Reconciliation:Prescriptions and PatientsA presentationby Regina Holliday
What a case study does not show: The Holliday Family Christmas 2007
Where did ourstorybegin?Fred Holliday suffered at home fromJanuary to March 2009.We purchased medicationsfrom this CVSor were given samples by Fred’s doctor.For pain:Heating Pad, Heat Packets, Bengay,Tylenol, Advil, Hydrocodone-apap 5-500,Naproxen Sodium and UltramERMuscle relaxants:Skelaxin and CyclobenzaprineHigh Blood Pressure: Atacand HCT32Indigestion: AcipHex-rabeprazoleLaxatives: Senna, Miralax, Maalox and Dulcolax
On Friday March 13th, we went to the ER because Fred was in so much pain .We waited three hours before being sent homewith a prescription for more pain medication.
Hospital 1:Fred was hospitalized on March 25th2009for the administration of tests. We did not know all the medicines he was taking. I put them in a bag and brought them to the hospital. The nurse left them in Fred’s room. On March 27th, he was told while alone that he had “tumors and growths’ throughout his abdomen and kidneys. He was told all alone in a room with 44 tablets of opioid painkillers.
This is my husband’s medical record.I was told it would cost73 Cents per pageand we would have to wait 21 days to get a copy.This document included all the things we needed tohelp him including the MAR(Medical Administration Record).
Throughout my husband’s stay he had a lidocaine patch.Although he was supposed to have 12 hours on and 12 hours off, this did not happen.The medication reconciliation report specifies that there were not sufficient breaks.The patches were also frequently left without a marking for date and time. Upon transfer to anew hospital the lidocaine patch Fred wore was unmarked and the transfer nurse remarkedupon the error.The patches were also disposed of inan open trash can although theMedical Reconciliation Report specifies:“Should be disposed of in such a ways toprevent access by children or pets.”My three year old and ten year old wereoften in the same room with patchesin open view in the trash.
Hospital 2:After waiting for 5 days for a transferto another hospital for a second opinion,We were sent with an out of dateand incomplete medical recordand transfer summary.The new staff spent 6 hours trying tocobble together a current medical recordUsing a telephone and a fax machine.
This is thevital clinical informationfrom Fred’s electronic medical record.Presented in the style ofthe Nutrition Facts Label.Then painted on the wall ofPumpernickel’s Deli inWashington, DC.
What about the chemotherapy?We were told an order for Sutent had been placed.It did not come. The hospital pharmacy kicked out the orderas it was too expensive.I would have to order it from a specialty pharmacy and havedelivered to our apartment.This painting is “Sutentin a Shadow Box.”It is a mixed media piece of pills & paper.It is priced at cost in homage of theretail price of the pills alone.17 pills $24,285.71
The Inpatient Rehab CenterFred was sent to rehab to try to walk again.I was told I would need pharmacy approvalto give him his new chemotherapy drug.I waited three hours for the pharmacist to come toFred’s room, then I went search of the pharmacy.It was in a quiet hallway on a lower level, the doorwas closed with no window or buzzer.I knocked. The pharmacist was very surprisedto see a patient caregiver.She wrote out the permission slip.We talked. Her son also had Autismand later that week I would help her with herson’s IEP.
Hospital 3.We were transferred for a blood transfusion.I asked for a copy of the MAR as I was veryexperienced with medication errors during transfer.I was secretly given a copy by the nurse.By the time Fred was admitted to the floor therewere errors in the MAR that were rectifiedby my copy.
Inpatient HospiceWe were in hospice for about 3 weeks,then we were being transferred home.I asked for a copy of the MAR to help giveFred his medicines.The nurse said she wasn’t supposed to do that.She did any way.
Home HospiceThe home hospice nurse explainedFred’s list of medicines.The she gave me the“Hospice Comfort Pack.”She told me to place it in my fridge.I said would not do that with youngchildren at home. Did it really needrefrigeration?“No, she said. “That is just where we tellpeople to place it.”
The Last InstructionsOn June 16th the nurse wrote this medication note and I taped it to my kitchen cabinet.Fred died the next day.The note still hangs from the cabinet door 3 years later.
This is the CVS where are story began.I still get coupons for Laxatives.Facing the CVS is the painting73 Cents.Our story is the last thing a CVS customerSees as they leave the lot clutching theirPharmacy bag.
True reconciliation does not consistin merely forgetting the past.-Nelson MandelaThere are speakers here today who will explain how toprevent healthcare harm through better reconciliation.I am here to tell you why.Do not forget our story.-@ReginaHolliday