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Senior Alert
Watch Drug List if Senior Citizen Being Moved in the
Hospital – Mistakes Kill
Too many medication errors occur as patients change care settings
Jan. 26, 2006 – Senior citizens and their
caregivers should be alert to this warning of a threat to life that is
occurring in hospitals. Medication errors cause more than 7,000 deaths a
year in U.S. hospitals. Many of these can be prevented if more attention
is paid to the accuracy of medications given to patients as they are
moved from one area of a hospital to another, from supervision of one
healthcare worker to another or to any other new care setting. This
caution flag was waved yesterday by the Joint Commission on
Accreditation of Healthcare Organizations.
JCAHO issued a new Sentinel Event Alert that
said failure to reconcile medications during these transitions can cause
serious patient injuries and even death.
A key recommendation says each patient should be
provided with a complete list of
prescribed medications, as well as instructions on how to take any new
medications. The patient should be encouraged to carry this list and
share it with any caregivers who provide any follow-up care.
Senior citizens and their caregivers should be
certain they are provided this information and understand it.
According to the Alert, medication reconciliation
should occur whenever a patient moves from one location to another
location in a health care facility (for example, from a critical care
unit to a general medical unit); or from one health care facility to
another or to home; and/or when there is a change in the caregivers
responsible for the patient.
When effective medication reconciliation does not
occur, patients may receive duplicative medications, incompatible drugs,
wrong dosages, or wrong dosage forms among the array of potential
errors. The medication reconciliation process also provides an important
opportunity to assure that the patient is receiving all medications
necessary to his or her care and to eliminate any medications that are
no longer needed by the patient.
Last year, United States Pharmacopeia received more
than 2,000 voluntary reports of medication reconciliation errors, and a
1999 Institute of Medicine report estimated that more than 7,000 deaths
occur each year in hospitals alone due to medication errors.
The Joint Commission's Sentinel Event Database also
identifies medication errors as one of the most frequently occurring
threats to patient safety.
This Database reveals that 63 percent of the
reported medication errors resulting in death or serious injury were due
to breakdowns in communication, and approximately half of those would
have been avoided through effective medication reconciliation.
The fact that medication reconciliation errors
continue to occur, despite repeated warnings and rigorous standards,
prompted the Joint Commission to issue the Sentinel Event Alert on
medication reconciliation to the more than 15,000 health care
organizations it accredits.
"A systematic approach to reconciling medications
must be the foundation for all efforts to prevent drug errors," says
Dennis S. O'Leary, M.D., president, Joint Commission. "As challenging as
this effort may be, it will be well worth the investment for caregivers
and patients alike."
To reduce the risk of errors related to medication
reconciliation, the Alert recommends that health care organizations:
● Put the list of medications in a highly visible
place in the patient's chart and include essential information about
dosages, drug schedules, immunizations, and drug allergies.
● Reconcile medications at each interface of
care, specifically including admission, transfer and discharge. The
patient and responsible physicians, nurses and pharmacists should be
involved in this process.
● Provide each patient with a complete list of
medications that he or she will take after being discharged from the
facility, as well as instructions on how and how long to take any new
medications. The patient should be encouraged to carry this list and
share it with any caregivers who provide any follow-up care.
In addition, as part of its current National
Patient Safety Goals, the Joint Commission also specifically requires
that each accredited health care organization:
● Implement a process for obtaining and
documenting a complete list of the patient's current medications upon
admission. This includes a comparison of the medications the
organization provides to those on the list. The patient should be asked
to describe or confirm any prescription medications, over-the-counter
medications, vitamins, herbs or other supplements that he or she takes.
● Communicate a complete list of the patient's
medications to the next service provider when the patient is referred or
transferred to another setting, service, practitioner or level of care
within or outside the organization.
The warnings about medication reconciliation are
the latest in a continuing series of Sentinel Event Alerts issued by the
Joint Commission. Much of the information and guidance provided in
these Alerts are drawn from one of the nation's most comprehensive
voluntary reporting systems for serious adverse events in health care.
The Sentinel Event Database includes detailed information both about the
adverse events and their underlying causes. Previous Alerts have
addressed wrong-site surgery, medication mix-ups, health care-associated
infections, and patient suicides, among others. The complete list and
text of past issues of
Sentinel Event Alert can be found on the Joint Commission website at
www.jcaho.org.
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