The next morning he forgot to take his medications and at noon he experienced transient loss of consciousness. He went to the ED and was found to have a blood sugar of 55. The loss of consciousness was attributed to hypoglycemia secondary to an alcohol binge. The patient says he showed his medication list to one of the ED staff but was not given any advice, except to follow-up with his personal physician. Last night his wife insisted he take his medications since he had missed them in the morning. He did so. This morning he took his medication as prescribed and developed hypoglycemia at about 4 P.M. (while in the car), precipitating this admission.
Q: Why did the patient-carried medication list not seem to help in this case?
A:____________________________________________________________
Why didn’t the list help? A complete, accurate, up-to-date list of a patient’s medications, held by the patient and made available to all healthcare providers to review and update, should be an effective means of tracking medications within and across healthcare settings, thereby reducing risk of errors including duplication. However, in this case, the ED physician did not detect the error even though the patient did have a list that was complete, accurate (except for the misspelling of glipizide), and up-to-date.
The precise circumstances were unclear, but one might speculate that the ED staff were so busy they did not notice the duplication or were unfamiliar with the medications (confounded by the patient’s misspelling of glipizide), or did not take the list seriously because it was poorly written and in poor condition, or were convinced that the hypoglycemia was precipitated by alcohol. Though the ED staff’s failure to recognize the duplication was a missed opportunity, to blame them would be inappropriate and unproductive. Instead, as will be re-emphasized later, we should focus on the underlying system issues that precipitated the failure, including the presence or absence of protocols for medication reconciliation, and the characteristics of the medication list that the patient was using.
Improving patient-carried medication records. These records have been used with varying success.9-11 Studies show it is difficult to ensure that patients carry records consistently, and to ensure that prescribers update them. Optimal characteristics of such records have yet to be determined, and they will likely vary depending on circumstances. However, the published experiences9-11 together with review of the present case suggest simple strategies that might help improve the list our patient was carrying.
First, the list should be easy to read and update and be durable.
Second, it should be convenient to carry (wallet-size, for example).
Third, it should include the appropriate amount of information that helps busy practitioners detect errors easily. This issue requires further study, but we might consider using generic names and including information about drug class and indication.
What about electronic media? One proposed solution to paper records is the use of electronic media such as flash memory cards or web-based records.12-14 Two challenges to widespread implementation of this strategy are cost and compatibility. To deal with the latter issue, current legislative efforts (Wired for Health Care Quality Act S. 1418) are aiming to create standard formats for exchange of electronic health information. Obviously the ability to link to electronic prescribing systems from anywhere would greatly reduce the risk of duplicate prescribing.
In the meantime it may be reasonable, especially for high-risk patients, to provide or encourage the use of paper-based medication lists with the caveat that they need to be kept up to date and shared with all providers.
FIGURE 1 Patient’s medication list
The need for vigilance never ends
The patient is managed appropriately by the inpatient team. His diabetes medications are discontinued and he is placed on a 5% dextrose infusion. He does well. By the following evening, he is off intravenous fluids, is maintaining adequate glucose levels, and is ready for discharge home. The plan calls for him to stop the Glucotrol XL and continue the generic glipizide XL only.
You go to the hospital to check on him and find that he and his wife are about to leave. The nurse has reviewed discharge instructions with them and the patient is holding a copy. You ask to see the instructions. FIGURE 2 shows the medication section of the instruction sheet.
Glucotrol XL appears correctly in the section “Discontinued medications” with the clear instruction “Do NOT take these medications.” However, it is also listed under “Pre-hospital medications to be continued.” When you ask the patient what medications he intends to take at home, he admits that he and his wife are a little confused by the instructions. He says they decided he should continue the same medications he was on before since these are what you and your office colleague prescribed. He adds, by way of explanation, that he trusts you more than he trusts the hospital team because you know him best. You are surprised by his answer but then realize that neither you nor the house staff has explained the duplication error to him. He still believes Glucotrol and glipizide are different medications and does not understand that taking them together caused his symptoms.