Pharmacy Adopts "Universal Precautions" for Medication Lists
Looks can be deceiving, which is why the pharmacists and pharmacy technicians at one academic medical center work on the premise that every medication list, until verified as accurate by a qualified person, contains errors.
The premise, said Cedars-Sinai Medical Center Chief Pharmacy Officer Rita Shane, is similar to the assumption underlying the adoption of universal precautions for prevention of transmission of bloodborne pathogens in healthcare settings: Treat the blood and body fluids of all patients as if those fluids were known to contain bloodborne infectious pathogens.
Assume There Are Errors
Shane, who recently proposed "universal precautions for medication lists" and a related protocol in the journal BMJ Quality & Safety,1 wants healthcare personnel to treat all medication lists, even those in electronic health records, as "contaminated" (erroneous) until verified.
"We found 7.4 errors per medication list" for patients admitted through the Cedars-Sinai emergency department, Shane said.
Another inhouse study at the Los Angeles hospital, this one focused on discharge medication lists and conducted in the first few days after a patient's discharge, found about 3.5 errors or discrepancies (or both) per patient.
Shane attributed half of those postdischarge errors or discrepancies to discharge medication lists that might not have accurately reflected the current medications the patients should be taking on the basis of the admitting medication history and hospital stay.
The other half, she said, resulted from patients "really not understanding what they're supposed to be on" after leaving the hospital.
Now, a team of five pharmacists and four specially trained pharmacy technicians follows the universal precautions for medication lists whenever possible for the hospital's medical–surgical patient admissions, Shane said.
The precautions involve the following proposed protocol:
- At each healthcare encounter, consider a medication list contaminated or erroneous until verified for accuracy.
- Verify a medication's name, dose, frequency, dosage form, route of administration, and duration of therapy with the patient and, whenever possible, with additional sources, including the patient's pharmacy and primary physician.
- If the above verifications have not occurred, do not simply continue a medication regimen from the medication history, especially if the regimen involves a high-risk drug or one with a narrow therapeutic index.
- For a medication taken before hospital admission, do not at discharge automatically continue the regimen unless it is needed to treat one of the patient's underlying conditions.
- At discharge, verify the patient's continuing medication list to ensure documentation of medication changes, including discontinuations, made on the basis of the hospital stay.
The team reaches about one third of the medical–surgical population, focusing on the high-risk patients, Shane said.
A checked-off box on a Cedars-Sinai medication list indicates to physicians and other healthcare personnel whether a pharmacy staff member has verified the contents.
"Initially, it was such a new thing for them that they didn't know what it mean[t] for them," pharmacist Olga Zaitseva said of the physicians' early reaction to the pharmacists' and pharmacy technicians' diligence.
"But now since they realize the value of this service, they're looking for" the verification mark, she said.
Trust But Verify
Pharmacist Caroline Nguyen said an important part of verifying medications with patients is covering "each element of the medication regimen—and that's the name, that's the dose, that's the frequency."
Zaitseva said the team uses data from Surescripts LLC, which provides pharmacy claims data, to obtain details on prescriptions filled by outpatient pharmacies and to cross-check the patient-provided information.
"A lot of times patients can be poor historians" about such specifics as the number of milligrams in a dose, she said.
Some patients initially resist the interview, saying things like "It's in the computer, it's in the computer," said pharmacist Holli Rose.
Her response: "Just humor me. Let's go over this again, with me."
The unverified medication list in the electronic health record "might look OK" at first glance, Rose said. "But when you look at it closer, it's fraught with errors. It's almost overwhelming."
She said the team has found that individuals in various healthcare settings who reconcile medication information oftentimes assume that the medication list from the patient's pharmacy is correct.
But that list, Rose said, may not reflect a physician's direction to the patient to take the medication in a manner other than as directed by the container's label.
"We want to capture how the patient takes the medications," she said.
Newly admitted patients who have met high-risk criteria are a top priority for the team, said Transitions of Care Supervisor Donna Luong. The team's goal is to reconcile those patients' medication history within 48 hours, preferably 24 hours, of their arrival to the hospital.
Avert Postdischarge Problems
Pharmacist Christine Armbruster said patients who leave the hospital without a "clean" continuing medications list for reference can have a problem if their pharmacy automatically refills and mails prescriptions.
Without such a list, she said, patients "end up taking whatever medications are mailed to them [after discharge] by their pharmacies because they assume that these are the correct medications."
Pharmacist Jesse Wisniewski said community pharmacies familiar with the diligence of the Cedars-Sinai pharmacy services staff have asked him for a patient's updated medication list so that the pharmacists know for certain which prescriptions on file should still be dispensed.
Community pharmacies may have a hard time keeping an accurate medication list because patients retain bottles of medications that are no longer needed, said pharmacy technician Frank Diaz.
He said he finds bottles of discontinued medications while interviewing newly admitted patients.
"You see a lot of patients that are hoarding those pill bottles even though they've been told to [stop taking] those medications," Diaz said.
Wisniewski, who completed a postgraduate year 2 residency in transitions of care less than two years ago, relishes the team's work.
"I feel like this is the future of pharmacy," he said. "We need roles where we're kind of in patients' faces, so to speak, and [to help make sure] they know not only what we can provide but that they get used to it and they start to expect it."
Shane said three more pharmacy technicians are joining the team and the training-and-proctoring program with pharmacy students is expanding.
She said her plan is for the team to reach additional medical–surgical, pediatrics, and oncology populations next.
1. Shane R. Why 'Universal Precautions' are needed for medication lists. BMJ Qual Saf. Epub ahead of print (DOI 10.1136/bmjqs-2015-005116).
[This news story appears in the April 1, 2016, issue of AJHP.]