Mr. W had a heart attack and was in the ICU last week.  While reviewing his discharge medication list, you realize Mr. W unintentionally discontinued his medication for hypertension and dyslipidemia.  Unfortunately, these medications were not on the discharge medication list.  

Jay has been a well controlled diabetic for many years.  Today his A1C is 10.5.  He insists he is taking his medication regularly.  

A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. ¹   Efforts to decrease or prevent medication errors often focus on improving systems and procedures utilized by nurses, physicians and pharmacists during the multistep process of medication administration.  Decreasing medication errors by patients must also be addressed.  

According to the landmark 2006 report "Preventing Medication Errors" from the Institute of Medicine, medication errors injure 1.5 million Americans each year and cost 3.5 billion in lost productivity, wages and additional medical expenses.^​2 1/3 of medication errors occur in outpatient settings.  Patients often unintentionally discontinue medications after a hospitalization or transfer of care.  Numerous studies have shown that patients with chronic conditions adhere only to 50% to 60% of medications as prescribed despite evidence that medical therapy prevents death and improves quality of life.³   Knowledge deficits and poor understanding of drug label directions often result in medication errors initiated by patients. 

How to reduce medication errors by patients:

1. Decrease medication knowledge deficits.  Review with patients in plain language what medications were prescribed, how to take them, discuss side effects and address concerns regarding drug interactions and cost.  Use visuals and show me techniques to ensure patient understanding.  Enlist the help of the PCP and pharmacist for additional education.
2. 2.   An accurate medication list that includes discharge medications and/or chronic care medications is essential.  Learn how to take an accurate medication history.    Use clear communication techniques during conversations with patients.  Provide patient and PCP with discharge medication list.   
3. Monitor for medication adherence.  Ask patients to bring in all of their medications or contact pharmacies for information on most recent refill dates.  Evaluate and address medication knowledge deficits.  Medication reminders, automatic med refills, medication home delivery, assistance of family members or home care services can be utilized to improve adherence.  Call recently discharged patients to ensure they are taking prescribed medications and chronic care medications. 

Stephanie Wilborne, APRN

HealthLit.com:  Clear & Simple Patient Education/ Tools for Chronic Disease Management

¹ National Coordinating Council for Medication Error Reporting and Prevention: http://www.nccmerp.org/aboutMedErrors.html

²Anderson, Pamela, and Terri Townsend. "Medication errors: Don't let them happen to you." American Nurse Today 5.3 (2010): 23-27: http://www.nursingworld.org/mods/mod494/MedErrors.pdf

³ Bosworth, Hayden, Bradi Granger, Stephen Kimmel, Larry Liu, John Musaus, William Shrank, Elizabeth Buono, Karen Weiss, Christopher Granger, Phill Mendys, Ralph Brindis, Rebecca Burkholder, Susan Czajkowski, Jodi Daniel, Inger Ekman, Michael Ho, and Mimi Johnson. "Medication adherence: A call for action." American Heart Journal 162.3 (2011): 412-424. Print.

⁴ Preventing Medication Errors: Quality Chasm Series Committee on Identifying and Preventing Medication Errors, Philip Aspden, Julie Wolcott, J. Lyle Bootman, Linda R. Cronenwett, Editors