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