Transcript Managing Your Medicines

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??
Reasons for errors – from Doctors
St Vincent’s Hospital in Sydney:
Conducted study where doctors
were interviewed if an error was
found in their medication history
Acknowledgement: St Vincent’s Hospital Sydney
Reasons for Error:
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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
Error producing conditions
Environment factors
Workplace
Interruptions
Chaotic environment
Noisy
Embarrassed for pt time waiting/reviewed in chair
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
Staffing levels
Short staffed (incl. when only 1 registrar present)
n=
2
1
1
1
14
8
7
4
2
2
1
1
1
4
Error producing conditions
Team factors
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)
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)
n=
8
4
4
3
2
1
1
1
2
1
1
Other problems:
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Obtaining medication history from patient:
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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
Case Study
Mr L
85 yr old man
Brought into ED
 chest pain
 SOB
Case Study
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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…
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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…
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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…
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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:
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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
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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
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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
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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
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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
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Check you have all pages of profile
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Check date of profile
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Check for medications with cease dates
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Check entire profile – especially “regular
non-packed medications”
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Assess prn medications
Other
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Previous admissions
– Check DATE to assess if current
– Confirm with patient
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Brand name  generics
– If unsure, check (MIMS, AMH etc)
– PPIs/statins are major offender
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Nexium® – esomeprazole
Zoton ® – lansoprazole
Acimax ® /Losec ® – omeprazole
Somac ® - pantoprazole
Still no luck?
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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:
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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
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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
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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…
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asdf
Consequences…
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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
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Stent thrombosis and subsequent MI
directly attributed to lack of antiplatelet
therapy
Learning from this case study
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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:
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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...