Commentary | Bridging Gaps in Healthcare: An Urgent Call for Avoiding Medication Errors and Improved Medication Reconciliation

by Angela Buxton

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Why can I speak about this issue? I worked as a pharmacy technician before working as a Registered Nurse (RN) and ultimately becoming a Nurse Practitioner (NP) in 2000. I have been employed in health care for 33 years, including over 20 of those years as a NP. At present, I work in a specialized emergency service, and am attending the University of Washington for a Doctor of Nursing Practice (DNP) degree. I am writing in hopes to affect change on this ubiquitous delivery of health care problem.

A personal story exemplifies this issue. My 90-year-old grandfather was discharged from an ER and resumed taking a long discontinued antihypertensive (blood pressure) medication from an old pill bottle. He took this in addition to his newly prescribed antihypertensive medication, both medications listed as active in his discharge instructions.

Fortunately, my grandfather was okay, and my mother caught this error and understandably had something to say about it. She drove back to the hospital to give them a piece of her mind, before recommending they come up with a better system. They agreed.

One recurring and nationwide theme are health care providers, and patients, becoming confused with the list of medications in their medical records in all phases of care, including at hospital admission and discharge. This medication list often includes medications that are listed as active and those they haven't taken at times since many years ago.

Sadly, this is not an exaggeration, and often leads to harmful medication errors which are a big problem during all phases of health care. Affected phases include outpatient ambulatory care clinics, during hospital admissions, during hospital stays and hospital discharge. Because of these gaps, medication errors are not surprisingly a leading cause of injury or death.

This is a serious issue that I believe can be solved with a concerted effort by an interdisciplinary team approach along with a streamlined electronic health record system. This is in addition to an emphasis on patient education throughout all stages of treatment which includes outpatient care, an urgent hospital visit or inpatient stay. Providers and ancillary services should always be involved in this process.

Better practice solutions:

1. For health care providers, at all phases of treatment, if it remains unclear if a patient is taking a medication, ask questions, and if medication reconciliation is not possible then list it as such. Increasing awareness of this problem in the advent of increasing use of Electronic Health Records (EHR) is key.

2. Incorporation of admission and discharge medication reconciliation as a continuous process by admitting and discharging RNs, the pharmacist and nurse practitioner and physicians.

As noted by J AM Med inform Association (2016) working towards a solution would include incorporating reconciliation modules that are interoperable with other Electronic Health Record components. This includes medication history, the computerized order set and discharge documentation. Some EHRs have some interoperability with external sources (hospitals, clinics, pharmacy) to import medication history and share updated medication list at discharge, although this is not fail safe and should not be relied on itself alone.

3. As health care consumers, don't be afraid to ask questions or clarification. Most health care providers want you to be involved in your own care. You reserve this right 100 percent and it is okay to ask questions and include your loved ones to advocate for you in your treatment plan.

In summary, medication confusion and errors are fear reaching. It is up to us as health care providers to be conscientious and provide essential emphasis on patient education and collaboration. Encouraging patients and their loved ones to actively participate in their care is vital. This includes asking questions and seeking clarification about medications along with interdisciplinary providers to help prevent confusion and potential medication errors. Involving patient's loved ones can contribute to healthy outcomes. Refining EHR is of the utmost importance.

I thank all health care providers for dedication to this important cause, and I wish success in your continued efforts to make a positive impact on health care practices while encouraging health consumers to be proactive in their care.

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Angela Buxton, FNP-BC is a national Board-Certified (BC) Family Nurse Practitioner (FNP) since 2000 and who is originally from Massachusetts, obtaining her undergraduate and graduate degrees at UMASS, Amherst, and worked as both a Registered Nurse (RN) and FNP throughout her career. She is currently attending the University of Washington to expand her skills as a Doctor of Nursing Practice in Psychiatric Mental Health. She has now been working as a NP at Harborview Medical Center in Seattle, Washington for the last 20 years. She enjoys her role in assessing, diagnosing and developing client centered treatment plans, not limited to prescribing medications. Population includes those who are underserved and across the lifespan. She has membership in Snohomish County, WA Search and Rescue (SSAR), has participated in team endurance events with lessons learned that crossover into daily life. Other outside interests include photography, painting, skiing and hiking the Pacific Northwest.

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Going to the hospital? Here's what you should consider taking with you

Photo: Stephen Andrews/Unsplash

by Tim Ditman
OSF Healthcare

URBANA - You’re coming to the hospital to give birth. You’ve had a hip replacement and now will have a hospital stay to complete rehabilitation. There are a lot of things swirling through your mind, notably thoughts like “Am I going to be OK?” Questions like “Where is my toothbrush?” are probably on the backburner. That’s why it’s a good idea to make a “hospital essential items” checklist now.

Kurt Bloomstrand, MD, sees these scenarios plenty while providing care in the emergency department at OSF HealthCare. He says a hospital will provide basic toiletries, blankets, food and clothing like a gown and socks. But some people prefer their own toiletries, clothes and snacks.

Other things to do and bring:

• Write down your health information: health insurance, medications, medical history, name of your primary care provider, allergies and legal documents like power of attorney and a do not resuscitate order. Have an identification like a driver's license, too.

“Some people in the emergency department are not able to tell us their health information given what they’re presenting for. So, it’s so valuable to have basic health information written down,” Dr. Bloomstrand says. He adds that knowing your health information allows providers to care for you properly. You can also bring legal forms to your provider anytime to be added to your medical record.

• Bring other items essential to your well-being: eyeglasses, contacts, hearing aids, dentures and a continuous positive airway pressure machine (CPAP) for sleeping. Bring cases and batteries for these items, too.

• When choosing clothes, opt for loose-fitting and short-sleeved garments.

“If you have an IV, a short-sleeved shirt is much better to access it than a long-sleeved shirt,” Dr. Bloomstrand says. “You can bring a robe to cover up.”

• For moms giving birth, bring your birth plan in written form. Pack a few pairs of clothes for you and your baby.

“Babies notoriously spit up on their clothes,” Dr. Bloomstrand said.

• The hospital can provide diapers, wipes and a breast pump. But, you can bring your own if you prefer a certain type.

“Not only can you use your breast pump, the people at the hospital can teach you how to use it.

What babies don’t need at the hospital: rattles, books and toys. Save those memories for home.”

• Don’t overdo it with personal items and food. This can cause your room to get cluttered and create a trip hazard. Have someone who can take unneeded items home.

• Don’t bring valuable items.

Dr. Bloomstrand says a phone is OK to keep in touch with loved ones. But other electronics and jewelry should stay home.

Hospitals have security, but like any other place, there is a chance for theft.

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Expecting a newborn soon? Be flexible with your birth plan

by Tim Ditman
OSF Healthcare

URBANA -- "If you’re ever gonna find a silver lining, it’s gotta be a cloudy day.”

No one may epitomize that song lyric more than Erin Purcell.

Photo Courtesy OSF

In July 2020, the Bement, Illinois, woman gave birth to her first child, Adalyn, via Cesarean section (commonly known as C-Section). Long story short, it did not go well.

"I was in a lot of pain afterward,” Purcell says.

Two years later, Purcell found herself at OSF HealthCare Heart of Mary Medical Center in Urbana, Illinois, preparing to deliver her second child.

"I was terrified to do another C-section,” Purcell recalls.

But a C-section became necessary, and her son, Elliott, was brought into the world without major issues.

"It restored my faith in doctors,” Purcell says.

Now, part of a happy and healthy family of four, Purcell is telling other parents-to-be to be flexible with their birth plan. And the woman’s care team is educating mothers about what to expect if a vaginal birth is not possible.

What is a C-section?

A C-section is when a doctor removes a baby through an incision the mother’s abdomen. The naming is a matter of historical dispute and may be tied to Julius Caesar, according to the U.S. National Library of Medicine.

Kelli Daugherty is a certified nurse midwife at OSF HealthCare in Urbana and was a member of Purcell’s care team. She says while a small amount of women will choose a C-section long before birth, health care providers prefer to perform them only when medically necessary.

"Baby is in the wrong position - maybe breach instead of head down,” Daugherty lists as a need for a C-section. "Maybe we’ve seen fetal distress that’s concerning enough that we need to deliver quickly. It could be that mom has an infection.”

Or, if labor is not progressing, doctors may consider a C-section, Daugherty says.

Regardless, Daugherty says providers will have a conversation with the mom-to-be about the risks and benefits. She says risks are like any other major surgery. There’s a chance for organ damage, blood loss (blood is on standby for every birth for a possible transfusion) and the rare need for more surgery later, like a hysterectomy.

The benefits of a medically necessary C-Section: the baby comes out quicker, and there’s less risk to the mom and baby’s health.

The procedure

Daugherty says a mother will start out in the labor room with antibiotics and an IV for fluids. Then, she goes to the operating room.

"She would sit on the operating table, and the anesthesiologist would place a spinal anesthesia,” Daugherty explains. "We always attempt to do a spinal. We try to avoid general anesthesia for a C-section unless it’s a true emergent situation.”

The mother lays down, and Daugherty says the anesthesia should have its intended numbing effect very quickly. The care team cleans and preps the skin, and the surgeon makes incisions layer by layer until they reach the baby in the uterus.

"We get the baby out usually in less than five minutes,” Daugherty says. "We hand the baby to the neonatal team. Then we start suturing everything back up in reverse. We start with the uterus, go layer by layer and do the skin last.”

Typically, moms stay at the hospital two days after a C-section to manage pain, Daugherty says. There are the standard follow-up appointments, and the new parents will have to keep mom’s incision site clean and dry to avoid infection or other issues. The incision usually takes six weeks to heal, Daugherty says.

"C-sections are not really as scary as you might think,” Daugherty says. "It’s certainly concerning because it is a major surgery, but it’s also a very common surgery. [Providers] are very confident that we can complete these surgeries safely, and you and your baby will be well taken care of.”

Daugherty agrees.

"I always tell my moms to please bring in your birth plan. We will follow that as closely as we can,” she says.

"But, you have to understand that sometimes labor just doesn’t go the way you planned it. We may have to veer from that birth plan,” Daugherty adds. "But if we do, we will always have the discussion with you. It will always be shared decision making.”

You can prepare physically and mentally, too.

"I just kept telling myself in my head ‘It’s only temporary. This pain is going to go away. You can get through it,’” Purcell says. "You have your nurses, too, in your ear saying ‘You got this. You’re so strong.'”

For more information on OSF HealthCare's pregnancy and child birth resources visit the healthcare facilities website at https://www.osfhealthcare.org/heart-of-mary/ .