• Medication Handoffs: Mending the Gaps

    Mar 01, 2012

    Providers are testing high-tech and low-tech solutions to curb medication mistakes inside the hospital and missed doses after patients return home.  

    Key Takeaways
    To prevent medication errors and boost patient compliance with prescription orders, hospitals and health systems are testing four tactics:

    • Asking patients and their families to review medication lists
    • Taking advantage of technology to prevent dispensing mistakes
    • Ensuring patients understand medication regimes before being discharged
    • Having a pharmacist call patients at home to review medications

    pg08_feature-medicationEarly each morning, every patient being treated in one of Memorial Healthcare System's six Florida hospitals receives a patient- and family-friendly daily medication schedule (see the exhibit below). The list includes the names and doses of each medicine that the patient is scheduled to receive and the time the medicine will be given.


    By sharing that information, Memorial encourages patients and families to help ensure that the right medications are administered to the right patient in the right dose. "We have had some amazing catches, such as 'I'm not a diabetic, so why would insulin be on this list?'" says Rebecca Caschette, RN, MS, Memorial's administrator of quality and patient safety.

    Like Memorial, many leading health systems are trying to improve medication management, using process improvement techniques, care coordination, and technology. For the most part, these providers are focusing on two serious and expensive problems: a high rate of medication errors in hospitals and poor compliance with medication orders after patients are discharged. Fixing these problems is first and foremost a patient safety priority; however, it is also becoming a smart business strategy as providers must answer to payers and the public for high readmission and error rates.

    Error Prevention

    At least 1.5 million medication errors occur in U.S. hospitals each year, according to the Institute of Medicine (Preventing Medical Errors, 2006). That means that, on average, there is at least one medication error per hospital patient per day. While not all medication errors lead to injury or death, the Institute of Medicine estimates that 400,000 preventable drug-related errors in hospitals add $3.5 billion to U.S. medical costs each year.

    Treating patients as partners. Memorial Healthcare System received input from its Patient and Family Advisory Council to help develop the easy-to-read daily medication schedule. The health system's electronic medication administration record is programmed to create and print the patient-friendly schedules for all inpatients each morning. Nurses pick up the schedules at designated printers and distribute them as they round on their patients.

    Patients and family members like the medication schedule, says Caschette. But nurses were wary when the initiative started four years ago. They feared patients would criticize them if a medication was not given at the exact time indicated on the sheet, not realizing that nurses have a window of time in which to administer a patient's medication and must juggle competing priorities. "But it's better to be questioned than to injure somebody," says Caschette.

    The patient-friendly medication schedule provides a level of transparency that many health systems say they want-but might regret if a medication error occurs. "You definitely need heavy-duty C-suite support for this and a good understanding about the legal ramifications," says Caschette.

    Obtaining robotic assistance. In an entirely different approach to patient safety, Nash General Hospital in Rocky Mount, N.C., started using an automated system to reduce dispensing errors in the pharmacy last year. "Every pharmacy that has a predominantly manual system will have errors," says pharmacy director Mike Lamonds. 

    pg11_nash-pharmacy-robotNash General's automated system has two tracks. For most medication orders, an automated medication dispensing system-or pharmacy robot-is used. First, physicians place the medication order into the system electronically. The pharmacist then verifies the electronic medication order, and the pharmacy robot swings into action. It selects the prescribed, prepackaged medication from a unit stocked with the 500 most commonly prescribed medications and places the medication in an envelope with the patient's name on it for delivery.

    Less common medications are stocked in an electronic carousel in the pharmacy. When an order is received for one of these, pharmacy software prompts the carousel to rotate to give the pharmacy technician access to the correct medication.

    Nash General spent nearly $3 million to acquire the technology and renovate the pharmacy to accommodate the new automated workflow. The hospital is already realizing some labor savings. The pharmacy has eliminated one technician position because of increased efficiency and will probably eliminate another in the foreseeable future, says Lamonds.

    However, Lamonds thinks the technology's ROI should be evaluated on its patient-safety attributes rather than its financial merits. Many hospitals are moving to barcoded medication administration at the bedside, and this robotic technology extends that same level of accuracy to the pharmacy. "If you're going to barcode the medications, you might as well use the barcodes in the dispensing portion of the medication management system," he says.

    Lamonds cannot yet estimate how many dispensing errors the technology is avoiding at Nash. But another community hospital-Cookeville Regional Medical Center in Tennessee-that bought the pharmacy robot and electronic carousel in 2006 can.

    "Sometimes we would have 35 errors in a single day," says Opless Walker, Cookeville Regional's pharmacy director. "I learned that humans can't seem to get it right."

    By eliminating errors, Walker estimates that the robot and carousel are helping Cookeville Regional avoid 215 adverse drug events each year, saving the hospital more than $1 million in additional costs of care. "I figure it paid for itself in the first year," says Walker. "The financial auditors love it."

    Patient Adherence

    While inpatient medication management requires focused attention, helping patients properly take their medications after they are discharged has become the hospital's job as well. The World Health Organization estimates that only about 50 percent of U.S. patients with chronic diseases follow medication recommendations. That poor adherence rate is one reason why Medicare beneficiaries have a 20 percent readmission rate within 30 days of their initial discharge (Jencks, S.F., et al, "Rehospitalizations Among Patients in the Medicare Fee-for-Service Program," NEJM, April 2, 2009, vol. 360, pp. 1418-1428).

    Enhancing bedside education. Because hospitals will be at risk financially for high rates of readmissions beginning in 2013, many are developing ways to improve patients' compliance with medication orders. For example, Regions Hospital in St. Paul, Minn., developed a medication boot camp to identify congestive heart failure (CHF) patients who are likely to have trouble taking their medications properly on their own after they leave the hospital (America's Health Insurance Plans: Health Literacy and America's Health Insurance Plans: Laying the Foundation and Beyond, 2011).

    A pharmacy technician visits all CHF inpatients who will be responsible for administering their own medications at home. The technician asks each of these patients to fill a pill box with colored beads-to represent pills-and demonstrate his or her ability to manage medications. Any patient who is unable to follow the medication orders is referred to care management to receive extra assistance after discharge.

    Meanwhile, Gottlieb Memorial Hospital in Melrose Park, Ill., sends pharmacists to the bedside to educate patients about their medication regimens. The visits reinforce the patient education provided by nurses. "When you look at the time nurses spend educating patients, medications are just one small piece of all the things they need to discuss," says Mary Clausen, RPh, assistant director of Gottlieb's pharmacy.

    Five pharmacists round on the following groups of high-risk patients:

    • Patients who take high-risk medications, such as warfarin and insulin
    • CHF patients
    • Patients who take a very large number of medicines
    • New mothers who need to learn how to measure medications for their infants

    The program did not require any additional full-time employees since the pharmacists added patient education to their other responsibilities. Any reluctance the pharmacists may have had evaporated when they started talking to patients, says Clausen. They quickly learned that some patients did not understand that prescriptions need to be refilled, and other patients did not know crucial facts about when or how their medicines should be taken. "The pharmacists realize the value in it," says Clausen. "Now I hear, 'I can't believe we were letting people leave the hospital, and they didn't know these things.'"

    Reaching out after discharge. Novant Health, a 12-hospital system in North Carolina, South Carolina, and Virginia, goes one step farther by having pharmacists call patients within a week of discharge at their home to discuss their medications. Those phone calls-which often last more than an hour-allow a pharmacist to review all prescription and over-the-counter medicines a patient is taking, to educate the patient about how to properly take the medicines, and to reconcile the patient-reported medication list with the discharge instructions. If necessary, the pharmacist arranges for immediate medical or disease management follow up.

    Having these conversations after the patient is home helps ensure a better exchange of information than when the patient is in the hospital, says Terri Cardwell, the pharmacist who directs the program, which is called Safe Med. For one thing, a patient who is excited about her impending discharge may not pay attention to what the pharmacist is saying. For another, patients often forget to ask questions or mention relevant information. "When patients are back in their own environment, they can get out all their pill bottles, including medicines that they did not think to mention during admission," says Cardwell.

    Novant established its Safe Med program in 2006 after participating in a research collaborative that revealed that many recently discharged patients-particularly those on high-risk medications such as blood thinners-were being readmitted to the hospital for adverse drug events that could have been prevented.

    An evaluation of the program in late 2008 found that Novant's 30-day rate for readmissions related to adverse drug events had fallen from 3.4 percent to 2 percent- and the overall readmission rate had decreased from 13.1 percent to 6 percent. Novant estimates that the Safe Med program is avoiding more than 300 readmissions annually-and saving $3.4 million in hospital costs by doing so.


    The multidisciplinary steering committee that developed the Safe Med program experimented with various staffing models before determining that the expertise of pharmacists was essential because some patients take more than a dozen medications. Currently, five full-time pharmacists staff the program, assisted by two pharmacy technicians who send copies of the medication reconciliation reports to patients and their primary care physicians.

    In the early days of the program, Novant tried a less effective approach-increasing the number of hospital pharmacists and expecting all pharmacists to make Safe Med calls, says Nan Holland, senior director for clinical excellence for Novant Medical Group. "We found out early on that effective Safe Med pharmacists are different from most hospital pharmacist roles," she says. "Safe Med pharmacists must enjoy engaging and coaching patients."

    Another lesson learned: Physicians must be educated about the value of the Safe Med program to their patients so that they understand the pharmacists are not second-guessing their clinical decisions. After a pilot with patients in six Novant-owned primary care practices, Safe Med pharmacists attended medical team meetings and published information in Novant's physician newsletters to describe the program as it expanded throughout the system.

    Culture Changes

    Some of the interventions being deployed by hospitals and health systems to improve medication handoffs symbolize changing mindsets about who's responsible for ensuring patient safety and adherence. Take, for instance, hospital efforts to monitor a patient's medication after discharge. Such efforts would have been unthinkable just a few years ago. Yet, they show that pharmacists and nurses recognize that patients need help after they go home.

    If patient safety is a part of an organization's culture, taking steps to extend that safety to a patient's home is a natural extension, says Clausen, the Gottlieb pharmacist. "This is part of our responsibility," she says. "That is why we are here."  

    Interviewed for this article (in order of appearance):

    Rebecca Caschette, RN, MS, is administrator of quality and patient safety, Memorial Healthcare System, Hollywood, Fla. (rcaschette@mhs.net).

    Mike Lamonds is pharmacy director, Nash General Hospital, Rocky Mount, N.C.

    Opless Walker, BSPh, DPh, PharmD, director of pharmacy operations, Cookeville Regional Medical Center, Cookeville, Tenn. (owalker@crmchealth.org).

    Mary Clausen, RPh, is assistant director, pharmacy, Gottlieb Memorial Hospital, Melrose Park, Ill. (mary_clausen@ghr.org).

    Terri Cardwell, is director of Safe Med, Novant Health, Winston-Salem, N.C. (tbcardwell@novanthealth.org).

    Nan Holland is senior director for clinical excellence, Novant Medical Group, Winston-Salem, N.C. (nlholland@novanthealth.org).