Reconciliation:Prescriptions and Patients

A presentation by Regina Holliday

What a case study does not show:

The Holliday Family Christmas 2007

Where did our story begin? Fred Holliday suffered at home fromJanuary to March 2009.

We purchased medications from this CVS or were given samples by Fred’s doctor.

For pain: Heating Pad, Heat Packets, Bengay, Tylenol, Advil, Hydrocodone-apap 5-500, Naproxen Sodium and Ultram ER

Muscle relaxants:Skelaxin and Cyclobenzaprine

High Blood Pressure: Atacand HCT32

Indigestion: AcipHex-rabeprazole

Laxatives: 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 25th 2009 for 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 cost

73 Cents per page

and we would have to wait 21 days to get a copy.This document included all the things we needed to help 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 a new hospital the lidocaine patch Fred wore was unmarked and the transfer nurse remarked upon the error.

The patches were also disposed of in

an open trash can although the Medical Reconciliation Report specifies: “Should be disposed of in such a ways to prevent access by children or pets.”

My three year old and ten year old were often in the same room with patches in open view in the trash.

“Go After Them, Regina.” April 18, 2009

Hospital 2:

After waiting for 5 days for a transfer

to another hospital for a second opinion,

We were sent with an out of date and incomplete medical record and transfer summary.

The new staff spent 6 hours trying to

cobble together a current medical record Using a telephone and a fax machine.

This is the

vital clinical informationfrom Fred’s electronic medical record.

Presented in the style of the Nutrition Facts Label.

Then painted on the wall ofPumpernickel’s Deli in Washington, 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 have delivered to our apartment.

This painting is “Sutent in a Shadow Box.”

It is a mixed media piece of pills & paper.It is priced at cost in homage of the retail 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 to Fred’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 Autism and later that week I would help her with her son’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 there were errors in the MAR that were rectified by 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 give Fred his medicines.

The nurse said she wasn’t supposed to do that.

She did any way.

Home HospiceThe home hospice nurse explained Fred’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 young children at home. Did it really need refrigeration?

“No, she said. “That is just where we tell people 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 painting

73 Cents.Our story is the last thing a CVS customerSees as they leave the lot clutching their Pharmacy bag.

True reconciliation does not consist in merely forgetting the past.-Nelson Mandela

There are speakers here today who will explain how to prevent healthcare harm through better reconciliation.

I am here to tell you why.

Do not forget our story.

-@ReginaHolliday