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Medications Matter — Urgent Action to Correct a Dangerous Misstep

Residential in the Real World

Residential nurse Jennifer not only helped to catch a medication error, but also intervened to stop a possible life-threatening complication.Former U.S. Surgeon General C. Everett Koop is known for saying, ‘Drugs don’t work in patients who don’t take them.’ Having to remember complicated medication instructions — sometimes for multiple drugs, possibly to treat several chronic conditions — can understandably lead to errors or missed doses. There are numerous complex reasons why people may not follow their drug regimens: perhaps they’re discouraged by an unpleasant side effect, or forget to fill or refill a prescription. Another reason may be a knowledge gap, if individuals don’t fully understand what a drug does or why it is important for their health.

This is why the process of medication reconciliation is standard procedure during the first visit with Residential Home Health. This thorough clinician assessment reviews all medications in the home, comparing them with each other and with the patient’s medication list from electronic pharmacy and health records. In order to have a successful plan of care, after a transition to home or any time, it’s important to ensure that patients are taking all the medications they should (and at the proper times and doses), and none that they shouldn’t. For Residential nurse and case manager Jennifer, a recent visit with a new patient revealed an especially dangerous medication error. Read about her urgent response, and how she helped protect her patient from possibly life-threatening consequences.

A Surprise Symptom

The patient would be receiving home health care primarily for her ovarian cancer; other areas of concern included a wound on her heel, maintenance of her central catheter, and pain and symptom management. However, when Jennifer arrived at the home to begin care, she was surprised to hear that her patient was in pain, located on the right side of her groin. This wasn’t an expected symptom based on her health situation, but rather a signal that something else was wrong.

Further examination showed swelling in the patient’s right leg, with the skin showing deep pitting and a mottled appearance. Jennifer recognized that these symptoms pointed to a possible blood clot, a complication that can lead to a dangerous health emergency or even death. The patient’s medication record showed that she should be taking an anticoagulant drug, which helps prevent blood clots from forming; however, it turned out that the order for anticoagulant had not been filled. Jennifer asked the patient about this drug, but realized that the patient had not been made aware of its importance, and so she was not aware of the omission.

Immediate Follow-Up

Without proper anticoagulant injections, Jennifer realized that a blood clot was very likely, and her patient could be in serious danger. She explained her concern so that the patient could better understand the importance of taking immediate action. Although an appointment was scheduled with the patient’s primary care physician in two days, Jennifer insisted that this wasn’t soon enough. She called the physician’s office right then and there and advocated for her patient, making sure she would be seen by the doctor right away.

Later, Jennifer received a call from the physician, thanking her for catching what turned out to be a very large blood clot in the femoral artery. Her advocacy and insistence on immediate care had saved her patient from the potential of serious harm. Since its discovery and prompt treatment, the patient’s blood clot is resolving, and the swelling has decreased. An anticoagulant was re-added to the patient’s medication regimen, and Jennifer was set to return to her home to teach her how to administer the drug.

Industry-leading medication reconciliation is a vital component of Residential Home Health’s SMART Care TransitionsSM service bundle. Click here to see how else we use timely, thorough, and cutting-edge technology to cut readmission rates for high-risk patients in half.