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The Important Thing to Do Before Leaving the Hospital

Many patients and families forget, which can lead to complications later


When Celeste Jordan, 70, was admitted to a New York hospital for removal of a parathyroid gland (tiny glands in the neck), her daughter, Jasmine Pearlman, was by her side. The parathyroidectomy treated only one of Jordan’s many medical conditions, and all 13 of her medications were duly reported on admission.

But when Jordan was discharged from the hospital, the medication orders included an opioid narcotic for pain, even though she was already on another opioid for a different condition. Just as troubling, no antibiotic was prescribed, even though she had been on one in the hospital.

Jordan then developed a serious infection at the wound site, which led to a complicated recovery.

Pearlman, a researcher and author, as well as a millennial family caregiver, says this example is only one of many similar medication errors her mother has experienced. And it’s not unusual. For example, one study in cardiac patients found that over half of them had a clinically important medication error within 30 days of discharge from the hospital.

One of the most important steps before a hospital discharge is a review of medication orders. Yet in the press of time, other paperwork and transportation worries, many patients and family caregivers don’t focus on the details until they get home.

Too many medications, too little time and too much room for error. Many people leaving the hospital mistakenly believe that all of their medications are “in the system,” even though information comes from many sources and is often incomplete or contradictory.

Medication Reconciliation Explained

What can patients and family caregivers do to prevent these errors? Isn’t that the hospital’s responsibility?

Yes, but patients and caregivers have vital information that only they can provide. They may never have heard the term “medication reconciliation” and its abbreviated cousin “med rec.”

Many people mistakenly believe that all of their medications are “in the system,” even though information comes from many sources and is often incomplete or contradictory.

Medication reconciliation is the process of comparing medications reported on admission to those ordered at discharge to ensure accuracy. It involves many steps and different professionals. It’s something like reconciling a checkbook: Withdrawals should be balanced by deposits, and neither should omit or duplicate items.

To improve patient outcomes and prevent costly readmissions, hospitals are working to prevent these errors through improved record-taking, collaboration and communication. But more needs to be done.

The second Multicenter Medication Reconciliation Quality Improvement Study (MARQUIS II) recently completed at 18 hospitals, has shown that the medication reconcilation process works most effectively when patients and caregivers are involved from the beginning of their hospital stay.

There are four times when medication reconciliation is most important: before hospitalization or at admission; during the hospital stay; the day of discharge and follow-up after discharge.

On or Before Admission

When a hospital stay is planned, creating or updating a medication list is a critical step. But because hospitalizations are often unplanned, it is best to always have an up-to-date medication list with you in case of an emergency.

Be sure to include all prescription drugs with dosages, timing, method of administration (oral, injection, inhaler) and any other instructions. All over-the-counter products (vitamins, supplements, herbals) should also be included, because some ingredients may react with newly prescribed drugs.

There are several free medication forms available online in different formats:

  • MyMedRec from the Canadian Institute for Safe Medicine Practices is a comprehensive, data-protected smartphone app that even includes an archive of past medication use.
  • My Personal Medication Record from AARP is an easy-to-read two-page form that can be downloaded and printed. If you print the form, make multiple copies.
  • Next Step in Care Medication Management form from the United Hospital Fund is also two pages and can be downloaded. This form is available in English, Spanish, Chinese and Russian.

You can use another form or create your own. To be useful, the form should be complete, current and readily available.

And here’s what to do during a hospital stay, the day you’re discharged and after you’re discharged:

During the Hospital Stay

  • Keep track of all medication changes. Some may be temporary, but others may become part of the discharge list.
  • Ask questions. If you don’t understand why a particular drug is being tried or discontinued or why you need it, ask more questions. If you remember something that was not on the original medication list but may be important (a drug allergy or side effect, for instance), tell the staff to include that in the medical record.
  • If you get conflicting information from different staffers, ask for clarification.
  • If new, expensive drugs are prescribed, ask whether your insurance covers them. There may be alternate sources of financial assistance or an alternative that is less expensive.
  • The hospital staff should involve you in their discussions about medications. If they don’t, ask to be included.

Day of Discharge

  • No matter how rushed the discharge, make sure you go over the medication list with a staff member. You should understand what changes have been made to your list, why those changes were made and what to watch out for (such as common side effects) once you’re home.
  • Have a friend or family member sit in on the discussion to ask questions and take notes.
  • Look out for the most common discrepancies: duplication of medications; omissions of drugs that should be on the list; unexpected changes in dosages or how often to take medications and drugs for which you have an allergy or a known side effect.
  • Ask whom to call if you have questions about the medication list once you are at home.

After Discharge

  • Send a copy of the updated medication list to your primary care physician and any specialists you see regularly.
  • Make sure anyone who helps you follow your medication schedule — family member or aide — understands the new regimen.
  • When filling a new prescription, ask the pharmacist about any special concerns.

Your contribution to the medication reconciliation process can make the difference between a smooth recovery and the onset of a new problem. Be honest, forthright and cooperative with the professionals in charge of your care. Together, you can reduce the risk of a serious medication error.

By Dr. Jeffrey Schnipper
Dr. Jeffrey Schnipper is research director for the Division of General Internal Medicine and Primary Care at Brigham and Women's Hospital and associate professor of medicine at Harvard Medical School. He is the principal investigator of the Society of Hospital Medicine's second Multicenter Medication Reconciliation Quality Improvement Study (MARQUIS II).
Carol Levine
Carol Levine is a senior fellow at the United Hospital Fund in New York City and author of Navigating Your Later Years for Dummies. She is a member of the Society of Hospital Medicine's second Multicenter Medication Reconciliation Quality Improvement Study (MARQUIS II) Patient-Family Advisory Council.

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