Medication reconciliation is a critical assessment during transitions in care that helps prevent adverse drug events, or ADEs. Any transition in care--entry into the hospital, discharge to a care facility, discharge home--is challenging for elders and caregivers. Oral instructions are often confused or forgotten, and discharge instructions are many times stuck in a stack of other paperwork that gets put aside and not looked at again.
Adverse drug events are serious and common, with an estimate by the Institute of Medicine of over 7000 deaths a year related to medication errors. The FDA reports that half of medication errors are made on patients over sixty.
Medication reconciliation is an assessment done at many primary care visits as well as during transitions in care. But the critical piece is often missing in the office, and can only be done during an in-home visit: comparing the actual bottles with the medication lists, and seeing how daily meds are prepared, and observing the way medications are stored and handled.
Several common errors require education for a behavior change. Medicine is expensive, even with good insurance, and when doctors change prescriptions, most people hang on to the old medication. They think if the new prescription doesn't work out, they can always go back to the old without having to go to the trouble of refilling. While this is a very understandable practice, it can cause medications to get mixed easily between old and new prescriptions. Old medicine belongs to a patient who purchased it, so health care providers can't force the patient to throw away the old bottle of medications. But putting a black X on the label with marker, and physically putting the bottles in a different location from current meds, can reduce the risk of getting mixed up.
Some pharmacies will put generic names on the labels and some will put brand names. If a patient has changed pharmacies, they could have two bottles of the same drug with different drug names on the labels. Checking bottles carefully, making a notation on the bottle about usage, such as "BP" and "sleep," and making the medication list with both brand names and generic names will help reduce this error.
Medication lists should include brand and generic names of each drug, how often it should be taken in plain language, times to take medications, rather than just "bedtime" or "morning," and what the medication is for in simple terms. Patients do not have to remember all of the information, but they should be able to consult a detailed medication list if they're having a side effect or need to speak to the doctor's office over the phone.
Include over-the-counter (OTC) medications and supplements on the list, and look at the over-the-counters to make sure duplication and interactions are not occurring. If someone has three different over-the-counter meds at home for sleep, and no prescriptions for sleep medication, ask if they have discussed sleep problems with their primary care doctor. Over-the-counter medications are well-known for causing lightheadedness. The risk that this side effect can lead to falls is very high.
Pain medication should include careful assessment of both prescription and OTC. For any controlled substance, care should be taken to assess where the medication is stored and who has access to it. If there are a number of early refills, ask if the patient knows what happened to the medicine. If there appears to be a pattern of lost or stolen medications, family and caregivers should engage in a frank discussion about who has access to the controlled substances and how to properly secure them.
For many elders in reduced circumstances, sharing medications with a spouse or partner is common practice. If an in-home assessment reveals evidence of significant poverty, asking about medication sharing is appropriate, as well as offering social services assistance. If patients do not have bottles on hand of medications they have been prescribed, ask if they might be sharing a prescription.
A careful discussion about side effects may give the in-home provider some valuable information about how medications are taken. Some medications cause constipation, for instance. If it is the patient's practice to stop a medication until a side effect resolves itself, that is information that the primary care doctor needs to know.
Check the lids. Make sure people can actually get the lids off, and that child-proof caps are not being used. If small children share the home, assess how medications are stored so they cannot be accessed by children.
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