Monday, March 07, 2011

Would someone please figure out a way to rectify med rec?

Happy says patients need to own it, but they won't.

Early in my blogging career, naïve about the law of unintended consequences, I thought Joint Commission's med rec initiative was a great idea. Turns out it hasn't worked. When it comes to medication safety across transitions of care we're no better off, maybe even worse off, than before the initiative.

Decades ago docs had their own simple version of med rec. Admission orders might read “give home meds, home dosage, home schedule except D/C digoxin.” Discharge orders might read “home meds same as pre-admission except change digoxin to every other day, increase lasix to bid, increase Ktabs to bid.” I remember one time as a resident discharging a patient from the “private” service. I asked the attending what to order in the way of discharge medications. He said “just tell the patient to take his bottles to his druggist and have the druggist call me.” And you know what? It wasn't perfect but it worked. One reason it worked as well as it did was that the patient did have to own it, along with the nursing staff. But through the years, every so often someone would get the bright idea to turn it into a “process,” which usually meant a new form or a new template. And with each new process, and its accompanying forms or templates, came another opportunity to mess stuff up.  With Joint Commission's med rec process the paper form and the electronic template became a substitute for someone sitting down with the patient and really addressing the details.


Scot M Silverstein MD said...

My father with his little private drugstore from the early 1950's until the early 1990's, was Med Rec for an entire community.

-- SS

William said...

if you take the time to listen you will find that there
are always at LEAST 10 different versions of what the patient takes. There is the LIST the wife has.
There is the list the family doc has
There is the idea that the daughter has
There is the list the nurse wrote down in the med rec admit sheet
There is the list the wife confirms after
you discuss all the drugs on the first list, eliminating at least 3 , adding at least 2.

There are the drugs the patient takes but does not think of as drugs, including insulin shot and all kinds of useless inhalers
There is the list with new corrected
doses doses that the patient remembers he took a few days before coming in
There is the list from the last admission
There is the list the admitting doctor
wrote in the chart that is ALWAYS wrong
There are the drugs samples some specialist gave him, that the wife finds in the bathroom on day three of the hospitalization.
There is the list of drugs the patient forgot to take or took too much of

(Sorry that is 11)

The correct list is a fog, encircled in a cloud, shaken up by a low pressure front, disrupted by a sand storm and distributed in a thousand pieces
over the Texas Hill country.
The only response to someone who thinks he knows what the patient takes is an attitude of Christian forgiveness for the hubris of modernity.

William Reichert, MD " hospitalist", although
I prefer the antiquated " attending physician"