Dialogue Volume 12 Issue 3 2016 - Page 37

practice partner Patient Safety Medication errors at transitions a preventable cause of harm photo: istockphoto.com A ll health-care organizations are reminded to have formal medication reconciliation processes in place for times of transitions in patient care. The reminder is prompted by a review undertaken by a committee of the Chief Coroner’s office after examining the circumstances surrounding the death of a 91-year-old woman. The woman developed complications from her severe hypothyroidism after she was transferred from a long-term care home to hospital. The woman’s thyroid replacement therapy was not continued upon admission to hospital or upon return back to the long-term care home. All transfer documents indicated a diagnosis of “hypothyroidism,” but no health-care provider noticed that the patient was not receiving levothyroxine. The patient was prescribed levofloxacin orally. The woman died of congestive heart failure and aspiration pneumonia. An aggravating factor was likely her severe hypothyroidism, said the Geriatric and Long-Term Care Review Committee (GLTCRC). It is believed that proper medication reconciliation would have prevented the severe hypothyroidism that the patient experienced. The GLTCRC says that all health-care facilities should do a formal medication reconciliation at all points of patient care transition, such as admission, transfer and discharge. The medication reconciliation processes should occur according to best practices defined by the Institute for Safe Medication Practices (Canada), and Accreditation Canada. Medication errors at transitions in care have been recognized as a preventable cause of harm to patients. Medication reconciliation is the set of processes by which these errors are avoided. The Institute for Safe Medication Practices Canada has extensive information on medi- cation reconciliation in Canada, including the links to North American and World Health Organization patient safety campaigns (http://www.ismpcanada.org/medrec/). Medication reconciliation is now a “Required Organizational Practice” for health-care institutions in Canada undergoing accreditation by Accreditation Canada. But even the most robust processes will not help if they are not used, stated the Committee. “The GLTCRC was concerned that many health professionals who interacted with this patient, both in the hospital and at the longterm care home, did not seem to recognize the diagnosis of “hypothyroidism” that was written on many of her records. There is no substitute for time and attention to detail in health professionals’ practices, especially when it comes to patient safety,” it stated. The purpose of the Geriatric and Long-Term Care Review Committee is to assist the Office of the Chief Coroner in the investigation, review and development of recommendations towards the prevention of future similar deaths relating to the provision of services to elderly individuals and/or individuals receiving geriatric and/or long-term care within the province. MD Issue 3, 2016 Dialogue 37