Problem:
The FDA receives more than 100,000 medication error reports per year. These errors can occur in hospitals, clinics, patient homes, or pharmacies (FDA, 2019).1 Research suggests the average hospitalized patient is subject to at least one medication error per day, and an estimated 40% of errors occur in handoffs during admission, transfer, and discharge of patients.2,3 Of these, an estimated 20% result in preventable and costly utilization, such as hospitalizations and fatalities due to serious side effects.
Solution:
Inbound is doing its part to eliminate medication errors in its at-home care programs. The care teams provide education on all medications sent home to patients to ensure they understand the reason for taking, correct dose, timing, and importance of taking all medications as prescribed.
The care team also reviews discharge summaries, sorts through all new, existing, and old medications to ensure they are taking only needed medications at appropriate times. The team also helps with refills of any prescribed medications, and looks for medications that may not interact well together and reach out to a pharmacist if any issues.
Over a 2.3 year period (01/01/2022-03/31/2024) Inbound Health reported a >95% medication reconciliation completion rate, preventing costly and avoidable adverse events for over 5,000 patients in the post-acute care-at-home programs.
Patient Snapshot
A 73-year-old male patient was recently discharged from the hospital with a detailed discharge summary. The Community Paramedic team was tasked with reviewing this summary, conducting medication reconciliation, and ensuring proper medication management. During a thorough review, the Community Paramedic discovered that the patient had mistakenly included several discontinued medications, including some antihypertensives, in his weekly medication supply. Had this issue gone unnoticed, the patient might have faced a higher risk of hospital readmission due to potential medication errors.
The Community Paramedic team undertook a meticulous review of the patient’s medications, verifying each item in his pillbox. Medications not included in the prescribed care regimen were removed, a process that took approximately 45 minutes to an hour. The community paramedic documented the incident and the corrective actions taken. An adjustment was made to the patient’s Amiodarone dosage, which is critical for managing certain abnormal heart rhythms and ensuring patient safety.
An Inbound Health analyst was assigned to research the clinical outcomes associated with hypertension medications and identify potential safety issues arising from incorrect dosages of drugs like Hydralazine and Amiodarone. The team also ensured the patient received the correct medications and understood their use, which helped build trust with both the patient and his family.
The Community Paramedic team verified that the patient was sent home with the correct medications and that they were received as prescribed. They coordinated with the patient’s pharmacy to ensure timely access to medications and provided additional support, including managing other aspects of the patient’s care such as steroids for infections, insulin for high blood sugar related to steroid use, medications for lung conditions, and arranging for oxygen needs. The patient received a transport tank and later a concentrator for home use.
This case underscores the essential role of medication reconciliation in preventing potential readmissions and ensuring patient safety. The proactive approach of the Community Paramedic team in identifying and addressing medication discrepancies highlights the importance of thorough medication management and effective communication within the healthcare team.
Sources:
- https://www.singlecare.com/blog/news/medication-errors-statistics/#:~:text=The%20U.S.%20spends%20more%20than,errors%20(NCBI%2C%202021).
- Institute of Medicine. Preventing medication errors. Washington, DC: National Academies Press; 2006.
- Rozich JD, Howard RJ, Justeson JM, et al. Patient safety standardization as a mechanism to improve safety in health care. Jt Comm J Qual Saf. 2004;30(1):5–14.
