Obtain better medication histories for each patient
'Digging deeper' can prevent needless work-ups
After an elderly man told ED nurses he felt dizzy and weak, he handed them two boxes — a cereal box that held medications he took every day, and an oatmeal box containing drugs his doctor told him to stop taking.
"When I asked the patient why he kept the old medications, he told me, 'Medicine is expensive. If the doctor gives me another prescription, I just might have it in my oatmeal box,'" says Candice Parras, RN, MHA, CEN, director of emergency services San Ramon (CA) Regional Medical Center.
When Parras listed all the "cereal box" drugs on the ED's medication reconciliation form, she realized the patient was taking three vials of diltiazem, all with different doses and instructions. "I asked my patient if he knew he was taking the same medicine three different ways. He said, 'If my doctor tells me to take them and doesn't tell me to stop one and move it to the oatmeal box, I just keep doing what he tells me.'"
In this way, Parras discovered the reason for the man's weakness and dizziness. "The incident has always taught me to dig deeper when looking at and listing patient's medications," she says.
Parras now routinely calls the patient's pharmacy or physician to get a current list. "Many time, a family member has a list that is up-to-date," she says. "Sometimes this further investigation process takes a lot of time. But in the long run, it is much safer for the patient and can prevent an expensive, long work-up in the ED."
Pharmacist IDs more allergies
ED nurses and physicians failed to identify medications and allergies after taking a patient's medication history, says a study done at the University of Kansas Hospital in Kansas City.1 During a three-month period, 252 medication histories taken by ED providers and a clinical pharmacist were compared. The pharmacists identified 1,096 home medications vs. 817 home medications documented by ED providers, and they identified 375 medication allergies vs. 350 reported by ED providers.
An ED pharmacist can have a dramatic impact on safety, but only about 30 EDs have a designated pharmacist currently, says Melinda Carter, PharmD, the study's lead author. "The responsibility of recognizing drugs or doses that 'don't make sense' is lifted from already overburdened ED nurses," says Carter. The pharmacist contacts local pharmacies and physician's offices to obtain or clarify medication histories, which allows nurses to spend more time at the bedside, she adds.
If your ED doesn't have a pharmacist, look up doses to make sure they make sense with respect to your patient's medical history, recommends Carter. "Unfortunately, this activity takes time, which nurses often don't have," she says. However, just asking the question is sometimes enough, says Tina Pelosi, RN, an ED nurse at Brandon (FL) Regional Hospital. "Many times patients tell us that they have no medical problems, yet when you ask, 'What medications do you take?' the list comes out," she says.
For example, when ED nurses at Brandon Regional obtained a medication history from a 57-year-old man with a head injury, they discovered that this patient was on warfarin — a fact that became very important when 20 minutes later, the patient became unresponsive, was sent for a CT scan, and was diagnosed with a large intracranial bleed with shift. Susan Ruzin, RN, the ED nurse who cared for the patient, says, "That was a red flag that the patient was at an increased risk for bleeding, and it prompted immediate attention."
To be sure the patient's medication history is correct, you can do the following, advises Lorna K. Prutzman, RN, MSN, director of emergency services at University of Colorado Hospital in Denver:
- Reconcile the medication list if your ED's electronic medical record is connected to the patient's primary care physician's office.
- Review the patient's previous ED record.
- Review every bottle in the "medication bag" the patient brought with them to the ED.
- Copy the list of medications the family brought with them.
- Call for the patient's previous medical record, and reconcile it with the medications the patient is reporting.
- Ask emergency medical services if they found a medication list in the home.
- Call the primary care physician during business hours.
- Ask the pharmacy to do pill recognition for medications in the patient's possession that are labeled incorrectly, are not in containers, or are mixed together in containers.
Another important intervention is providing the patient with an accurate, up-to-date list of their medications, says Parras. Type an easily readable list of the medications in a large font with daily times and dosages noted, along with a description of what the drug looks like, such as "round, bright-blue pill," Parras recommends. "The patients are instructed to always carry this list with them," she says. "If family members accompany the patient, a copy is given to them also."
Reference
- Carter MK, Allin DM, Scott LA, et al. Pharmacist-acquired medication histories in a university hospital emergency department. Am J Health Syst Pharm 2006; 63:2,500-2,503.
Sources
For more information on obtaining medication histories in the ED, contact:
- Melinda Carter, PharmD, Saint Luke's Hospital, Pharmacy Finance and Research Coordinator, 4401 Wornall Road, Kansas City, MO 64111. Telephone: (816) 932-1765. Fax: (816) 932-6168. E-mail: [email protected]
- Candice Parras, RN, MHA, CEN, Director, Emergency Services, San Ramon Regional Medical Center, 6001 Norris Canyon Road, San Ramon, CA 94583. Telephone: (925) 275-8383. E-mail: [email protected].
- Lorna K. Prutzman, RN, MSN, Director of Emergency Services, University of Colorado Hospital, 4200 E. Ninth Ave., Denver, CO 80262-0001. Telephone: (303) 372-8696. E-mail: [email protected].
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