Pharmacists are sometimes accused of "not coming out from behind the counter" while advocating for patients, not necessarily viewing all issues from the patient's perspective. Hopefully, what you are about to read will resonate new approaches for developing teamwork and improvement.

This (unfortunately real) story is about a resident of a long-term care (LTC) dementia unit where pharmacists are not on site, but where consultant pharmacists provide input and a pharmacy corporation provides medications. For any healthcare professionals reading this, imagine you are Mrs. T the resident or the family member involved, attempting to protect your loved one.

An elderly widow, Mrs. T, had been through a difficult period while in another LTC unit. Over several weeks, she had been prescribed multiple antibiotics, anti-anxiety medications and oral steroids for an undiagnosed respiratory illness.

Her behavior became more and more erratic, and nurses complained that she was increasingly demanding and complaining, motivating the medical director to increase her doses of the various meds. The family caregiver, not comfortable with conversations with the physician, became concerned that the medications were not helping and not appropriate.

The family member took Mrs. T to the local hospital where she was immediately diagnosed with drug-induced delirium — an unfortunate, often-missed diagnosis that is frequently the consequence of excessive drug combinations. For the next 10 days, as an inpatient, she was taken off of as many medications as possible. Mrs. T was left with residual brain damage, creating the need to be placed in the LTC dementia unit upon her release from the hospital.

The first few days at the new location were especially difficult for all involved — new surroundings, new medical issues and a new medical staff and physician, not knowing what was usual or unusual for the patient. Family members attempted to keep track of how things were going. They felt fortunate just to have a place for Mrs. T, even though the unit was not highly rated by CMS/Medicare.

The family had hand-carried the discharge orders and prescriptions into the facility, feeling this would simplify the transition. Several family members are healthcare professionals and expressed concern that Mrs. T not be given new medications unless absolutely necessary while recovering from this bout — leaving word for the new physician, who was off-site and too busy to speak with them.

For days, Mrs. T struggled with getting oriented, learning new routines and trying to compensate with the new deficiencies created by the brain damage. She was seen by the nurse practitioner from the facility's physician practice. Family members left written concerns about medication-related issues attached to the chart, but the physician never stopped in to see Mrs. T.

The family became more concerned when Mrs. T fell, spraining her wrist. When they looked Mrs. T over several hours later, the family could not understand why she had purple bruises all over her abdomen and significant bruising, not just where she had fallen. The staff had not mentioned noticing bruising previously.

The family took some initiative, asking to see the medication administration record, checking it against hospital discharge orders. They found that Mrs. T had received 40 doses of heparin, not prescribed to her, over the course of the first 10 days in this unit. A medication order had somehow been created by mistake, and the new physician had signed off, even without seeing Mrs. T. The abdominal bruising appeared to be where the injection sites were located.

Discussions and anger ensued. How could this happen? Why was it the family identified the error and not the staff? Why hadn't the doctor come in before then to evaluate the patient? What happened to create the medication-related errors? How would the facility protect Mrs. T from here out?

The facility determined the nurse who initially electronically inputted the orders had not been double-checked by another nurse, as no policy specifically required reverification. The family was assured that things would change, focusing nurses on reverifying order entry with one another.

Fast forward more than a year later yes, the patient is still at this facility. The sad reality is there are few dementia units in the area, and the family has not been able to find more highly rated facility able to take Mrs. T.

Shortly after the heparin incident, the family found a new primary care geriatrician for Mrs. T. Also new to the facility, he has been amazingly helpful and competent, an excellent advocate.

The family tries to consistently monitor Mrs. T's care. But, in the past year and a half, evidence of nearly 100 other medication-related errors has accumulated. These are just the ones the family knows about. Errors have included:

  • other patients' entire batch of prescriptions being found in Mrs. T's walker seat on numerous occasions
  • drugs not being given at appropriate times in appropriate amounts (even controlled substances)
  • drugs being discontinued when the doctor's order stated to continue the treatment indefinitely
  • Mrs. T being given drugs in excess, to duplicate orders for the same drug to be given in two different ways
  • not providing adequately identified, accurately labeled medications for a short-term leave, as no specific policy existed
  • pharmacy providing incorrect amounts of medications in inappropriate containers

The family identified their concerns each time a problem was found and spoke with an often-changing administration. Nearly a half-dozen new nursing directors in a year and a half and different administrators reduced continuity of purpose.

Promises that had been made after the heparin incident may never have been followed in a systematic way. Little was being done in the way of improvement, with little daily operational oversight by accrediting agencies. What often goes unreported, remains unnoticed.

And so we come to the point of all of this do we as pharmacists always know the reality from the patient's perspective? Do we ever contribute to the problems, by not going over and above to ask questions, or educate the staff or corporate clients, even those health professionals in another discipline, or step up to recommend systematic improvements when we bump into things that just don't look right?

Yes, the authorities have been called into this facility. Management repeatedly says they did not understand the seriousness of these issues. And truly it appears the administration still does not grasp the serious nature of the risks associated with the many different aspects surrounding the errors.

The parent company does not seem to be tuned into the crises of this location, perhaps because they have similar situations in other locations. On-site management has not rushed to show continuous assessment of the quality issues. That is not a good excuse, and we all know that.

They have many problems dragging down the daily facility operations. Problems include an often low-quality staff, and not surprisingly, high turnover. The parent corporation, not rated high in quality measures, does not condone individual locations, making upgrades or changes to corporate policies.

Staffers feel they will be penalized for reporting errors. With perception being reality, staff does not report leading to less information for making improvements. The mix is a perfect storm, creating numerous unnecessary opportunities for significant adverse events.

Medication errors are quite common in long-term care facilities. They are often responsible for preventable injury. LTC lags significantly in newer health information technology, in decision support methods and built-in medication error detection methods, leading to an increased need to understand and prevent errors that do occur.

In LTC, as in acute care, repeat medication errors are defined as those that have identical patient characteristics, drugs or type of drug involved, error type, potential causes, personnel involvement and point of reference in the medication care process. A recent LTC study show these errors occur 38 percent of the time and are repeated one or more times. Wrong doses and wrong administration are the most commonly repeated events.

Generally speaking, errors can be reduced just by adopting better methods of oversight. For example, nurses should reverify other nurses' orders, by actually looking at the initial physician order instead of depending on what may be verbalized between the two. Nurses must not be afraid to report actual errors or even near misses.

Supporting the no-fault concepts and pushing for greater ease of error reporting can be a major step forward. Educating staff on the "whys" of doing things a certain way is helpful. If they can visualize the reason something is being done using a specific technique, it can make it easier to incorporate into their daily routine. Avoiding verbal orders, except in emergencies, and asking physicians to indicate the purpose for each medication as written on the prescription protects the patient.

Mrs. T has had some horrible luck in both places. The first facility's lack of adequate medical care and competence caused a common, serious adverse event that changed Mrs. T’s life.

Unnecessary severity of illness, economic hardship with hospitalization and residual brain damage are just some of the burdens. And now, Mrs. T continues to be at higher risk than anyone should have to experience until the facility can be brought up in overall quality. And even in other LTC locations where a higher level of quality is the norm, every patient is at some risk.

The question remains, how much risk is acceptable? LTC regulations allow 5 percent medication error rates as the standard of care. But if adequate reporting of errors is not occurring, precise figures cannot be calculated.

And sadly, Mrs. T is in a facility where employees continue not to embrace the concept of the "patient being first." It is remarkable that she has not been more seriously harmed — but the errors have taken a huge toll on her and her family.

All of us, whether nurse, pharmacist or physician should always be the patient's advocate. Verifying accuracy of orders, questioning anything that does not look right, and using extra caution with high-risk medications build a stronger system.

If a policy is not adequately protecting patients or is not followed by staff, and therefore is not being helpful, revise or eliminate it. Reworking procedures that do not work makes for a better overall strategy. Saving patients from adverse events, while allowing them the best possible care, is a beautiful thing.

Staff needs to be tuned into how to avoid excess risks they need to walk in Mrs. T's shoes for a few minutes. Each healthcare professional can grow and support a philosophy that includes accurate medication error reporting and follow-through.

Push for a programmatic change in your corporation if staff is not being applauded for bringing concerns to the attention of quality assurance. A first step can be creating a "compliment-concern" suggestion box, allowing anonymous contributions.

Mrs. T and others depend on us to provide her protection that is consistent, thorough and as fail-safe as possible. No one should have to experience more than 100 medication-related errors. And what about the other patients in that facility? Who will advocate for them and others like them?