Medication Reconciliation Meets Patient Safety: Many Cooks in the Kitchen
I hate to be a spoiler, especially amidst all the deafening applause, but I must ask: Just how reasonable is it to expect that most, or even many, patients (or their friends and family) will produce an updated and accurate medication form (much less schlep it around with them)?
The health care field is becoming increasingly fragmented (I mean, specialized), and it is now commonplace to interact with numerous “prescribers.” There is a doctor for the lung and a doctor for the kidney and a doctor for the chi, and probably even a doctor for navel lint. canada drugs online
There are outpatient “primary” doctors, many of whom no longer “do” hospitals and thus do not follow their patients into the acute-care setting. If you become really sick and require institutionalization, there are so-called hospitalists (practitioners you’ve probably never seen before) who meet and greet you at the hospital and manage the intimate details of your care until it’s time to go home. And for those less emergent situations when you really need to be seen but the primary doctor can’t squeeze in another appointment or when the sun goes down, the weekend arrives, a vacation calls, or the Fourth of July beckons, there are occasional-care docs (like yours truly) who act as substitutes.
So there are a lot of faces and scripts swirling about the modern patient. It hurts my feelings to consider how few people still remember my name, amidst the madding crowd of “providers,” even a month after I’ve seen them for postnasal drip or a throbbing hemorrhoid. And what do they recall about the medications that I might have prescribed?
Let’s assume that most patients could be taught to carry around paper or computer files containing their medications (maybe even inserted under the skin by a microchip); how many do you reckon would keep these lists up to date?
Consider how many of us—even those of us with compulsive tendencies—are current with balancing our checkbooks, cleaning the rain gutters on our roofs, changing the oil in our cars, cutting our hair and toenails, dusting, submitting our expense reports, reading our professional trade magazines.
Remaining up-to-date is a tough proposition, even for the most “anal” of us. Add to this the fact that people who take multiple drugs (the truly at-risk population for medication-related problems) often have more than one chronic ailment and might not be feeling well or thinking clearly all the time. Does it really make sense to try to make patients the central nervous system for communicating important medical or drug information?
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Don’t get me wrong. I am a patient-safety patriot to the core. I get misty at the mere thought of improving the doctor-patient relationship, making the health care system more transparent for the “customer,” and encouraging greater patient participation and shared decision-making (violins, please).
I also love the idea of forcing physicians to consider, with each patient encounter, which drugs patients are taking and whether they should still be taking each one of these. Moreover, as medications may be stopped or started during hospitalization, it is completely logical to have each new caregiver, or the same practitioner for that matter, assess whether the patient should continue to receive each medication, as well as the proper dose, route, strength, and frequency of each one, every time the patient is moved from one venue to another (e.g., from the intensive-care unit to the medical ward).
Finally, it is crucial to make sure that the medications that patients are instructed to take upon discharge from the hospital are the proper ones.
But if doctors write some of their initial orders based partly on less than reliable information from the outset, we may simply be reconciling garbage collected from admission with garbage transcribed on discharge, beautifully compliant with the latest regulations but woefully inadequate in achieving the true goal of improving patient safety. And if we simply rely on patients to take the discharge list to the outpatient “provider,” without making sure ourselves that the details of the hospitalization and medication discharge list are delivered to other practitioners, we may in fact be making a mockery of the concept of “continuity” of care.
Furthermore, by focusing on “processes of care” such as documentation, which are relatively easy to measure, we may be missing opportunities to improve patient safety, such as (1) educating patients about the reasons for prescribing each medication on a list and the possible side effects (good and bad) for each one and (2) understanding what drives patients to take or not take different drugs.
Both of these opportunities require time—something, alas, that is in short supply these days. Admittedly, both prospects have more qualitative than quantitative aspects to them, making them less desirable for measurement purposes and less titillating as commandments. Yet if we ignore the power of education and the power of listening, we might be doing our patients a royal disservice and might be merely fooling ourselves into believing that our surrogate measures of patient safety are meaningful.
If we subscribe to the concept that better “compliance” leads to better outcomes, we had better understand the factors that lead to compliance and noncompliance.