Discharge Medication Reconciliation Disasters.

A reader asks a question regarding the discharge medication reconciliation process when patients are discharged from the hospital:

Why don't hospitalists consult a patient's primary MD,   esp when it involves the meds a patient is d/c'd home on. This is a major problem with patients having duplicate meds, some brand name, some generic, different doses, similar meds, etc. It is a nightmare for a home health nurse. Thanks, RN

You bring up a great question.  The answer is that there is no one right answer.  Here are all your answers.
  1. Correct medication reconciliation on admission is paramount for correct discharge medication reconciliation.  As a hospitalist, I've been battling correct admission  medication reconciliation for eight long years.  If there are any experts out there who have discovered what works, make yourself known. Now.  And please, publish a white paper so we can all help ourselves make our patients' hospital experience a safer one.    If systems processes aren't in place on admission to get it right, it's not going to be right for discharge.  The last time I took a medication history on admission was as a resident in training.  I don't have time to play this role. I will never have the time to be in charge of this process.  It can be done by others who aren't trained to do what I do so I can spend my time doing what I'm trained to do. 
  2. Primary care offices rarely have the correct list of a patient's medication because their patients often see three,  four, five or more other specialists and nobody communicates or updates their records.  The best place to get a medication history is either from the patient (if they can)  or their pharmacy (if it's not a mail order after hours).  Frequently, calling a PCP for a medication list is no better than calling, say, the patient's neighbor.   
  3. Medication reconciliation on admission, after hours, is nearly impossible if the patient doesn't care or is  incapable of caring enough about their health to know what medications they are ingesting one, two, three or four times a day.
  4. Cardiologists, pulmonologists, nephrologists, gastroenterologists, surgeons, blah, blah blah, and yes, hospitalists, are frequently the culprits for initiating new medications that don't make any sense in the clinical context of the patient (starting lipitor and Advair in a homeless and uninsured patient for example).  Don't blame the hospitalist alone.  There are many doctors not paying attention to the patient's reality. 
  5. There are too many insurance formularies to know what is and what isn't covered.  Until the entire process is computerized and integrated between the patient's insurance company, their  primary care office, their subspecialty offices and  their pharmacy, the discharge medication reconciliation process will be dependent on a patient that cares (such as this patient who took the time to make their own medication labels).  Unless, of course, they live in a nursing home.
  6. The only great thing about nursing home admissions, usually, is that they come with an accurate medication list.  I take that back.  There are two great things about nursing home patients.  They usually have an unobtainable ROS, which makes for a quick admission process AND they have an accurate medication list.  
Before blaming the hospitalist because the medication list isn't accurate, realize that our discharge medication reconciliation process is mostly determined by our admission medication reconciliation process and the number of subspecialists who get consulted to care for the patient but pay no attention to the big clinical picture when they write for their medications.    Me personally?  I write for the cheapest thing possible, most of the time, because I know the difference between the cheap good stuff and the expensive good stuff is clinically irrelevant when the protoplasm I am given to work with has already mostly determined what kind of outcome I can expect.  Whether I write for $4 lisinopril or $100 Altace, $20 simvastatin or $150 Crestor, it's not going to change the outcome in my morbidly obese tobacco addict.  It just isn't.  So, if you're getting a discharge medication reconciliation from me, you can be rest assured that 
  1. I also have a discharge summary performed immediately on discharge with an expected turn around time of 24 hours, unlike some patients who bounce back into the hospital after a three week stay a month ago on another service and have no discharge summary to review the details of that care.  If I was that patient, I would be pissed.  
  2. I will rarely change any home medications as documented on the admission medication reconciliation unless dosing changes are necessary based on the clinical presentation or medications need to be discontinued indefinitely or temporarily based on the clinical presentation. 
  3. If I start a new medication, I will use the cheapest variation, whenever possible, but I will never verify the medication with the patient's insurance formulary.  Unless that process is automated, it just ain't gonna happen.
  4. If the admission process is wrong, the discharge process will be wrong as well.  The hospitalist, or any physician, is not the ideal person to spend their time in admission medication reconciliation.  It must be owned by the hospital, as a matter of patient safety,  and the resources must be provided to make it happen.
This original Happy Hospitalist medical ecard helps to explain.   

"I'm going to recommend you stay in the hospital one more day for no reason at all so I can punt your complicated discharge to my partner who knows nothing about you.
I'm going to recommend you stay in the hospital one more day for no reason at all so I can punt your complicated discharge to my partner who knows nothing about you doctor ecard humor photo.

Some of this post is for entertainment purposes only and likely contains humor only understood by those in a healthcare profession. Read at your own risk.

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