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When communication is unclear, things go wrong for patients

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This is a slightly unusual patient story in that it isn’t about a patient at a hospital. This story is about my granny, but I think it gives some context to processes that we follow and the documentation we should do for patients surrounding admission and discharge.

My granny is a frail 82 year old lady with dementia, complex medicines management requirements and she was taking warfarin - a high risk drug. There were several failures in my granny’s care that the pharmacy service could/should have prevented.

She was admitted to my family’s local hospital in March this year after a fall where she had hit her head. On admission she was very confused and disoriented and was diagnosed with a UTI. Pre-admission she had been self caring, managing her medication from a blister pack with daily prompting from my mum who would also put out her daily dose of warfarin for her from original packs. Unfortunately, during her stay she had 2 further falls, one with another associated head injury and was also diagnosed with postural drop resulting in two of her blood pressure medicines, bendroflumethiazide and doxazosin, being stopped.

She needed some respite care and physiotherapy to get her back to her baseline, so she was discharged to a residential care home for short term care up to 4 weeks.

I saw the copy of her TTA (to take away) form when I went to visit her with my parents and there was no documentation about any of her medicines management pre-admission. There was no mention of her blister pack, chemist details, any of the changes to medication or that she had significantly deteriorated from her base line and would need a medicines management review before being discharge home.

Neither her GP or pharmacy had been contacted about her admission and the changes to her medication and neither received a copy of this TTA. The care home also did not know how she managed her medications and had to ask my parents if she could do her medication herself or if they should administer them.

There was no documentation about the indication and duration of her warfarin, what her dose was on admission or on discharge. The only documentation was that it had been held for a few days following a fall. There was no mention of reviewing appropriateness of continuing this medication in light of her recurrent falls with head trauma or of weighing up her bleed versus clot risk. From checking her yellow book I could see she was prescribed double her usual dose for 3 days following it being stopped and she had an appointment in 2 days’ time.

This is potentially dangerous practice and unnecessary for an elderly lady with a high falls risk. The indication was atrial fibrillation and she had had an ablation. She could have had a serious bleed if she fell and hit her head again.

Within 10 days she bounced back to hospital with an unresolved UTI, where she was prescribed more antibiotics and discharged back to the care home 3 days later. Again, the GP and pharmacy were not contacted and did not receive a TTA copy associated with that admission.

She then bounced back a 3rd time 5 days later when the GP at the care home admitted her for a UTI or slight hypertension, though it’s not clear which as neither were found on admission.

This admission, her drug history was obtained from a GP fax, which was an out-of-date list of medicines as they hadn’t received any copies of any TTAs and they weren’t aware she had ever been in hospital or had any medicines changed.

My granny has dementia, was quite confused from her baseline still and was not capable of providing this information. She was admitted from a respite home who were administering her medication and had an accurate list but they were not contacted. This was also her 3rd admission in just over 3 weeks so there should have been electronic records of previous admissions or TTA documents.

This was unsafe and dangerous practice and supports why the standard of care is to use a minimum of two appropriate sources.

When my mum visited her she checked her drug chart and found that she had been prescribed doxazosin as drug history from the GP and the dose had been doubled for “slight hypertension”.

My mum told her nurse that this had been stopped on her first admission because of postural drop and the nurse was unaware of any previous admissions. It was only after my mum asked them to call the care home and confirm her medication list properly that doxazosin was stopped.

My granny was discharged to my parents’ care a week later. The only TTA both my family and the gp have received for any of her 3 admissions is for an admission from her last short admission for a diagnosis of hypertension; omitting any of the other issues experienced, including stopping warfarin at some point. There is also no pharmacy or other documentation of any of the issues that I have just talked about.

As I said, my granny is an 82 year old frail lady with dementia, complex medicines management requirements and she was prescribed a high risk drug. None of the pharmacists who checked any of her 3 TTAs documented any of the medication changes, warfarin details, medicines management or contacted her GP or community pharmacy. A pharmacist also used an out-of-date GP fax as a sole drug history source when she was admitted from a care home who were managing her medication and she was on her 3rd admission in as many weeks. They also didn’t check any previous hospital discharge letters.

The RPS standards of hospital practice and guidance following the Francis, Berwick and Keogh reports are all intended to stop these kinds of incidents happening. But only if the guidance is followed.

My granny is lucky. She has a GP, nurse and pharmacist in her immediate family. How many of your patients have that?

This case highlights the importance of clear documentation and communication on discharge, why it is essential to use at least two sources to confirm medication history in vulnerable patients plus the importance of checking for any previous electronic documents.

I hope this unfortunate scenario helps you focus on the patient as the end point and think about what can happen when processes are skipped or rushed through. 

Unfortunately, Lucy’s granny has passed away since the publication of this blog


Readers' comments (1)

  • I am truly saddened to read this account. Lack of communication and documentation is one of the most frustrating and yet avoidable aspects of healthcare and I believe there is no excuse for it. Poor (or in most cases complete lack of) communication causes hospital re-admissions and patient harm. This is not only a problem in pharmacy but across all healthcare sectors and needs to be addressed.

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