When geriatricians and nurses at the University of Massachusetts (UMass) set out to reduce medication errors in the state's skilled nursing facilities (SNFs), their solution was an education program for nurses at the nursing homes. But it rapidly became apparent that the problem began before patients even entered the SNF.
“One of the issues that kept coming up was when people come from the hospital, the paperwork doesn't match up,” said Alice Bonner, PhD, RN, an instructor at UMass Graduate School of Nursing.
The paperwork problems reported by the SNF nurses confirmed the experience of geriatricians on the project. “It just rang true for me and everybody else who gets information from the hospital,” said UMass geriatrician Jennifer Tjia, MD. “Before we look at reconciling the medications in the skilled nursing facility, we need to look at the information that we're getting from the hospital.”
The scope of the problem
Their observations, published in the Journal of General Internal Medicine last March, revealed some significant and potentially dangerous discrepancies. The researchers analyzed 199 admissions to two Massachusetts SNFs. More than 70% of the time, medication lists did not match up among the hospital discharge summary, the patient care referral form and the SNF admission orders. Disagreement between the discharge summary and the patient care referral form, in particular, accounted for 62% of the discrepancies.
“Given the amount of emphasis we've placed on patient safety and medical safety in general over the last five years, the fact that this is still happening with this frequency is worrisome to all of us,” said Eric Coleman, FACP, director of the care transitions program at the University of Colorado, Denver.
One explanation is that medication reconciliation efforts have not really targeted patients moving from hospitals to SNFs. “The vast majority of patients go home from the hospital, so people study that a lot,” said Dr. Bonner. “Here you've got the most vulnerable patients, very often elderly, and they're coming with a lot of discrepancies.”
There's potential for discrepancies to arise at a number of points in the discharge process, the experts said. When discharge summaries are dictated quickly over the phone, transcription errors are more likely. “Ideally, a discharge summary will be produced, reviewed, corrected and signed before it goes out, but I think that doesn't happen very often,” said Dr. Tjia.
Sometimes the discharge summary is correct when it's completed, but outdated before it's used. “The discharge summary will be generated and then the patient will get sick and not get discharged when they're supposed to go. It can be one, two, three days before the actual discharge happens. In those three days, a lot can happen,” Dr. Tjia said.
Delays can happen to any patient, but some aspects of the transition to an SNF increase the risk of discrepancy. “The name of the game is to find the patient a bed. It's not uncommon for the discharge planning services team to be a little ahead of the care team,” said Dr. Coleman.
Early in the process, discharge planners begin sending patient information—including medication lists—to the nursing home to determine whether the facility will take the patient. Not only does this increase the risk of discrepant information being collected at the SNF, but it can reduce the flow of accurate information, too. “As a result, the care team sees that the discharge planning team has been sending over information and starts to come to the conclusion that they are already up to speed,” explained Dr. Coleman.
In reality, the process of an SNF getting up to speed on a patient is a slow one. “There's often a 24- to 48-hour gap between when the patient gets admitted to the SNF and when they might actually see a physician,” said Dr. Tjia.
In the meantime, SNF nurses typically consult with a receiving physician over the phone. “The medications that are listed in the paperwork when a patient comes in are pretty much the equivalent of admission orders. Typically a nurse reads the medication list to the doctor, and the doctor knows very little about the patient,” Dr. Tjia said.
One additional phone call between a hospitalist and the SNF could help to clear up much of the confusion. “Ideally, it'd be the attending physician to the attending physician. It could also involve the nurse practitioner or physician assistant. Chances are they're going to be the ones writing the orders and clarifying the discharge,” said Dr. Coleman.
Some hospitals and SNFs are experimenting with asynchronous modes of communication, such as text messages or voice mails, but the phone still works pretty well. “You've got the meds in front of you and you're talking to somebody who's been taking care of the patient. She can say, ‘Oh no, we didn't give the furosemide for the last two days.’ You can immediately straighten it out,” said Dr. Bonner. Some SNFs have made such phone calls mandatory, she added.
Another nursing home guideline that hospitals could learn from is the requirement to list not only a medication's name, strength, dose and frequency, but also its indication. “It's a great idea because it does help avoid some of the confusion. Is the patient on this drug for their high blood pressure, for their congestive heart failure or for their kidney problems? When the next care team doesn't have that insight, it's very easy for them to say, ‘Let's just take them off this,’” said Dr. Coleman.
Even an interoperable electronic health record (EHR) won't, in and of itself, eliminate these misunderstandings. “Typically when we talk about interoperability, the nursing home has read-only access. The concern is that access is generally given to the physician, sometimes to the nurse practitioner, but nobody else in the nursing home, including the pharmacist,” said Dr. Coleman.
Transcription errors can also arise with EHRs, because in most nursing homes, the information still has to be collected from one computer and entered into another, he explained.
So, even in the modern age of electronic communication, it's still necessary to pay attention to the paper. “[Discharging hospitalists] could just check both forms and make sure that they're the same before the patient actually leaves, even if they didn't actually dictate the discharge summary themselves,” requested Dr. Tjia. “Somebody has to actually look at all these forms before they let the patient go.”
The person to whom you hand the forms is also worth a look, suggested Dr. Coleman. “The people who are actually doing the transfer—the ambulance drivers or the paramedics—are usually an untapped resource for ensuring timely, accurate, safe transmission of information around medications. These individuals are very good at organizing information [and] asking clarifying questions,” he said.
The UMass researchers are continuing their efforts training SNF nurses to be on the lookout for medication discrepancies, but they say that hospitalists can help the situation by taking on more accountability for patients who have left their care.
“Hospitalists are so busy these days it's hard to think about asking people to do anything extra, but that single phone call could mean the difference between a serious medical error and smooth sailing,” said Dr. Bonner.