I review several dozen medication lists each week. I do so in my office visits as well as prior to performing procedures. This routine task is not always as easy it seems. One would think that this would be a breeze in the era of the electronic medical record (EMR). But it’s not. On a regular basis there are inaccuracies riddled throughout the list. There may be medicines listed that the patient is no longer taking. More challenging, there may be medicines being taken that do not appear on the list. Many patients are on more than a dozen medicines. Medication dosages often change and I often have to hope that the recorded dosages are accurate. And, as every physician knows, patients are often unaware of the purpose or doses of some of their medicines.
I regularly query patients if they are taking a particular
medicine on the list and often they simply do not know.
The medical profession has made progress is closing these
gaps. For example, when patients are
discharged from the hospital, the care team engages in a process called medical
reconciliation when a final and accurate list of discharge medicines and dosages are
recorded and reviewed with the patient.
Gastroenterologists like me are always interested if
a patient is taking a blood thinner. When
I formerly cared for hospitalized patients with internal bleeding, often it was
this class of medicines that caused the hemorrhage. As expected, thin blood can lead to unwanted internal bleeding.
Gastroenterologists are keenly interested when a patient who will be undergoing a procedure such as a colonoscopy or surgery is taking a blood thinner. In most cases, these medicines are temporarily held prior to a procedure in order to minimize the risk of a bleeding complication after removing colon polyps, for example. Holding a blood thinner, however, should not be casually undertaken. Patients are on blood thinners for good reasons. If the purpose of the blood thinner is to reduce the risk of a stroke, then holding the medicine would involve some risk. In these situations, it is important for the medical team to collaborate so that the patient can be maximally protected from harm. A decision to hold a blood thinner requires a risk/benefit analysis and discussion.
When I schedule a procedure on a patient I am seeing in my office whose blood thinner
will be held for a number of days in
advance, I inform the patient that on procedure day, my nurses and I will ask
precisely when the blood thinner was stopped.
Despite this caveat, often patients arrive uncertain when the blood thinner was stopped This is always vexing for
us as we can’t be certain that the blood thinner has left his system. This might curtail our activities inside
the colon.
In the perfect world, which is not the planet we inhabit, every patient
would carry with him an accurate and updated medication list. Wasn't the EMR supposed to be the fix? Yet another promise that the EMR zealots failed to keep.
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On a previous visit when the patient brings all their meds, simply mark their prescription bottle with a big red mark (maybe something resembling a blood droplet) & tell them that med bottle is the one with their blood thinner and it is the drug they are supposed to stop prior to surgery. Many patient not only font know which medication dies what, they are reluctant to admit that. Even of a patient confidently claims to know which drug is their blood thinner, you have no way to confirm their statement.
ReplyDeleteAnd telling them what to do on a visit weeks before a procedure is often unhelpful, as is advice to stop a medications x number of days before a procedure.
Murphy's law definitely applies!
Make things easy for the patient by making them simple. Mark the bottle of anticoagulants with a red droplet. Tell them "Your procedure is Sept 19th. Take this drug Sept 13th and then don't take any more until I advise you, which will be after your procedure". Giving specific instructions with specific dates always works better.
Of your patient is a male, make sure his wife/daughter/mother or some female is also listening. My experience with males is that information goes in one ear & immediately out the other because they just don't want to be there.