The Case

A 76-year-old man (Patient A) was admitted to the hospital for headaches after a recent diagnosis of B cell lymphoma with central nervous system (CNS) involvement. During the hospitalization, he remained in a double occupancy room with another patient (Patient B). Patient A was discharged after he received appropriate clinical care and his acute symptoms resolved, while Patient B remained admitted.

Both patients had brought their oral home medications to the hospital because their specialty oncology drugs were not on the hospital formulary. The medications were verified by the pharmacist and bar-code labeled for the individual patients who were intended to receive them. The home medications were then placed into the automatic dispensing cabinet so that the floor nurse could access, administer, and return the medications to the respective patients at discharge. The discharge process was reportedly rushed but otherwise uneventful.

Three days after discharge, Patient A’s son called with concerns about his father’s medications, one of which appeared to be new. It was discovered that Patient A was inadvertently discharged home with Patient B’s medication (ponatinib) along with his own medication (temozolomide). By the time Patient A’s son called with this concern, Patient A had taken three doses of Patient B’s ponatinib, which is only approved for use in chronic myeloid leukemia and Philadelphia chromosome-positive acute lymphoblastic leukemia. While Patient B remained hospitalized, it was discovered that his home medication (ponatinib) was “missing”, and efforts were made to obtain an early refill for him to receive upon discharge.

The Commentary

By Garima Agrawal, MD, MPH, and Diana Mai Nguyen, MD

Medication errors are costly, contributing to patient suffering, healthcare expenses, and distrust within the healthcare system.¹ Transitions of care are an especially vulnerable time for patients, and unfortunately the risk of medical error during these transitions is exacerbated for those with complex medical diseases and treatment regimens.² The case above highlights the unique opportunity for error associated with home medications brought into the hospital for use. It is generally understood that carefully performing medication reconciliation can identify and reduce medication errors, duplications, or omissions at various transition points in care. However, to the best of our knowledge, there is a lack of literature on standardized practices on how to safely handle, store, and return patients’ home medications that are brought in for use during the hospital stay.

Sassatelli outlines the fundamental framework for nursing medication practice, where prior to any medication administration, nurses must confirm the identity of the patient, the medication, and the dose, route, and timing of the medication.³ An error in any of these elements has the potential for harm. She specifically outlined a nursing strategy titled “Cause to Pause” to reduce the potential for error: (1) stop what you are doing, (2) eliminate distractions, (3) think clearly, (4) consult with organizational resources to ensure compliance with the standard of care, and (5) proceed with caution. In the situation described in the case above, such a framework may have benefited the nurse who felt rushed at the time of discharge.

To better support safe nursing practice, it is critical to establish standardized processes to reduce the opportunity for human error in dispensing high-risk medications, including chemotherapeutic agents. “Double-checking” is a well-known process utilized prior to high-risk medication administration, whereby two nurses independently verify key information.⁴ The goal is to minimize human error by avoiding any endogenous or exogenous risk factors unique to one staff member. While double-checking sounds reasonable in theory, only one of three good quality studies in a recent review showed a significant association between double checking and a reduction in medication-related adverse events, while another showed no association and the third reported only adherence rates.⁵ In this case, hospital processes may have required “double-checking” for inpatient administration of chemotherapy, but not for dispensing oral chemotherapeutic drugs for home use. However, “double checking” may not have intercepted the error if both individuals were affected by the same disturbances in the environment, or if there was an imbalance of authority.⁴

Home medication storage during hospitalization

In the United States, each health care system has its own Pharmacy and Therapeutics Committee responsible for formulary development.⁶ The committee develops a list of medications that are effective for treating the conditions commonly seen at that facility while considering cost effectiveness. Healthcare providers are encouraged to prescribe only medications on the hospital’s specific formulary; however, when the desired medication is not available, patients are encouraged to bring their home prescriptions. In the case above, both patients required specialty oncology oral medications that were not on the hospital formulary, and thus they brought their home medications to continue treatment without interruption.

The storage of medications required for daily use is an interesting challenge, and research examining medication administration errors shows that storage systems may contribute to efficiency, security, safety, and patient experience.⁷ In large hospitals, there are multiple storage facilities across many wards, and the medication stock available for administration is constantly adjusted to meet the patient population’s needs. The resulting variation in medication storage practices across units and over time may result in missed or delayed doses.

The medication storage issue is even more complex for home medications.⁸ For medications on formulary, central surveillance is required to ensure that the individual medication storage units are appropriately serving patient needs. Home medications, however, require a storage solution that is independent of the workflow for medications on formulary. Home medications must be brought by the patient, provided to the nurse, approved by the healthcare provider, and managed by the pharmacist. Furthermore, patients are often relocated within the hospital and home medication must be tracked to appropriately follow each patient to avoid misplacement. The lack of a standardized workflow for surveillance and storage creates a unique opportunity for medication misadventure.

The limitations of technology in identifying medication error

The home medications in the case above utilized bar-code labels that could be scanned to ensure accurate medication identification and then matched to the patient’s wristband identification barcode. The subsequent medication error despite this barcode medication administration practice, illustrates both the limitations and potential opportunities of technologic solutions in high-risk settings.

Providers electronically prescribe medications in the patient’s electronic medical record (EMR) for pharmacists to prepare and reconcile. The patient’s EMR is attached to a medical record number (MRN), which is also associated with a barcode for use by a specific patient. Nurses can then utilize barcode medication administration (BCMA) technology to automate the drug-checking process. After verifying the patient’s name and date of birth, the nurse scans the patient’s wrist band, which must match the label on the medication prior to administration. This match confirms that the medication to be administrated is intended for the current patient, reducing the risk of errors. In the current case, while the medications from home were properly verified and bar-coded to support the use of BCMA technology for doses administered in the hospital, the BCMA technology was not part of the workflow for verifying accuracy of returning a home medication to a patient at discharge. Implementing BCMA technology as part of the discharge process, as a step in returning home medications, could have avoided the error that occurred in this case.

However, the process of medication administration is complex and requires provider autonomy to sustain best practices. Technology is binary and unable to utilize clinical judgement to guide priorities and maintain an effective workflow. In one qualitative study in a large academic medical center, nurses exerted agency by trusting their own judgment over system information when the system did not consider workload complexity. There is some risk that the BCMA system’s rigidity may clash with adaptive needs embodied by the “orienting frames” that nurses use to organize, prioritize, conduct, and evaluate their professional work.^9,10

Accordingly, technology should be used as an adjuvant to clinical practice, but not as a crutch given its shortcomings. The BCMA process requires appropriate bar code labeling and functional scanning technology.¹¹ Only after that can compliance be assessed to confirm that the barcodes are being scanned as intended to ensure accurate identification of medication for each patient.

Take home points:

• Home medications brought into the hospital for use require vigilance to ensure proper inpatient storage during the hospitalization and return on discharge.
• Technologic practices such as barcode medication administration (BCMA) serve as an adjuvant to support safe clinical practice but have clear limitations.
• “Double checking” high-risk medications by two or more individuals may intercept some errors, but this practice also has recognized limitations, especially when the involved staff are both affected by the same environmental factors or stressors.

Garima Agrawal, MD, MPH
Division of Hospital Medicine
UC Davis Health
gagrawal@ucdavis.edu

Diana Mai Nguyen, MD
Division of Hospital Medicine
UC Davis Health
deenguyen@ucdavis.edu

References

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