Medication Errors Affecting 2000 Patients at Lifespan Hospitals: Need to Improve Care Transitions

The issue of medication errors affecting 2000 patients at Lifespan Hospitals in RI is understandably catching the media's and public's attention.

Although the apparent explanation offered by the hospitals is "software error", the article in FierceHealthcare quotes RI State Health Director, Dr. Michael Fine: this represents a "risk in the handoff process" and requires a "more robust team approach for care transitions".

It may be a relatively subtle mistake that was made - substitution of time-release medications for shorter acting formulations, however, a robust "care transitions process" that the article alludes to could have provided a safety net to catch mistakes made by a software glitch:

• At the time of discharge, it is a common expectation at US hospitals that a formal "medication reconciliation process" be undertaken. 
• Many, if not all, hospitals struggle with medication reconciliation due to the complexity of the task. 
• However, the minimum requirement that all institutions should be able to uphold is that the physician discharging the patient review all discharge medications explicitly, and indicate whether each should be continued or not. 
• The nurse discharging the patient should also review the medications ordered by the discharging physician, providing a "double-check" of the medication reconciliation process. 
• Prior to discharge, the discharging nurse (or delegate) should review the discharge medication list with the patient in order to ensure that the patient understands which medications to take and the indication for each.  
• While many patients may not be in a position to question a subtle substitution of formulations, the aware patient and/or representative family member can often be a "triple-check" in the medication reconciliation process. 
• Subsequent to discharge, the patient's primary care physician and visiting nurse (if involved) should review the discharge medication list to ensure clarity regarding each medication prescribed. 
• These clinicians may be at a disadvantage at determining which medications may not be appropriate since they were not involved in the inpatient care, however, their astute judgment can be a "fourth check" to protecting patient safety. 
• The corollary discharge documents - usually a discharge summary, medication list, and "referral form" - should be completed in a timely manner by the inpatient clinicians and communicated reliably from the hospital to the outpatient care providers. These documents can provide an essential link in the communication chain to ensure safe patient care. 

For an error not to be caught by any of these "safety mechanisms" does imply that there are more serious issues than a software glitch, and Dr. Fine is right to identify that the "care transitions" process needs to be carefully reviewed and may need to be redesigned.