Originally Published: Common Sense, November/December 2008
Original Author: Greg Casey, AAEM/RSA Medical Student Council President
An elderly man sat on the edge of his stretcher, attempting to describe his abdominal pain. He did not even need to speak. Vomiting after a few minutes, I realized that this stoic individual was truly sick. As I thought through a differential, I continued to ask questions. His answers were short, but his wife helped him. When I asked about medications, he was unable to recall any of the therapies his physicians had prescribed. His wife dug through her super-sized pocketbook but was unable to help. When we decided to admit the patient with the working diagnosis of intussusception, I talked to the patient and his wife about the importance of maintaining a list of their medications.
In the 2008 March/April edition of Common Sense, the immediate Past President of the AAEM/RSA Medical Student Council, Dr. Michael Ybarra, wrote about “teachable moments.” There are times when we can make a difference in a patient’s life by recommending simple solutions to problems that affect the care we give and our patients receive. As medical students in the emergency department, we are often limited in the number of patients we can see. However, there are advantages to this limitation. While the attending physician is managing an entire emergency department, often tending to the most critically ill, we have time to hone our skills completing detailed histories and physicals. We can learn to process information, interpret relevant data and tie it all together to make a diagnosis. Additionally, we can develop a rapport with our patients and find ourselves in a “teachable moment.”
During clinical rotations, and especially my emergency medicine block, I was surprised by the number of patients that were unable to recall any of the medications they take on a regular basis. The patients who were able to remember their medications often were not sure why they were taking the drug, when they started taking it or at what dose and frequency they take the medication. While waiting for results from studies and laboratory work, we are often left with extra time that can be used to improve a patient’s care by performing medication reconciliation. This often arduous task is performed by various members of the healthcare team and can be life saving.
The Institute of Healthcare Improvement has an interesting article on its website detailing the importance and challenge of medication reconciliation. [Accuracy at Every Step: The Challenge of Medication Reconciliation: www.ihi.org] Also on their website is a copy of the Joint Commission’s Journal on Quality and Patient Safety. This report singles out patient transition points as “especially vulnerable to medication errors.” Since a large percentage of hospitalized patients are admitted from the emergency department, this important transition point is a great place for students to intervene in the process to ensure accuracy. It also represents a great “teachable moment” when one can educate patients and their families about the importance of being involved in their own healthcare. When patients are admitted from the emergency department, the admitting team often copies the medication list from the patient’s chart. What happens if this list is wrong? What happens if it is incomplete? Warfarin or Clonidine may not cure a case of intussusception, but they can prevent recurrent pulmonary embolus or a case of rebound hypertension while the patient is in the hospital.
During the majority of my rotations, I have had numerous opportunities to counsel patients on keeping records of their most up-to-date medications. It is the doctor’s responsibility to educate the patient about the medicines being prescribed, but it is also important that patients take an active role in their care. This means learning to ask questions when something is not clear or if they are unsure what is required for treatment. At every opportunity, we can reconcile the medications a patient is taking, and mistakes can be avoided, and ultimately, lives can be saved.
Simple solutions to alleviate confusion during the course of a patient’s hospital stay will go a long way to decrease medical errors. While medication reconciliation may not be as exciting as placing a chest tube or suturing a laceration, it will help prevent adverse drug reactions. Taking the extra time to thoroughly review medications with a patient may be the most successful life saving maneuver you do all shift. Good luck during your emergency medicine rotations, and remember to check your patients’ medications!