Continuity of care means better instruction on meds
Are patients going home with enough information?
By Patrice Spath, RHIT
Brown-Spath Associates
Forest Grove, OR
Improvements in the continuity of patient care have traditionally focused on care coordination among practitioners and organizations. Hospitals have made significant strides toward assuring adequate clinical information is communicated to other settings where patients will receive care after discharge.
One aspect of continuity that frequently is overlooked is the transfer of information to patients. An area of high risk is medication instruction. Patients who are discharged from the hospital with take-home medications must have clear instructions on how those medications should be taken. While the nursing and pharmacy staff may verbally discuss the medication regimen with the patient, it is important that the prescription itself contain written full dosage instructions that the patient can refer to after leaving the hospital. Incomplete or missing dosage instructions can be the cause of much irritation and time-consuming discussions between pharmacists, patients, and doctors. The ability of some of patients to take their medicines as the doctor has intended may be compromised with resulting medication errors or patient noncompliance.
How often are clear and complete dosage instructions missing from take-home prescriptions? Start your investigation of this issue by determining the importance of the problem. Remember, something may be important because it occurs frequently or, although it occurs infrequently, it takes a large amount of time and energy to resolve. You may find that only a small percentage of take-home prescriptions contain unclear dosage instructions, but if the resources are not available to resolve the problems caused by incomplete instructions, then the consequences can be significant. By conducting a baseline study of this issue, you can determine if problem-solving actions need to be taken.
To determine the extent of the problem, conduct a study to identify the number of take-home prescriptions that do not have full dosage instructions and what impact, if any, the lack of instructions had on resource use and patient outcomes. Information you can collect might include:
• number of occasions the pharmacist had to seek clarification of the dosage instructions from the ordering physician;
• number of times prescriptions are dispensed without full dosage instructions and how this related to the total number of take-home prescriptions that are dispensed;
• number of times patients contact the pharmacist or another hospital caregiver to clarify dosage instructions after they’ve been discharged;
• number of times patients request clarification of dosage instructions during telephone follow-up by a case manager or other caregiver;
• number of health problems that arise due to incomplete or inadequate dosage instructions (e.g., lack of symptom control, treatment failure, adverse effects, etc.);
• number of rehospitalizations that appear to be related to medication errors caused by inadequate instructions.
The form shown above can be used to collect data. This is a baseline study, so you only need to collect information for a sample of take-home prescriptions (30 is suggested as a minimum number). In selecting your sample, be sure to take into consideration the variations in daily workload and staffing. Because this can be a labor-intensive study, you may wish to avoid starting the collection at the busiest part of the week/month/year. Data can be gathered on a random group of prescriptions, those dispensed to a specific patient category or those drugs in a certain therapeutic group.
What can the baseline study tell you about the importance of the problem? If you find that a significant number of patients are receiving take-home medicines with incomplete dosage instructions or the number is small but troublesome, several steps should be taken to investigate the problem in greater depth. Start by listing the types of situations that cause the greatest difficulty in relation to dosage instructions, e.g., on weekends, a particular physician, a particular class of drugs, patients receiving repeat prescriptions. Do different physicians use a different approach in writing out instructions? Do different pharmacists have varying tolerance for incomplete dosage instructions? List the steps the pharmacist normally takes to clarify the appropriate dosage instructions to be included on the prescription label. This may include checking with the patient and the physician.
Patients’ lack of compliance with therapeutic treatment regimens is often overlooked as a continuity-of-care problem. There is mounting evidence to suggest that it may be a contributory or even causal factor in treatment failure, representing significant avoidable morbidity and mortality. Taking medicines depends on a variety of factors, including motivation to comply, anxieties relating to risk and side effects, physical ability, and knowledge of the medicines. Hospitals can do much to reduce these risks by assuring the patient has sufficient information about how medications must be taken to obtain optimal benefits.
Confirming missing dosage instructions with the ordering physician is a time-consuming activity for the pharmacist, often causing discharge delays while questions are sorted out. Time pressures can decrease the likelihood that patients and families will ask questions about dosage instructions. Studies such as the one described in this article can help hospitals quantify the problem and identify patient or drug groups where instructions might be conveyed better through different means (e.g., instruction booklets for steroids/warfarin, inhaled drugs, etc.). Inpatient education practices might need to be reviewed and amended. Practitioners may need to change established prescribing habits. As our patients begin to assume more responsibility for self-care at home, we must ensure that continuity of care is not compromised by inadequate transfer of information.
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