Poor communication on patients’ medication across health care levels leads to potentially harmful medication errors

Figures & data

Figure 1. Frame: Definition and categorizing of medication error.

Table I. Characteristics of the 30 emergency patients admitted to the medical ward of Innlandet Hospital Trust Gjøvik, Norway, included in the study.

Sex	Female 12, male 18
Age	44–94 years, median 78.5
Admitted from	GP 19, municipal emergency 9, direct with ambulance 2
Diagnoses	Infectious disease 10, heart disease 9, stroke 4, lung disease 6, abdominal disease 3
Days in hospital	1–16, median 4
Number of drugs on admission	4–15, median 8
Number of medication changes in hospital	0–8, median 2
Number of drugs at discharge	4–15, median 9

Table II. Total number of errors according to NCC MERP Index for Categorizing Medication Errors.¹

	NCC MERP Index for categorizing Medication Errors
	B	C	D	E	F
Admittance:	n = 2	n = 9	n = 2	n = 8	n = 4
Errors in ML in RL compared with ADT	insulin no dose travoprost eye drops missing	glucosamine 400 mg × 3 was discontinued phenylpropanolamine 50 mg × 3 missing acetylcystein 500 mg × 2–3 missing penicillin v missing hydroxyzine missing escitalopram was discontinued diazepam 5 mg × 1 missing zopiclone 7.5 mg missing	paroxetine too high dose prednisolone 5 mg missing	acetylsalicylic acid 75 mg × 1 was discontinued trimethoprim 100 mg × 1 missing nabumetone 1000 mg × 1 was discontinued amlodipine too high dose gabapantin 300 mg × 3 was discontinued sotalol too high dose triotropium bromide 18 missing salmeterol/fluticasone 50/500 × 2 missing	ibuprofen 400 mg × 1–2 missing digitoxin too high dose
					spironolactone too high dose
					furosemide too high dose
Curve:	n = 1	n = 15 (8 from RL)	n = 1 (paroxetin from RL)	n = 16 (7 from RL)	n = 1 (ibuprofen from RL)
Errors in ML in curve compared with ADT	salmeterol/fluticasone inhal. No dose	oxazepam 10 mg missing paracetamol 1 g × 4 missing pantoprazole was discontinued diclofenac 50 mg × 0–3 missing calcium 500 mg × 1 missing prednisolone 10 mg too low dose		calcium 500 mg × 2 was discontinued gabapentin 300 mg × 3 missing lercanidipine 5 mg × 1 was discontinued metoprolol 25 mg too high dose montelukast 10 mg × 1 missing
Discharge:			n = 1	n = 6
Errors in ML in DL			budesonide depot too high dose	diazepam 5 mg × 3 not continued
				haloperidol 1 mg × 2 not continued
				metformin 500 mg 2 + 1 + 2 missing
				insulin dose reduced but not written
				amlodipine/valsartan/hydrochlorthiazide 5/160/12.5 missing
				salmeterol/fluticasone 50/500 × 2 inhal. missing

Notes: ¹A–D no harm, E–I with harm. Drugs in same category are only written once. Total number of errors in the curve includes the errors coming from referral letter. Total of 30 emergency patients admitted to the medical ward of Innlandet Hospital Trust Gjøvik, Norway. There were no errors in categories A, G, H, or I. See the NCC MERP frame for detailed information. ML = medication list; RL = referral letter; ADT = actual drug taken.

Box I. Patient number 2.

88-year-old woman with heart failure, living at home, home care services 1 hour/week. Ten regular drugs, medication in dosette. Eleven days in hospital for acute urinary tract infection.

• Submitted by her GP.

• Several errors in medication list (ML) in the referral letter.

• This ML is used as information for ML in the medical curve.

• She also brings a correct ML from home care services. This ML was not used for information in hospital.

The ML in referral letter is missing trimethoprim 100 mg, phenylpropanolamine 50 mg × 3 and zopiclone 7.5 mg. It says wrongly that she takes acetylsalicylic acid 75 mg and glucosamine 400 mg × 3. These were discontinued some time ago.

Acetylsalicylic acid may harm her because she has a hiatus hernia (category E). Missing trimethoprim 100 mg given prophylactically for chronic urinary tract infection may worsen this problem (category E). It is also important to recognize a sleeping problem in old people admitted to hospital (category C). Glucosamine was discontinued again in hospital.

After 6 weeks the GP had no objections to the ML in discharge letter except to discontinue haloperidol 0.5 mg x 2 that was started in hospital.

Box II. Patient number 8.

86-year-old man with atrial fibrillation and heart failure. Living alone with responsibility for the medication himself. Using 14 regular drugs.

He stayed in hospital for five days for treatment of heart failure.

• Submitted by a GP at the out-of-hours municipal emergency unit.

• The GP found a medication list (ML) in his file there and let it follow the referral letter.

• The patient stated this to be the true medication. In the interview he added acetylcystein 500 mg × 2 (category C).

• This ML was used for the medical curve, but 2 of the drugs in the list were not transferred onto the curve: doxazosin 4 mg (category E) and montelukast 10 mg (category E).

Montelukast and acetylcystein were reinforced during the time in hospital and doxazosin was continued by the GP after five weeks.

The information on medication at referral was close to correct, but two important drugs were not transferred to the medical curve on admission.

To omit these three forgotten medications might have worsened the patient's condition, but he was able to see to it being corrected.

Box III. Patient number 21.

78-year-old man, with COPD and rheumatoid arthritis. Living and managing alone. Nine regular drugs, uses a dosette. Stays three days in hospital for treatment of pneumonia.

• Submitted by his GP's locum.

• Medication list (ML) in the referral letter is taken from GP's file.

• The patient stated this to be correct except for prednisolone 5 mg missing (category D).

• In hospital his previous hospital file is used for information even if there is a close to correct ML in referral letter.

Lercanidipine 5 mg (category E) and pantoprazole 20 mg (category C) had been discontinued some time before admission, Lercanidipine because of hypotension and pantoprazole because of dyspepsia. Both drugs were given during hospital stay. Lercanidipine was discontinued at discharge due to hypotension.

The information on medication at referral was close to correct, but was not used.

Ipratropium bromide inhalation (category E) and zopiclone (category C) are missing during hospitalization but were reinforced by the GP at the first consultation.