Patient Danger Zone: Hospital Discharge

As a nurse myself, I have to say that reading this post troubles me. First and foremost being the outcome of the patient was death which is very sad for the victim's family that they have lost a loved one over a medication error. This was never the intent of the nurse and I'm sure was never the intent of the pharmacy technician who wrote down the wrong medication. In saying that I do believe it is the responsibility of the nurse to go through the patient's medications upon admission to the home health agency. The nurse is to assess the drug in it's entirety and go through the five rights- which is a very basic nursing practice- right patient, right drug, right dose, right time, and right route. It is the nurse's responsibility to inform the patient of the harmful side effects of the drug. Those steps I believe were never completed or else the catch would have been made by the admitting home health nurse that the drug dispensed by the pharmacy was methotrexate and not metolazone, which was the correct drug. It is, however, outside of a nurse's practice to track harmful drug interactions unless there is a computer system that would alert the nurse of such interaction. It is of utmost importance that the pharmacy do this because they have the endless drug database that would be able to detect even the most subtle of interactions and provide the patient and/or patient's representative with such crucial information. Patient safety is of utmost importance when providing patient care. We as health professionals need to be diligent in all we do so that errors like this one may be avoided at all costs. There is such a phenomenon known as the "Swiss cheese effect". This phenomenon proposes that if you have holes in a system, and they all line up back to back then you have a breakdown in the system that no one was able to detect and/or stop. Unfortunately sometimes the consequences are as devastating as death. I can only hope we may learn from our mistakes so that errors like this occur much less frequently if ever.

It MUST be a team approach ie: Physician, Pharmacy, Nurse & HHA. Patient/family must question the who, what, when, where why & how for EACH treatment and medication...upon admission, during stay, day of discharge & post discharge>medication reconciliation! At the educational level the patient/family can understand & in their native language. Basic safety 101.

The problem is not only at discharge, but also on admission. While I agree with the article, there also needs to be an analysis of the admission process.

It is interesting how this article points to home heath by stating "...such errors are frequently missed by home health agencies." How about the discharging facility - the nurses, physicians and pharmacists? They have the responsibility to discharge the patient with the right medications and instructions. They are more liable than the accepting HH agency.