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Getting Less By Asking More

The Perspective piece written by Mary Brennan-Taylor in September’s JAMA Internal Medicine really struck a cord with us. Brennan-Taylor writes of her mother, Alice, an active and vibrant woman who died unexpectedly at age 88 after a series of tragic and preventable medical and medication errors. It took only 48 days for Alice to spiral downward from an alert, independent woman with nagging pain in her neck and shoulders to a delirious, dehydrated patient dying of sepsis acquired when mistakes in her medications left her frail and malnourished. This was despite her daughter’s active involvement in her care and hospitalization. Alice and Mary’s story could so easily have been our own.

Alice’s encounter with the health care system began on a July 4 holiday, when she went to the emergency room seeking pain relief for her aching neck and shoulders. She was prescribed cyclobenzaprine– a medication on Beer’s List, a compendium of medications considered potentially dangerous for older adults. Although Alice never actually took that prescription because her neck and shoulder pain subsided on its own, it was nevertheless added to her medication list a week later when Alice was diagnosed with gout and hospitalized to have fluid drained from her knee. The hospital began routinely administering the cyclobenzaprine, which was continued when she transferred to a rehab facility 5 days later. After 12 days, she was readmitted to the hospital suffering from dehydration and delirium. This time, medications were added to treat confusion and agitation. By the time Mary recognized the medication error, it was too late. Alice’s weakened and malnourished body could not fight off the health care associated infection she had acquired.

The cascade of events is a reminder not only of the rationale for the “Less is More” movement in health care (see RightCare as an example), but of how important it is for health care professionals across the continuum to ask questions if something doesn’t seem right. The hospitalization Alice received was likely unnecessary. The medication reconciliation completed on admission was ineffective due to an inaccurate EHR and failure to communicate and confirm information with the patient, caregiver, and primary care physician, which led to inappropriate medication, followed by a series of serious adverse events, hospital-associated infections, additional treatment, and ultimately death.  It is easy to see how these events were preventable (hindsight is indeed, 20/20).

This story highlights the dangers we all, and older adults in particular, face when accessing the health care system. At several points during her series of events, this woman, Alice, received a written prescription, a medication, or a procedure that she did not really need, or was of questionable value.

As both health care professionals and patients, we must be hypervigilant when accessing the health care system. 

  • Is the treatment, medication, or procedure absoluately necessary?
  • Have the benefits and risks of the treatment been reviewed by both the patient or family caregiver and the professional?
  • During each transition in care, a time where medication errors are very common, were the medications thoroughly reviewed by a pharmacist and discussed with the patient?

Medication therapy management (MTM) and comprehensive medication review (CMR) are 2 benefits offered under Medicare that could have provided value, though very few Medicare beneficiaries are actually receiving these benefits. (see definitions here or here or here). The medication reconciliation process obviously failed for this patient, but it seems there were multiple other stops along the way that were missed by many professionals, likely due to system-wide processes that are insufficient and too impersonal to allow professionals to take the time needed to catch this type of problem.

This is a call to action. For all of us. Don’t assume someone else asked the question or looked into the details. Talk to the patient and caregiver. Talk to the health care provider. Communicate—face-to-face. A culture of safety is everyone’s responsibility.

Other links of interest:

Safe Patient Project

National Transitions of Care Coalition (NTOCC)  

Medication Reconciliation to Prevent Adverse Drug Events

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