NUR 650 Module 8 Medication Paper Example

Medication Discrepancies at Discharge: Reconciling Lists With Patients' Reality and Closing the Loop With Primary Care

[Student Name]

Southern New Hampshire University

NUR 650: Care Coordination and Outcomes Management

Module Eight Medication Paper

[Instructor Name]

[Date]

Medication Discrepancies at Discharge: Reconciling Lists With Patients' Reality and Closing the Loop With Primary Care

A heart failure patient may leave the hospital on six to twelve medications, some new, some changed in dose and some stopped. The discharge list is supposed to tell the patient, the pharmacy and the primary care clinician exactly what to take. In practice, lists conflict, patients keep taking stopped medications from bottles at home and changes never reach the clinic. In the composite Brookhaven setting, where a heart failure transitional care bundle is being tested, the pharmacist follow-up calls during the first test cycles found that 26 of 104 patients were taking something different from their discharge list at one week. This paper examines why medication discrepancies occur at transitions, reviews what interventions have and have not achieved and designs a reconciliation process for Brookhaven. It argues that reconciliation must compare documents with what patients actually do and must end with a usable handoff to primary care.

Why Medications Matter After Discharge

Forster et al. (2003) followed 400 medical patients after discharge and found that close to 20% went on to have an adverse event, an injury resulting from medical management rather than from the underlying disease. Adverse drug events were the most common type, accounting for about two thirds of the events, and many were judged preventable or ameliorable, often through better communication or monitoring. For heart failure patients, the medications most often involved, diuretics, anticoagulants, potassium and drugs affecting kidney function, are exactly those where a missed change can quickly cause dehydration, bleeding, dangerous potassium levels or fluid overload.

Types of Discrepancies

Coleman et al. (2005) studied older adults after hospital discharge and found that about 14% had at least one medication discrepancy, and that patients with a discrepancy returned to the hospital within 30 days at over double the rate of patients without one. They classified discrepancies as patient-associated, such as intentional nonadherence, not filling a prescription or confusion about instructions, and system-associated, such as conflicting information from different sources, incomplete or unclear discharge instructions or a prescribed medication that was unaffordable or unavailable. The distinction is useful because each type needs a different fix: patient-associated discrepancies call for teaching and support, while system-associated discrepancies call for changes to the process that produced the list.

Brookhaven's 26 discrepancies fit both categories. Nine patients were still taking a medication that had been stopped, usually because they had old bottles at home and no one had told them clearly to discard them. Seven had not filled a new prescription, five because of cost. Six had a dose different from the list because the discharge instructions and the pharmacy label disagreed. Four had stopped their diuretic on their own because of frequent urination.

What Interventions Have Achieved

It would be natural to assume that more pharmacist involvement solves the problem. Kripalani et al. (2012) tested that assumption in a randomized trial of adults hospitalized with acute coronary syndromes or acute decompensated heart failure at two academic centers. The intervention included pharmacist-assisted reconciliation, inpatient counseling, adherence aids and a follow-up phone call after discharge. About half of patients in both groups had at least one clinically important medication error in the 30 days after discharge, and the intervention did not significantly reduce the number of errors. The authors suggested that errors after discharge arise in many places, including outpatient prescribing and patients' use of medications at home, which an inpatient-focused intervention may not reach.

This finding shapes Brookhaven's design. The pharmacist call already in the bundle remains useful for detection, but reconciliation cannot stop at the hospital door. It must address what happens at home and in primary care, where the trial suggests many errors occur.

A Reconciliation Process for Brookhaven

The revised process has four steps. First, on admission, the nurse or pharmacy technician obtains a best possible medication history from at least two sources, including the patient's own bottles or a photo of them brought by family and pharmacy fill records, since patient recall and old clinic lists are often wrong. Second, before discharge, the pharmacist reconciles the discharge list against this history, labels each medication as new, changed, continued or stopped and checks coverage and cost for new medications. Third, the discharge teaching includes a stop list: the patient or caregiver is asked to identify stopped medications at home and set them aside in a labeled bag, which the transitional care nurse or pharmacist asks about on the follow-up call. Fourth, the reconciled list, with changes and reasons highlighted, is sent electronically to the primary care office and the patient's pharmacy on the day of discharge, and the clinic is asked to confirm receipt.

Measuring Discrepancies Directly

Because the goal is fewer discrepancies, the program will measure them directly rather than relying on readmissions. On the day-three call, the pharmacist will have the patient pick up each container, say its name and dose from the label and match it against the reconciled list, recording discrepancies by type using Coleman's categories. The proportion of patients with any discrepancy and the number per patient will be charted monthly. Process measures will include the proportion of admissions with a best possible medication history from two sources, the proportion of discharges with a stop list completed and the proportion of reconciled lists confirmed as received by primary care. A goal of reducing patients with any discrepancy from 25% to 12% within a year was set, recognizing that the trial evidence counsels modest expectations.

Caregivers are part of the process. Many Brookhaven heart failure patients have a husband, wife, son or daughter who fills the weekly pillbox, and several discrepancies in the test cycles arose because the caregiver had not been present for teaching. The discharge nurse will ask who manages medications at home and, when it is someone else, will include that person in teaching by phone or video if they cannot attend, and will send the reconciled list to them as well.

Conclusion

Medication discrepancies after discharge are common, dangerous and caused by both patient and system factors. A pharmacist trial with a null result shows that inpatient effort alone is not enough. A process that begins with an accurate history from real sources, labels every change, helps patients remove stopped medications from home and hands a reconciled list to primary care, with discrepancies measured directly, addresses the causes Brookhaven found at each point where the handoff failed.

References

Coleman, E. A., Smith, J. D., Raha, D., & Min, S. (2005). Posthospital medication discrepancies: Prevalence and contributing factors. Archives of Internal Medicine, 165(16), 1842-1847. https://doi.org/10.1001/archinte.165.16.1842

Forster, A. J., Murff, H. J., Peterson, J. F., Gandhi, T. K., & Bates, D. W. (2003). The incidence and severity of adverse events affecting patients after discharge from the hospital. Annals of Internal Medicine, 138(3), 161-167. https://doi.org/10.7326/0003-4819-138-3-200302040-00007

Kripalani, S., Roumie, C. L., Dalal, A. K., Cawthon, C., Businger, A., Eden, S. K., Shintani, A., Sponsler, K. C., Harris, L. J., Theobald, C., Huang, R. L., Scheurer, D., Hunt, S., Jacobson, T. A., Rask, K. J., Vaccarino, V., Gandhi, T. K., Bates, D. W., Williams, M. V., & Schnipper, J. L. (2012). Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: A randomized trial. Annals of Internal Medicine, 157(1), 1-10. https://doi.org/10.7326/0003-4819-157-1-201207030-00003