July 30th, 2016 - Med Rec
What I love about Med Rec is that it is sort of detective work. There was one night this week where I was only able to get through one patient since it was a bit more complicated.
He was a 39-year-old white male who presented with chest tightness. He has bipolar disorder, hypertension, hyperlipidemia, COPD, anxiety, depression, panic attacks, PTSD, sleep apnea, chronic back pain, cardiac catheterization in 2011, gastric bypass in 2011, a history of alcohol abuse and smokes. He fractured his 9th rib on July 4th after falling while experiencing chest heaviness/dullness. For the next few days he felt tightness in his chest and nausea multiple times for up to an hour at rest.
Sometimes nurses will have finished a med history, and we’ll back check it then do the med rec. Sometimes the med history hasn’t been done at all so we’ll go ahead and do the med history and rec. In this case, the med history was done by a nurse when the patient came to the emergency department the night before. So the patient was already given medications (based on his home regimen) that first night.
There were 32 medications on the history list that the nurse approved. I went upstairs to talk with the patient to double check everything he is taking at home. I ended up speaking to his wife on the phone, and I went through every single medication with her, confirming the name, strength and frequency. Here are the issues I found when compared to the original med history:
- 3 medications that he is currently taking was not on his list at all.
- 11 medications were marked “prescribed, but not taking,” but actually are no longer prescribed at all.
- 7 medications were marked “still taking, as prescribed,” but they’re no longer prescribed.
- How he was taking some medications were incorrect.
I went back to the computer and updated his med list. I was happy that I was able to clear everything up, and clean out his history. I did the reconciliation and found that the only two medications that they missed giving him in-hospital was his amlodipine 5mg (blood pressure/heart), buspirone 5 mg (anxiety/depression), and propranolol (blood pressure/anxiety). Really out of those three, the one that he really should be given is the buspirone, but I figured I would recommend all three when I speak to the pharmacist.
I called to his floor to speak with a nurse about another patient, but she brought up this patient and said she wasn’t sure if the wife was giving us the correct information (since last night the wife told the nurse inconsistent information as well). We called his pharmacy and obtained a “fill list” (which is basically a history of when he filled all of his medications). It looked like there were 7 medications that either he should have run out a few weeks ago, he hasn’t filled since December 2015, or he’s never filled at all.
I went to clarify with him and his wife. I figured that he hasn’t been taking some medications because maybe they can’t afford it (that was the case). His wife was hesitant at first to tell me he wasn’t taking some of the medications, but I assured her that its okay, and we just wanted to clarify so we know what he has been taking so we don’t give him medications he isn’t even taking. So from that, I confirmed that he is no longer taking 3 medications that I had on my list.
One of the medications we were most concerned about was divalproex (bipolar), because he was on a high dose and we had given it to him last night. But if he is no longer taking it, we don’t want to be giving it to him (especially at such a high dose). It turned out that his doctor helped them obtain another 90 day supply through a medication assist program, so that’s why it was not on his fill list.
In summary, I found 6 errors after doing his medication history and reconciliation.
1. Since the nurse had marked the medication list as “final” last night, the doctor gave the patient 3 medications that he is not currently taking. The doxazosin (bipolar/PTSD), ziprasidone (bipolar/mood), and pregabalin (nerve pain). //Update, they discontinued these meds that night after I left!
2. Since these were not on his original history from last night, he wasn’t started on amlodipine, buspirone, or propranolol.
I confirmed my recommendations with the pharmacist, and I noticed the issues and told the nurse (who would tell the MD).
This was definitely one of my more interesting cases, and I’m glad I was able to clarify a few errors!