Hello JCAHO?

Ahem. JCAHO, if you are really serious about making medication reconciliation work here is what you need to do - pay attention now, here is something you could do that REALLY WOULD IMPROVE PATIENT CARE.

Create a national data bank that is immediately accessible by any health care provider that has all of a patients prescription information readily available. When a patient takes a prescription to a pharmacy it goes into the database, the pharmacist would also benefit by seeing what the patient is getting filled at other places, like the 120 Vicodin he filled across town yesterday. When a patient is given a sample his practitioner would have to hand enter the info into the data base.

Until something like this is created, medication reconciliation will never work. So many patients either a)Have no clue what they take or b)lie about what they are taking or c)get meds from many different doctors filled at many different pharmacies. We simply do not have infinite time to call around to all the pharmacies in town to try to figure out what they are actually on. I feel it is much more dangerous to send out an incomplete or inaccurate list than to not do one at all.

So JCAHO, here's your chance to walk the walk, show us that you really do mean to improve patient care.

One More Thought on the Medication Reconciliation Form

I hate it.

Seriously, whenever anyone even says the words to me I want to scream.

Why are people so lame? How can you take medications everyday and not know what they are? And, if you have been to the hospital 74 times and been asked to make up a list, when do you think you might get around to it?

Don't leave off your Viagra, I don't care if you need help with your willy but I do care if I give you a nitro for your chest pain and I kill you because you took Viagra which bottomed out your blood pressure. We need to know what medications your are taking to keep you safe.

And yes, Birth control pills are a medication. We may want to know that you are taking them especially if you are 21 and complaining of chest pain - it may speed up the diagnosis of pulmonary embolus - something we don't normally suspect in someone your age.

Don't forget to tell me that you take an opioid pain reliever, otherwise when I give you Nubain for pain it might be really unpleasant.

Medication reconciliation, bleah.

Oh and the VA - they sent us a patient today from the clinic that was minimally responsive but didn't send his medication list or any kind of history. So I called. Calls to the VA NEVER reach a human being. Several messages of increasing irritation later someone actually did call back. They told me they couldn't give us that information. 'But you sent him here.' didn't seem to carry any weight either. Several hours after he was admitted for metastatic cancer with new brain lesions we finally got a fax from them. Arggghhh!

I think people need to be implanted with a chip that contains all their information and when they come in we just scan it. Someone get to work on that will ya?

Medication reconciliation

The Happy Hospitalist has a great post on all the pitfalls and perils of the medication reconciliation process - go check it out. And here is the greatest paragraph ever written:

'For the amount of time a nurse spends hunting down this information, you could hire two or more full time medication reconciliation clerks in the ER who do nothing but gather information. They do it right the first time and the benefits extrapolate down line to the entire hospital system in terms of job satisfaction, patient safety. Putting ER nurses in control of a clerical job with high job dissatisfaction is a losing effort. And that losing effort results in bad information being extrapolated downline through the entire hospital system. It leads to medication errors. Over and over again. It starts with poor information from the patient and extends down the tree of data entry. Just as I did not go to school for 11 years to data gather a list of meds, neither did the nurse.'

The Nurse is always to blame

I was reading this post by Kim at Emergiblog and it really got my dander up. The hospital administration comes up with a stupid ass rule, the nurse is supposed to document exactly what medication and dose the patient says they are taking even if they know it is wrong and then when the doctor orders it incorrectly without verifying that the information is correct it is the nurses fault that it got ordered wrong.

Excuse me? I don't think so doctor, you are a professional and as such are responsible for your own practice. I am not your babysitter. If you read the reconciliation sheet and it says Xanax 25mg you shouldn't just check off yes and move on. Of course the hospital administration is wrong in expecting the nurses to write down information that they know is erroneous but each of us is ultimately responsible for making sure our own practice is safe and without error.

I worked at a hospital years ago that had gotten into trouble on the JCAHO survey because the doctors were not signing their telephone orders within 24 hours. So who got in trouble? The doctors who knew darn good and well that this was a requirement? No, of course not, it was the nursing staff. Apparently we were supposed to be chasing them up and down the halls with all their charts pointing out each and every order for their convenience and if they didn't get signed in 24 hours the nurse that had the patients got written up. Being the supreme rabble rouser that I am, my response to this was to refuse to take orders over the telephone except for emergency, which was the policy anyway. Imagine how that went....."hello doctor, your patients blood sugar is 351 and the order reads to call you for over 350. No I am sorry you will have to come in from home and write that order because my hospital policy states I cannot take routine orders over the phone." Then when I got into trouble for that I had to ask the Director of Nursing if she was asking me to go against hospital policy.

Everyone of us is aware of the requirements of our job. No one has to follow me around and have me sign my med orders or point out where to fill in my check sheets. If I don't comply I get disciplined, plain and simple. That needs to be an expectation of medical staff also, yes sometimes the rules are ridiculous and cause us extra work and yes we don't like them but we are all grown ups and responsible for ourselves so grow up and don't try to blame your mistakes on someone else and don't expect me to follow you around and make me do your job.

And if I didn't already know it, I would suspect Kim works in California, I've worked in a lot of states and this one is the worst for making up ridiculous rules and regulations and taking ridiculous rules and regulations and making them even more cumbersome than they already are.

Medication reconciliation

This is why medication reconciliation doesn't work in the ER.

LOL comes in from home. She lives alone with a caregiver that comes three times a week but didn't accompany her to the hospital. She is a very vague historian, has no clue what med's she takes or what pharmacy she gets them from. She gives me her physicians name so I put in a call to his office. Three calls and much time on hold later I finally get in touch with the medical assistant who is finally able to tell me that the patient is not theirs. Close to 45 minutes wasted and still no clue what medications she is on. He last hospital record is from three years ago and she was admitted by the hospitalist then. I could start randomly calling pharmacies but there are 39 of them in the area and that would take hours.

Nice 60ish gentleman comes in with Chest Pain. He knows he takes a blood pressure pill, a water pill and something for his sugar, not the names or the dosages. He gets his med's through the mail from the VA. I don't know about where you work, but I could part the Red Sea easier than I could get that information from the VA.

A 77 year old lady comes in with all her pills (14 different kinds) helpfully arranged in a pill box. It is midnight and her pharmacy and doctors office is closed. It takes over an hour with the identidex system and help from the pharmacist to identify 13 of them. The last one is an alien pill that denies definition and she has no idea what it is for.

I could go on and on. I don't have an hour to spend doing this nonsense. While I am trying to track down the elusive med list, the ambulances keep coming, I need to start IV's, titrate pain meds, do EKG's, start foleys, gastric lavage, restrain and monitor psychotic patients, talk to familys, take admit orders over the phone, arrange to get my patients upstairs and so on and so on. If I am spending hours trying to track down a med list that is one or two or three people that are sitting in the lobby waiting for a bed or a sick patient who's not being taken care of. If I only had one patient I might have the luxury of doing JCAHO's ridiculous tasks, but let's get real - this is the ER where the patients never stop coming.

Nurses need to be at the bedside. Period. If JCAHO insists on this stupidity then they can get the Government to pony up the cash to pay for someone to sit in the ER and do nothing but medication reconciliation forms all day, until then.......JCAHO REFORM NOW!!!!