Automating medical error: misadventures in medication reconciliation

I recently enjoyed a nasal surgery procedure. More on that in a later post, this one is about a medical error that followed the surgery. It’s a kind of error that fits my professional work in clinical computing (“medical informatics”).

The error, actually multiple errors, showed up in a part of my computer generated post-operative discharge summary labeled “CONTINUE taking these medications”. In the clinical computing industry this is the “medication reconciliation” or “medrec” section…

AHRQ Patient Safety Network - Medication Reconciliation

Patients often receive new medications or have changes made to their existing medications at times of transitions in care—upon hospital admission, transfer from one unit to another during hospitalization, or discharge from the hospital to home or another facility. Although most of these changes are intentional, unintended changes occur frequently for a variety of reasons. For example, hospital-based clinicians might not be able to easily access patients' complete pre-admission medication lists, or may be unaware of recent medication changes. As a result, the new medication regimen prescribed at the time of discharge may inadvertently omit needed medications, unnecessarily duplicate existing therapies, or contain incorrect dosages. These discrepancies place patients at risk for adverse drug events (ADEs), which have been shown to be one of the most common types of adverse events after hospital discharge. Medication reconciliation refers to the process of avoiding such inadvertent inconsistencies across transitions in care by reviewing the patient's complete medication regimen at the time of admission, transfer, and discharge and comparing it with the regimen being considered for the new setting of care.

Most of the electronic health record (EHR) industry more-or-less automated medrec in the 00s. Typically a physician (usually this is a physician task) reviews a list of “existing” (tricky term!) medications as well as “new” meds and, in theory, produces a reconciled list that  fits the patient’s current sate.

That’s the theory; in practice the “existing” medication list is often incorrect.  Additionally, it’s usually quite easy to, with a click or two, replicate the “existing” medication list without the tedious work of actually reviewing it.

Both errors, and more, showed up in the “continue” list I was given for:

• Afrin 2 sprays 2 times a day
• Flonase 50 mcg/actuation
• fluticasone 50mcg 1 spray into each nostril daily
• azelastine 137 mcg 2 sprays into each nostril two times a day.

Let’s count the errors:

• None of these meds are appropriate for my post-op fully obstructed nose. The Afrin and steroid sprays are theoretically harmful, but in practice none of them would go anywhere anyway. So that’s 3-4 errors depending on how one treats Flonase/fluticasone. These is most likely either physician inattention or a process error.
• Flonase and fluticasone are Brand and Unbranded names for the same medication. This is a software error or a data entry/design error (accepting free text meds rather than “coded" meds).
• The Afrin dose and frequency is incorrect, it would be dangerous to use it so often. This is likely a physician error. (I actually corrected this during an office visit, but my correction was evidently ignored.)
• The list omits QNasl. This almost certainly an error in compiling the “existing medication” list, but like all the others it shouldn’t have been on the list post-of. I’ll count this as an error anyway.

So in one medication reconciliation process we have 7 errors, 1 which is probably software (Flonase/fluticasone resolution) and 6 which are physician/process errors likely facilitated by poor software design.

In this case no harm was done. My wife and I are both physicians; we knew to ignore the errors. There might have been a small potential for harm with a non-expert patient, but in practice the nasal meds aren’t going to get far in a post-op obstructed nose. Obviously there’s potential for harm in different cases, which is why “medrec” has been a patient safety goal for the past … well … 25 years or so.

This isn’t a new problem — Emily and I both remember common medication reconciliation errors in the pen and paper era. I suspect, however, that quick-click list merges may make it faster and easier to make the same old mistakes.

It would be nice to think about what we could do differently…