As a practitioner at Yale-New Haven Hospital, Dr. Leora Horwitz has seen her share of patients who misunderstand medication changes made during their hospital stays.
Just recently, one of her female patients, who was switched to a new beta blocker for high blood pressure during an inpatient stay, landed back in the hospital after discharge because she had taken both the new medication and her old beta blocker – a combination that lowered her heart rate and blood pressure to dangerous levels.
“Every physician can tell you about these kinds of errors,” Horwitz said. “We do a relatively poor job of educating patients about their medications.”
As a researcher, Horwitz can now quantify those lapses. A recent study she led looked at 377 patients at Yale-New Haven Hospital, ages 64 and older, who had been admitted with heart failure, acute coronary syndrome or pneumonia, then discharged to home. Of that group, 307 patients – or 81 percent -- either experienced a provider error in their discharge medications or had no understanding of at least one intended medication change.
The findings that three out of four patients are going home with the wrong prescriptions or a lack of knowledge about their medications come as hospitals grapple with high readmission rates, and as adverse drug reactions post-discharge are exceedingly common.
“We’re talking about the vast majority of our patients going home at potential risk” of medication problems, Horwitz said. “That’s huge. Collectively, something is not right."
The Yale study relied on interviews with patients after discharge, who were asked about their medication regimen. The researchers also reviewed patients’ admission and discharge medication records to see if all changes were intentional, or if any appeared to be errors. A total of 565 admission medications were re-dosed or stopped at discharge.
In all, the study found that 24 percent of the medication changes were due to provider error. In addition, the average patient had no understanding of 60 percent of all stopped, re-dosed and new medications. Errors and misunderstanding were more common for medications not related to the patient’s primary diagnosis than for those related to the main ailment being treated.
Horwitz said the findings highlight two key gaps – one a “systems” problem, the other an education problem. The electronic medical records system used at Yale and other hospitals makes it hard to track and reconcile medication changes, and discharge lists don’t flag which prescriptions are new and which have been stopped. Patients at many hospitals get a quick drug rundown from a nurse before discharge, but it’s not the kind of “teach-back” process that ensures they understand the medication list, Horwitz said.
“The solution is actually not to have a nurse sit with you for an hour and go over everything - it’s pretty much guaranteed that you’ll forget it by the time you get home,” she explained. “We’re talking about getting patients educated over the course of the hospital stay, in a way that assesses their understanding in real time.”
Yale-New Haven already has taken steps to improve patient education, Horwitz said, and is set to launch a new electronic records system in February that will allow for detailed medication tracking. Those changes are part of the hospital’s larger effort to cut down on patient readmissions—a factor that the federal government is now closely tracking.
Starting in October, new federal rules allow the government to cut Medicare funding to hospitals with high rates of patients who are readmitted within 30 days of a hospital stay for three conditions: pneumonia, heart attacks and heart failure. In Connecticut, 23 of the state’s 31 hospitals, including Yale-New Haven, are among more than 2,200 nationwide that face Medicare penalties this year for high readmissions.
Readmissions are counted no matter why the patient returns within 30 days – meaning, for example, that a hospital would be penalized if a pneumonia patient returns with unrelated kidney problems.
Horwitz said the study’s finding that errors are more common for drugs not related to the primary ailment causing the hospitalization underscores the need for clinicians to pay close attention to patient’s chronic and secondary illnesses.
“Most patients who get readmitted to the hospital are coming back for other problems,” she said. “Very often, we do a good job managing medications for the reason they’re in the hospital -- what we do badly is managing the other stuff the patient was taking. . . We make mistakes in chronic disease management.”
Hospitals are trying a number of new measures to reduce readmissions, many of them related to better-equipping patients for the transition home. Yale-New Haven and its affiliated Hospital of St. Raphael have joined with the Agency on Aging of South Central Connecticut to have special care transition teams work with Medicare patients after discharge.
Nine other Connecticut hospitals are participating in a federally funded “ComPass2C” program, run by Connecticut Community Care, Inc., of Bristol, which assigns nurses and transition counselors to work with Medicare patients on managing their discharge care, through in-hospital coaching and follow-up home contact.
Dan Flynn, co-director of the program, said medication management is a “core piece” of the hospital-to-home intervention. Medication discrepancies were a key problem in a pilot program run by Connecticut Community Care at the Hospital of Central Connecticut, he said.
“The most prevalent issue at the patient level was non-intentional non-adherence” to a medication regimen, Flynn said, meaning patients wouldn’t know what drugs they were supposed to be taking. Many discharged patients lacked sufficient instructions on medications, he said.
While Connecticut Community Care provides the staff to serve as the “additional professional link” between hospitals and community care, Flynn said, the program’s goal is to educate and empower patients about their own medication needs, health status and health care scheduling.
“The goal is that patients will have their medication information in hand,” not only post-discharge but for subsequent hospitalizations or in other health care settings, he said.
The nine participating hospitals, in eastern and north central Connecticut, are: Bristol Hospital, Hartford Hospital, John Dempsey Hospital, Lawrence & Memorial Hospital, MidState Medical Center, Saint Francis Hospital & Medical Center, the Hospital of Central Connecticut, William W. Backus Hospital and Windham Hospital.