27%
of prescribing errors that occur in a hospital result from incomplete medication histories at admission.
22%
of discrepancies could have resulted in patient
harm during hospitalization.
59%
of discrepancies could have resulted in patient
harm after discharge, if they had continued as ordered.
This
stuff is no joke, folks.
Consider
This
IHI
advocates medicine reconciliation at all transition points: at admitting,
during transfer to another unit, and at discharge. We want to follow up with
complex cases; they deserve a post-discharge phone call, or two (or more).
Consider creating a web portal for continuous communication, utilize smartphone
apps, or consider the following options.
Printed Information Sheets
An
easy way to understand medication dosages, instructions, and side effects is a
properly written description of all new medications (as provided by your pharmacy).
They should look professional and be ready to print at the nurse’s station, so
they’re ready when you are. We should be supporting all verbal education about
medications with printed information sheets that patients can take home.
Bar Coding
There
is clear evidence that bar coding dramatically reduces errors. Have this technology
available!
Pharmacist Rounding
I
think pharmacist rounding is absolutely critical to an overall vision of
enhanced safety, never mind success with HCAHPS scores. Get the pharmacist onto
your floor as often as possible. With more sophisticated medications, or for
help educating patients taking multiple medications (or those who have complex
medical issues), it is ideal to have a pharmacist answer patient questions.
They’re on site! Pharmacists are the medication experts; they like being asked
questions and being treated as a resource. They’re not just pill-counters -
they’re valuable consultants for patients and healthcare professionals.
The
Take Away
We
have to make medication education as simple as possible - medication errors are
the leading cause of medical mistakes in the United States, and penalties for
readmitting patients within thirty days are going to become oppressive. Technology
is a valuable tool, but not as valuable as the skills and behaviors of staff.
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