ Web M&M [serial online]. http://webmm.ahrq.gov/case.aspx?caseID¼325. Published May 2014. Accessed December 5, 2014.) Dr Girard has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. http://dx.doi.org/10.1016/j.aorn.2015.01.014 ª AORN, Inc, 2015
396 j AORN Journal
www.aornjournal.org
Perioperative Grand Rounds
continued from page 396 pharmacist can remove them from the patient’s list. Community pharmacists rarely receive postdischarge information but almost always receive information for medication issues that are complex. In one study, pharmacist medication reconciliation at discharge reduced discrepancies for elderly patients.6 Two other studies looking at pharmacist home visits after discharge from the hospital2 and postdischarge transitions7 showed improved medication use and reduced resource use. Nurse-pharmacist collaboration can also identify and reconcile discrepancies.8,9 Medication reconciliation and all changes should be communicated to patients at discharge. The information can also be available via a patient portal.10 Communication with all key players (eg, patient, family members, nurses, surgeon, primary care provider, inpatient pharmacist, outpatient community pharmacist) at discharge reduces medication discrepancies.11 Electronic medical records, and access to these records through a health information exchange, should be used to prevent these types of errors. Development of the Assessment of Risk Tool for monitoring high-risk medication factors12 allowed hospital-based pharmacists to intervene with medication reconciliation in a more timely manner. In one study, the use of secure messaging for medication reconciliation, particularly during transitions of care, was also evaluated.13 The Seamless Transfer of Care Protocol, an electronic transfer-of-care communication tool, is currently being studied to determine whether it can help decrease readmissions, adverse events, and deaths.14 A multidisciplinary approach would be best for creating and maintaining an accurate medication list. This includes communication among inpatient pharmacists, patients, community pharmacies, and primary care providers. All parties responsible for patient care should ensure that correct and accurate medication lists are available. In this specific case, techniques such as multidisciplinary communication would have resulted in the patient not restarting his warfarin, thus preventing a serious medication error. It is time for there to be a single medication list and for that list to follow patients across the continuum of care.
PERIOPERATIVE POINTS Medication errors are common, particularly at the point-ofcare transition. Patient education is an integral component of medication reconciliation. 358 j AORN Journal
March 2015, Volume 101, No. 3
A multidisciplinary approach, including communication with the primary care provider and outpatient community pharmacy, is the best way to decrease the occurrence of adverse drug events after hospital admission.
References 1. Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. 2007;2(5):314-323. 2. Fitzgibbon M, Lorenz R, Lach H. Medication reconciliation: reducing risk for medication misadventure during transition from hospital to assisted living. J Gerontol Nurs. 2013;39(12): 22-29. 3. Salemi CS, Singleton N. Decreasing medication discrepancies between outpatient and inpatient care through the use of computerized pharmacy data. Perm J. 2007;11(2):31-34. 4. Allen AS, Sequist TD. Pharmacy dispensing of electronically discontinued medications. Ann Intern Med. 2012;157(10): 700-705. 5. van der Linden CM, Jansen PA, van Marum RJ, Grouls RJ, Egberts TC, Korsten EH. An electronic system to document reasons for medication discontinuation and to flag unwanted represcriptions in geriatric patients. Drugs Aging. 2012;29(12):957-962. 6. Lee JI, Ganz-Lord F, Tung J, et al. Bridging care transitions: findings from a resident-staffed early postdischarge program. Acad Med. 2013;88(11):1685-1688. 7. Kogut SJ, Goldstein E, Charbonneau C, Jackson A, Patry G. Improving medication management after a hospitalization with pharmacist home visits and electronic personal health records: an observational study. Drug Healthc Patient Saf. 2014;6:1-6. 8. Hawes EM, Maxwell WD, White SF, Mangun J, Lin FC. Impact of an outpatient pharmacist intervention on medication discrepancies and health care resource utilization in posthospitalization care transitions. J Prim Care Community Health. 2014;5(1):14-18. 9. Feldman LS, Costa LL, Feroli ER Jr, et al. Nurse-pharmacist collaboration on medication reconciliation prevents potential harm. J Hosp Med. 2012;7(5):396-401. 10. Heyworth L, Paquin AM, Clark J, et al. Engaging patients in medication reconciliation via a patient portal following hospital discharge. J Am Med Inform Assoc. 2014;21(e1):e157-e162. 11. Lindquist LA, Yamahiro A, Garrett A, Zei C, Feinglass JM. Primary care physician communication at hospital discharge reduces medication discrepancies. J Hosp Med. 2013;8(12):672-677. 12. Falconer N, Nand S, Liow D, Jackson A, Seddon M. Development of an electronic patient prioritization tool for clinical pharmacist interventions. Am J Health-Syst Pharm. 2014;71(4): 311-320. 13. Heyworth L, Clark J, Marcello TB, et al. Aligning medication reconciliation and secure messaging: qualitative study of primary care providers’ perspectives. J Med Internet Res. 2013;15(12): e264. 14. Okoniewska BM, Santana MJ, Holroyd-Leduc J, et al. The Seamless Transfer-of-Care Protocol: a randomized controlled trial assessing the efficacy of an electronic transfer-of-care communication tool. BMC Health Serv Res. 2012;12:414.
www.aornjournal.org
Discontinued Medications: Are They Really Discontinued? THE CASE
A 69-year-old man with chronic atrial fibrillation and a past cerebrovascular accident treated with warfarin and aspirin presented to the emergency department with a severe headache. A STAT computed tomography (CT) scan revealed bilateral subdural hematomas. His international normalized ratio (INR) was supratherapeutic at 4.9. He was admitted to the intensive care unit, and the warfarin was stopped. After resolution of the condition, warfarin was restarted because of the high risk associated with the patient’s previous cerebrovascular accident. One day after reinitiation of warfarin, the patient experienced a recurrence of subdural hematomas. Medical personnel discontinued the warfarin, and the patient stabilized clinically and was discharged. Warfarin was not on the patient’s discharge medication list, but a few days after returning home, the patient received a mail renewal from his outpatient pharmacy. Confused, he thought he should restart warfarin. At his followup appointment, he had an elevated INR again. A CT scan was, fortunately, negative for hemorrhage. To prevent a recurrence of subdural hematomas, warfarin was added to his allergy list with the comment “Never to be resumed.” Still, when the primary care provider contacted the pharmacy weeks later, warfarin remained on the patient’s active medication list with available refills. The primary care provider had it removed from this list.
DISCUSSION Transitions of care represent a period of vulnerability for patients. A reduction of transition-related errors is a priority for performance improvement efforts. Approximately half of adults experience a medical error after hospital discharge, with 19% to 23% experiencing an adverse event.1 A review of medication records for patients older than 65 years of age who are discharged from hospitals revealed that 86.2% had at least one medication discrepancy.2 Medication reconciliation prevents adverse drug events and has been a requirement of The Joint Commission since 2006.3 This includes documentation of a patient’s current medications at hospital admission and discharge. A study by Salemi and Singleton looked at medication
reconciliation as a method to decrease errors and adverse drug events.3 Discharge medication reconciliation could provide collaboration with community partners, important in payment models, such as bundling and accountable care organizations. In this case, the delivery of discontinued warfarin was an error. Although this type of error has not been well documented, it probably is common.4 A retrospective cohort study of electronically discontinued medications found that 1.5% of medications were dispensed during the 12-month followup.4 Also, a 27% rate of represcription after an adverse drug reaction during the first six months following discharge has been observed.5 A prescription becomes part of the pharmacy database upon receipt of a medication order, but there is no process to notify pharmacies when medications have been discontinued. When a medication is removed from the patient’s active medication list, patients and family members must be instructed about the change. However, the change is unlikely to be communicated to the pharmacist. Consequently, automatic refills of discontinued medications still occur. To prevent errors, pharmacies should get up-to-date medication lists, including discontinued medications, so the continued on page 358 This content is adapted from AHRQ WebM&M (Morbidity & Mortality Rounds on the Web) with permission from the Agency for Healthcare Research and Quality. The original commentary was written by Celina Garza Mankey, MD, and Prathibha Varkey, MD, MPH, MBA, and was adapted for this article by Nancy J. Girard, PhD, RN, FAAN, consultant/ owner, Nurse Collaborations, Boerne, TX. (Citation: Mankey CG, Prathibha V. Discontinued medications: are they really discontinued? AHRQ Web M&M [serial online]. http://webmm.ahrq.gov/case.aspx?caseID¼325. Published May 2014. Accessed December 5, 2014.) Dr Girard has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. http://dx.doi.org/10.1016/j.aorn.2015.01.014 ª AORN, Inc, 2015
396 j AORN Journal
www.aornjournal.org
Perioperative Grand Rounds
continued from page 396 pharmacist can remove them from the patient’s list. Community pharmacists rarely receive postdischarge information but almost always receive information for medication issues that are complex. In one study, pharmacist medication reconciliation at discharge reduced discrepancies for elderly patients.6 Two other studies looking at pharmacist home visits after discharge from the hospital2 and postdischarge transitions7 showed improved medication use and reduced resource use. Nurse-pharmacist collaboration can also identify and reconcile discrepancies.8,9 Medication reconciliation and all changes should be communicated to patients at discharge. The information can also be available via a patient portal.10 Communication with all key players (eg, patient, family members, nurses, surgeon, primary care provider, inpatient pharmacist, outpatient community pharmacist) at discharge reduces medication discrepancies.11 Electronic medical records, and access to these records through a health information exchange, should be used to prevent these types of errors. Development of the Assessment of Risk Tool for monitoring high-risk medication factors12 allowed hospital-based pharmacists to intervene with medication reconciliation in a more timely manner. In one study, the use of secure messaging for medication reconciliation, particularly during transitions of care, was also evaluated.13 The Seamless Transfer of Care Protocol, an electronic transfer-of-care communication tool, is currently being studied to determine whether it can help decrease readmissions, adverse events, and deaths.14 A multidisciplinary approach would be best for creating and maintaining an accurate medication list. This includes communication among inpatient pharmacists, patients, community pharmacies, and primary care providers. All parties responsible for patient care should ensure that correct and accurate medication lists are available. In this specific case, techniques such as multidisciplinary communication would have resulted in the patient not restarting his warfarin, thus preventing a serious medication error. It is time for there to be a single medication list and for that list to follow patients across the continuum of care.
PERIOPERATIVE POINTS Medication errors are common, particularly at the point-ofcare transition. Patient education is an integral component of medication reconciliation. 358 j AORN Journal
March 2015, Volume 101, No. 3
A multidisciplinary approach, including communication with the primary care provider and outpatient community pharmacy, is the best way to decrease the occurrence of adverse drug events after hospital admission.
References 1. Kripalani S, Jackson AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. 2007;2(5):314-323. 2. Fitzgibbon M, Lorenz R, Lach H. Medication reconciliation: reducing risk for medication misadventure during transition from hospital to assisted living. J Gerontol Nurs. 2013;39(12): 22-29. 3. Salemi CS, Singleton N. Decreasing medication discrepancies between outpatient and inpatient care through the use of computerized pharmacy data. Perm J. 2007;11(2):31-34. 4. Allen AS, Sequist TD. Pharmacy dispensing of electronically discontinued medications. Ann Intern Med. 2012;157(10): 700-705. 5. van der Linden CM, Jansen PA, van Marum RJ, Grouls RJ, Egberts TC, Korsten EH. An electronic system to document reasons for medication discontinuation and to flag unwanted represcriptions in geriatric patients. Drugs Aging. 2012;29(12):957-962. 6. Lee JI, Ganz-Lord F, Tung J, et al. Bridging care transitions: findings from a resident-staffed early postdischarge program. Acad Med. 2013;88(11):1685-1688. 7. Kogut SJ, Goldstein E, Charbonneau C, Jackson A, Patry G. Improving medication management after a hospitalization with pharmacist home visits and electronic personal health records: an observational study. Drug Healthc Patient Saf. 2014;6:1-6. 8. Hawes EM, Maxwell WD, White SF, Mangun J, Lin FC. Impact of an outpatient pharmacist intervention on medication discrepancies and health care resource utilization in posthospitalization care transitions. J Prim Care Community Health. 2014;5(1):14-18. 9. Feldman LS, Costa LL, Feroli ER Jr, et al. Nurse-pharmacist collaboration on medication reconciliation prevents potential harm. J Hosp Med. 2012;7(5):396-401. 10. Heyworth L, Paquin AM, Clark J, et al. Engaging patients in medication reconciliation via a patient portal following hospital discharge. J Am Med Inform Assoc. 2014;21(e1):e157-e162. 11. Lindquist LA, Yamahiro A, Garrett A, Zei C, Feinglass JM. Primary care physician communication at hospital discharge reduces medication discrepancies. J Hosp Med. 2013;8(12):672-677. 12. Falconer N, Nand S, Liow D, Jackson A, Seddon M. Development of an electronic patient prioritization tool for clinical pharmacist interventions. Am J Health-Syst Pharm. 2014;71(4): 311-320. 13. Heyworth L, Clark J, Marcello TB, et al. Aligning medication reconciliation and secure messaging: qualitative study of primary care providers’ perspectives. J Med Internet Res. 2013;15(12): e264. 14. Okoniewska BM, Santana MJ, Holroyd-Leduc J, et al. The Seamless Transfer-of-Care Protocol: a randomized controlled trial assessing the efficacy of an electronic transfer-of-care communication tool. BMC Health Serv Res. 2012;12:414.
www.aornjournal.org
