Transcription of Episode 14: Medication mistakes are the biggest reason for patient safety error.

Can you guess the number one reason for

patient safety error? Welcome to SBH Bronx health talk produced by SBH health system and broadcast from the beautiful studios at Saint Barnabas Hospital in the Bronx hello I’m Steven Clark. A recent report shows that the average hospitalized patient is subject to at least one medication error per day as many as 50% of medication errors are believed to result during handoffs when patients are either admitted transferred or discharged of these medication errors about 20% are said to result in harm with us today to discuss the issue of medication is Dr. Amanda Rampersaud, a transitions of care clinical pharmacist at SBH Health System welcome Dr. Rampersaud.

Hi Steve thank you for having me today.

And I guess when we’re talking about transitions of care I think we’re talking about handoffs, right?

Absolutely handoffs between the levels of care and also between different institutions and different organizations as well patients are seen all across the continuum of care.

Let’s start by talking about the elderly which I’m assuming is the most vulnerable population that we deal with obviously elderly patients see different physicians someone for their heart someone for their feet someone for their eyes and other for stomach issues it’s got to be tough trying to keep their medication straight right?

Absolutely Steve our elderly population is subject the most vulnerable population and they’re the the population that it’s most often subject to poly pharmacy and duplicate therapies and you know you know inappropriate therapy altogether for their age and their weight and their you know kidney function and all of those things so you know they’re always coming up with with different you know medications for these elderly patients and you know sometimes it really takes a lot of eyes to be able to review these these medications and these regimens and there to make sure that their appropriate one and to that their optimal that their there you know in doing what they’re intended to do.

I mean I’ve read that the average elderly person may take between nine and twelve medications a day plus supplements over-the-counter medications I mean that’s a lot to keep track of.

Oh absolutely for our elderly patients it’s more than than a lot to keep track of you know oftentimes the patients that I interact with tell me you know it’s just such a burden to keep up with the amount of medications that that I’m you know being prescribed and the amount of medications that I have to take on a daily basis and you know often times it’s not just medications that they’re gonna take one time a day it’s medications that they have to take multiple times a day and sometimes it involves them even injecting themselves and and and you know having to do really you know difficult things and you know keeping on track of all this you know it’s just part of the battle.

Well that’s your job how do you keep track?

Right so you know I always advise the patients that I interact with in the patients I see and their caregivers as well to make sure that they always keep consistent lists of medications that the patients are currently taking and you know you always are encouraged to update that list as the medications change you know and it’s very important to keep that with the patient and for the caregivers to keep it as well at all times because you never know what may happen and when it may happen so that’s one of the first piece of advice that I like to give my patients and their family members always keep a list with you and up-to-date accurate list and you know at minimum the name of the medication the dose the strength you know and the instructions for use.

I guess you should keep it proactively because you don’t know when you could end up in the hospital.

Absolutely so it’s you know anytime a change is made to your medication regimen it’s imperative that you you you know update your list and you know you remove what was on there before and you put what the new medication is and I always tell them you know at the bottom of that list you can keep a note of well you know I was on this med before but it was switched to this medication just so that going forward the next clinician or practitioner that you encounter has a clearer picture of exactly what you have med history is and you know what you comorbs are and what your comorbidities are or what your your you know your health issues are.

I know one thing that is interesting to me is that at St. Barnabas Hospital they have pharmacists embedded on different patient floors in the ICU in the ED in the center for comprehensive care we have a Diabetes Center asthma that must make a real difference.

Absolutely Steve that it’s you know one of the greatest things the pharmacists can do is is provide this this medication at here and in compliance assessments to make sure that the the patients are taking the medications as they should and to make sure that what they’re on is actually appropriate you know so being in these different patient care areas the pharmacist actually plays a very integral role in making sure that the medication reconciliation process is followed out accordingly and that it is done appropriately and consistently 100% of the time for every single one of the patients you know that comes through the SBH Health System and as well as any other healthcare facility be it a clinic be it another hospital you know medication reconciliation is is probably one of the most important things that needs to be done at every single visit you know every time you encounter a patient and and that’s because it’s constantly changing. You know meds are constantly changing medications are constantly being removed and added and doses are constantly being adjusted and if you know you think it’s trying for the patient to be able to keep up with that for the healthcare facility is also a very difficult issue for them to keep up with as well because it’s hard to compile accurate lists when patients have multiple providers across the spectrum you know so it’s it just proved to be a challenge but pharmacists are uniquely positioned to be able to help with that challenge and to be able to you know get these Med histories from these patients.

Let’s talk more specifically let’s take a case study I mean we’re not gonna breach anyone’s HIPPA regulations here but give me an example of how the patient coming into the hospital and what you know their medications may be and how you get involved?

Oh absolutely so I’m part of the internal medicine team usually on the Med surg units here at SBH and what happens as a patient is admitted a lot of the times the admitting physician or the admitting resident is usually the one that is tasked with obtaining that medication history and you know doing that medication reconciliation but in a perfect world we all know that that would be great 100 percent of the time but sometimes you know it is not always possible at that point so when I get my patients and I get the list of patients that I’m gonna be seeing for that day you know with the medical team in conjunction with them what I’ll do is I will review the Med rec to make sure that it was done appropriately to make sure that the list that’s in the system that we’re seeing is an accurate list oftentimes that will you know require the pharmacist and myself to call the patient’s pharmacy to make sure that that you know what we have is an accurate representation. Sometimes it require us to call the patient’s provider their primary care provider and say you know such and such as admitted to the institution today and for you know this reason and we need to follow up we need to know what meds the patient is taking so that you know we can start medications in the institutional setting as appropriate so you know that’s part of what I do sometimes I’ll call pharmacies I’ll call doctors you know I’ll check Bronx Rio because we are integrated with Bronx Rio as a health system you know to see you know this patient was seen in Montefiore a month ago does Montefiore have any you know history that they were able to acquire for this patient and you know oftentimes our patients come in and they don’t have a list of medications they don’t even have their pill bottles with them or something that we could reference.

So what are you doing that goes?

In that case Steve you know a lot if you’re thinking about it coming through the ED sometimes these patients may be unconscious they may not you know be able they’re not maybe nonverbal and you have to make your best faith effort to get a medication history for that patient because otherwise you will not know what meds they’re on at home and you will not know what their comorbidities are what their health issues are.

So you’re basically playing detective and a lot.

Absolutely sometimes that’s what it feels like detective work you’re you’re trying to identify medications from various sources of information and to make sure that it’s accurate because you know not doing med rec effects patient safety in so many different ways but the most important of those ways is the fact that you know you affect patient safety and you can prevent matters by actually doing an appropriate medication reconciliation and making know making sure you know what that med history is you know and a lot of times reconciling is not just obtaining the Med history it’s making sure that your starting and stopping those medication orders as appropriate persuade to you know whatever the patient may have come in with you know they came in with high blood pressure and they’re on a load of anti hypertensive but at home already you want to know what they’re already taking before you think to start additional medications so that’s why is it’s crucial that we do this 100% of the time and then it’s done with our best faith effort it’s not always going to be perfect and it’s not always going to be easy it’s going to be challenges and there may be things that we miss but that is all part of of making sure that we put that effort in and that you know we try to cover all of our bases being calling the pharmacy calling a provider calling you know the patient caregiver you know as appropriate you know a lot of our patients are elderly and they do have caregivers that take care of them and are are aware of their meds and and know it even better than the patient does so it’s appropriate to involve the patient caregivers and and to you know to make sure that everyone’s in the same on the same page and we’re all understanding of what the patient is taking and what they need.

I know you work on a patient floor but I know an outpatients there’s also the real problem with compliance.

Absolutely absolutely.

What do you do I mean if somebody goes to a pharmacy and they find out you their insurance won’t cover it or they they can’t afford it and suddenly they come in a month later and they say you know what I didn’t take my insulin this month because I couldn’t afford I took half of it, how’s the pharmacist do you deal with that?

So another side to what I do with my on a daily basis in my practice here at SBH is that I’m the transitions of care clinical coordinator as well so along with what you’re saying is the patient on the outpatient setting you know I try to ensure that all the patients that are discharged from SBH are discharged with the appropriate medications and have the appropriate access to the medications so that’s not something that’s often thought of very much in the discharge process you know our providers you know on you just in general and it’s like this everywhere providers will send their prescriptions to the pharmacy other patients choice and sometimes you don’t really know is the patient gonna pick this medication up is this medication even going to be covered you know is are they gonna even be able to afford it because there’s times when it’s covered by the insurance but the co-pays are so high that they have you know no means of being able to afford it so a lot of times what happens is just as you said the patient will go to the pharmacy the pharmacy will tell them well you have a two hundred dollar copay this one in insulin injection is very expensive unfortunately and they’re left in a situation where they can’t afford it they don’t have the appropriate access to it and they’re essentially being you know on you know not treated they’re not being medicated appropriately and then they come back into the institution the next time for you know an exacerbation of their issue of some sort and it’s sort of a cycle it’s sort of a cycle and as a transition of care pharmacists you have to be able to break that cycle so a lot of what do is address med access issues and I make sure that when a patient is being discharged the medications that they’re being discharged on are appropriate and that they can afford them and that they are covered by their insurance so a lot of times we reach out to our physicians here at SBH you know sometimes quite often and will say can you please switch this medication or can you please provide a you know a script for a different medication altogether because this one isn’t covered this may not be covered but I’m sure this is covered because I verified for you already that it is please send a different prescription or you know you may have sent the inappropriate dose to something and I come across it and I’m able to reach out and say please switch the dose of this to this as it’s is the recommended dose at this time so those are just a few areas where I can get involved in where I do get involved you know at SBH we do run well I do run the Meds to beds program here where we try to have all of our patients that are being discharged from the institution discharged with their medications at bedside before they leave the hospital so you know at least for that 30 days I can rest at ease knowing that you know they have the medications that they need prior to leave the institution.

Yeah what also I found interesting is that you’re also run interference the insurance companies.

Absolutely right so that’s another issue I wouldn’t call it an issue actually it’s another part of what we do as pharmacists you know a lot of times insurance companies will cover a medication but they want to prior authorization for it and our physicians know how timely that is and how how long and hard of grueling of a process that can be to get a medication covered for a patient sometimes it requires a lot of paperwork a lot of documentation a lot of you know follow-up to get it covered and you know I try to help in that sense I try to intervene with those types of things and I’ll have the physicians you know reach out to me say you know I have this patient they need to go home on this medication it’s not covered for whatever reason would you be able to help with them you know with that process and a lot of the times we are able to help because we know what is needed to get the medication covered what documents are needed what paperwork is needed to be filled out you know and the people that you need to speak to to get it covered so and we all know the medications can be extremely extremely expensive and for the population that we serve at SBH sometimes it is probably one of their biggest challenges and getting the appropriate care that they need and appropriate management med management that they need so it’s it’s definitely an area where I try to focus very heavily to make sure that you know before they leave they have their meds and and uh the other part to that too is that you want to make sure that they know what they’re gonna be taking you know and that the meds are communicated to them in a way here at SBH our nurses actually man the education process but I like to it’s a supplement that process and you know I encourage our physicians to consult me reach out to me you know and with difficult cases especially patients who you know have been admitted because they have not been at here and or there’s lack of compliance with their medications I love to get involved with those patients because you know you give them a different aspect of it all and the importance you are able to educate them in a different way than your physicians or your nurses are because you know the medications you know the benefits that they have for them so I find that oftentimes it helps when you know a nurse can educate and the doctor may be able to educate as well but I think it it in it’s different for the patient when a pharmacist comes in and says well you know I’m usually the gatekeeper of medications pharmacists are the gatekeepers and medications and you know we know what it can and cannot do and what the side effects are and best more knowledgeable in terms of being able to relate to the patient in that way.

You know I running out of time but I want to ask you one more question we have a very fancy piece of technology on the seventh floor of the pharmacy department just tell us quickly about that.

So the Riva is for that’s the technology that you’re referring to and that is actually a automated robot in some sense and what that does actually is it will batch IV preparations in the place of a pharmacist so the Riva is probably one of the most updated and advanced technologies that you can have in an in an IV you know in an IV room and if in any institution in any pharmacy Department of any institution it’s highly advanced very technical.

and it reduces the likelihood of medication

Absolutely reduces the likelihood of medication errors. it is it’s you know spot on when it makes these these IVs and you know it really allows for help in that sense to the IV pharmacists because it can batch you know sometimes we can batch 20 bags of something in in half the time that it would take a pharmacist to be able to do that so it is a very useful piece of technology that we have in the hospital. and this is the only one in the entire city right? Yeah absolutely whereas SBH IV room is probably one of the only rooms you’ll ever see that in as to date to what I know at least when the only Hospital in the area that has it.

Okay well on that note I want to thank you Dr Rampersaud for joining us today on SBH Bronx Health Talk.

Thank you

For more information on services available at SBH Health System visit and thank you for joining us.

Thank you Steve for having me I really appreciated it and you know physicians you know nurses anyone that needs any type of help or any additional services please reach out to me find me in the pharmacy department and you all pretty much have my number it’s everywhere so I encourage you all to consult me .

Okay well thank you again and thank you for joining us until next time.