What Medications Does Your Patient Take? Enhancing Medication Safety in the Outpatient Setting

​Medication safety remains a top concern in US health care, and with good reason. Last year the Institute of Medicine (IOM) reported that patients experience up to 1.5 million preventable adverse drug events each year. The findings were issued in the midst of a new effort at the nation’s hospitals to reverse this situation. Electronic medical records and accurate matching of patient and medication identifiers are one part of the solution. But hospitals know much more is needed. Mindful of the high number of mishaps that occur during transitions in care, hospitals are implementing systems that compile, maintain, and confirm accurate information about patients’ medications at every transfer point during an inpatient stay. Known as “medication reconciliation,” this process, when fully implemented, must include the outpatient setting.


“Medication reconciliation started in the inpatient setting because we know there are medication errors associated with hospital stays,” says Frank Federico, RPh, an IHI Director. “But when medication reconciliation emerged as a National Patient Safety Goal, we recognized that the need for accurate information about a patient’s medication spans the continuum and shouldn’t be limited to the inpatient setting.”


Indeed, inpatient and outpatient health care professionals rely on each other’s records as patients cross back and forth between care settings. It’s important, for example, for emergency department (ED) staff to know what medications a patient has been taking when he or she arrives for emergency care. And depending on the circumstances, patients arriving at the ED aren’t necessarily the best source. They may not be in a condition to communicate or remember accurately, and patients who do carry their medication lists with them may not have a list that is up to date.


Patients may assume all providers have access to the same information, regardless of the setting, and are often surprised to learn that this goal has yet to be realized. Records aren’t always immediately accessible, and clinicians who see a lot of patients may not have systems in place to quickly update and transmit large amounts of data.

Stemming Outpatient Medication Errors
The incidence of adverse drug events (ADEs) in hospitals — estimated at about 400,000 per year, costing more than $3.5 billion in additional hospital and medical costs — is well documented, and has been the focus of widespread quality improvement initiatives, including those led by the Massachusetts Coalition for the Prevention of Medical Errors, The Joint Commission, the Institute for Safe Medication Practices, the American Society of Health System Pharmacists, as well as IHI’s 100,000 Lives and 5 Million Lives Campaigns.
While medication errors in the outpatient setting are harder to measure, in its 2006 report, Preventing Medication Errors, the IOM estimates that about 530,000 medication-related injuries occur annually just among Medicare recipients at outpatient clinics.
Improved medication safety in the outpatient setting is the goal behind a comprehensive new effort in Massachusetts called the Ambulatory Medication Safety Project (AMSP). The program is designed to capitalize on patients’ knowledge of their medications and to support their role as an important source of information for providers across multiple settings. The program is a joint effort by the Massachusetts Coalition for the Prevention of Medical Errors and the Massachusetts Medical Society, with support from the Commonwealth’s Betsy Lehman Center for Patient Safety and Medical Error Reduction.
Launched in October 2006 after a pilot phase, the project seeks to improve communication about medications between patients and providers, and also among providers, through the use of a paper medication list (called the Med List) that patients maintain and regularly review with their providers. (The Med List and helpful tips may be downloaded free of charge.)
A Single, Comprehensive List
Effie Brickman, Director of the Ambulatory Medication Safety Project at the Massachusetts Coalition for the Prevention of Medical Errors, says that the Med List helps improve medication safety in three ways.
First, the Med List gives patients a single place to write down all their medications, regardless of how many pharmacies they use. Space is provided to list both prescribed and over-the-counter medications, any herbal, vitamin or dietary supplements they are taking, along with start and stop dates, the purpose of each medication, possible danger signs, and if monitoring is required.
Second, because patients are encouraged to bring the list to each medical appointment, there’s a built in prompt and reference for discussing everything on it, including medications a patient used to take. And third, the Med List enables providers to reconcile the patient’s list with the information in the medical record, looking for omissions, duplications, and potentially problematic interactions.
Putting the patient in charge of creating and maintaining an accurate medication list reflects two things, one a problem, the other an opportunity: the difficulty that physicians’ offices have coordinating information in a fragmented system where electronic record-keeping and reliable communication is still not the norm, and the impact of the movement toward more patient-centered care that seeks to give patients more access to information and involvement in decision making.
But to make this greater engagement meaningful, says Brickman, patients need to be educated about the specific role they can play and, in some cases, need help creating their first Med List. “People can fill it out online or print it out and fill it out by hand,” says Brickman. “Others may want a family member to help them. We expect physicians’ offices to work with patients in the beginning to make sure they understand why the list is important, to help them create the list if necessary, and to review all the medications on the list with them.”
Brickman says the practices that tested and helped refine the Med List during the pilot phase often revealed important information. “The biggest surprise for most doctors was how many patients thought the physician already knew all the medications the patient was taking, even those prescribed by other physicians. Physicians also learned how patients were thinking about and using their medications,” says Brickman. “One doctor learned that some patients didn’t consider birth control pills to be medication, for example. And other patients didn’t think it was important to report use of herbal and over-the-counter medications. Doctors do want to know this information because herbals and over-the-counter drugs sometimes negatively interact with prescription medications.”  
Internist Bruce Karlin, MD, who tested the Med List in his Worcester, Massachusetts, practice, says that conversations with patients about what medications they are taking can be frustrating for both parties. “Some patients will say, ‘I take a pink pill at night, and a blue one, do you know what they are?’ And we usually don’t know what they are, especially because the color and shape of medications can vary depending on what formulary the insurer uses.” Although Karlin has used an electronic medical record system for years to provide his patients with summary information at each visit, he says the Med List is important because it provides a standardized way for patients to gather and organize medication information. “Every practice does it differently, if they do it at all,” he says. “It’s great that someone is trying to standardize the information.”
Spreading the Word
Because use of the Med List is voluntary, Effie Brickman says her organization does not know how many physician practices are currently using it. With the help of the Massachusetts Medical Society, the Coalition is spreading the word about Med List’s benefits to hospital leaders and physicians. Patients are learning about the list from consumer organizations, the media, and payers and employers such as the state’s Group Insurance Commission. In addition, all major Massachusetts pharmacies have agreed to provide patients with a printed list of their medications on request, which they can then use to fill out a Med List.
Brooks Pharmacy actively promoted use of the Med List when the Coalition launched its campaign, printing and distributing the forms to patients at its nearly 200 Massachusetts stores. This tied in well with the pharmacy's special program for Medicare patients called Medication Therapy Management, whereby a pocket-sized Personal Medication Record (PMR), which serves the same purpose as the Med List, is generated. Ginger Lemay, PharmD, a Clinical Pharmacist with Brooks Pharmacy, says she uses the PMR when she meets with Medicare patients to review and explain their medications. At the consumer's request, Brooks is also happy to print out a list of every medication filled at the pharmacy to help patients complete their Med Lists. 
“We trained a subset of pharmacists in geriatric pharmacy,” explains Lemay, who developed the program for Brooks Pharmacy. “We meet with patients by appointment, at no charge to them, and go over all their medications, both prescription and over-the-counter.” Lemay says that Brooks pharmacists have identified issues in need of attention in all of their patient consults. “There’s always something, a dose that’s too high or too low, duplicative therapies, or questions from the patient. We work with their physicians to create a Medication Action Plan and we help the patient complete an accurate PMR with all their prescriptions, over-the-counter medications, and herbal remedies. Every time we meet with the patient, we review the list and bring it up to date.”
Physicians are also encouraged to get in the habit of requesting and reviewing a patient’s Med List at every visit and, comparing them with their own records. “The important information is what the patient is actually taking, not just what’s been prescribed,” says the Coalition’s Effie Brickman. “That’s why including the patient in the process of reviewing the list is so important.”
The importance of having doctors and patients review medications together can’t be overstated, says IHI’s Frank Federico, because only the patient knows what transpires after the doctor prescribes something. “Was the prescription filled? Was it refilled? Were the right doses taken? At the right times? Did the patient stop taking the medication without the physician’s knowledge? Did the patient take anyone else’s medication?” Federico says physicians who want to make the most of these conversations can benefit from special training in appropriate interview techniques, particularly focusing on issues of cultural differences and literacy. 
Effie Brickman acknowledges that getting the whole medication list system underway requires some upfront time commitment on the providers’ part. However she believes the investment will be well worth it as it reduces the time spent searching the medical record for the patient’s medications or notes from other physicians about newly prescribed medications. More importantly, it can prevent mishaps or worse, serious medication mistakes down the road.
The day may come when all patients’ medication records are available by computer or on “smart cards” that can be electronically read. Frank Federico urges careful thought as organizations move in that direction. “Electronic systems are wonderful, and eventually we will get there,” he says. “But today, the patients who most need this information may be the least likely to use computers. The sickest people are often the poorest and the least literate, and an electronic database and website would not serve their needs. As providers, when we develop systems, we always have to ask: are they helping us, or the patient? Smart cards would help the pharmacist and the provider, but not the patient because they can’t read it. Systems must be patient-centered. For many patients, a paper process is easier.” 
On the other hand, says Federico, there’s a balance that must be struck, and patients cannot be expected to bear all the responsibility for information sharing. “Primary care physicians who refer patients to a specialist should communicate the patients’ medications and problems along with the referral, no matter what means of communication they use,” says Federico. “The patient’s role — bringing their Med List to that specialty appointment — should serve as a redundancy, in case the referral information didn’t get through. Physicians’ offices still need to take responsibility for making sure their information is accurate and well communicated. And even though the patients’ input is essential to creating an accurate list, patients have the right to expect the system to be ultimately responsible for communicating that information effectively on their behalf.”
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