Carefully taken patient histories are vital in helping recognise medicine-related harm.

Transitions of care on admission to hospital and between clinical areas are risk points for medicine errors, particularly drug omission.¹

Patients who arrive at a hospital may be unconscious from an emergency event, delirious, or have dementia or another condition that affects their cognition. 

They can be admitted to a ward without their usual medicines, if presenting after an emergency event, or have multiple bags of their usual medicines. Frequently, they have non-prescription medicines purchased from a pharmacy or supermarket that are not presented during admission, or that family may bring in later. 

On occasions, patients can become confused about what medicines they are taking, which is where liaison with the patient’s general practitioner (GP) and community pharmacy can be crucial. 

Some instances demonstrate where a pharmacist review on, or as soon as possible after, admission is vital to decipher the patient’s current medicines and to create a best-possible medication history. This process, particularly in older adults, is useful in detecting drug-related pathology or drug-drug interactions.¹ It can also help determine how medicines have been discontinued, either inadvertently or intentionally by the patient, without the prescriber’s knowledge. 

Medicine harm can be averted with pharmacist attention during medicine reconciliations, hospital reviews and conversations to double-check with patients themselves whether they: 

• are taking, vitamins or herbal supplements from the supermarket or pharmacy 
• are taking any medicines including injections, inhalers, drops or creams, or brought in a medicine list 
• can give the names of their regular pharmacy and GP. 

Then there are the less common situations for remote patients in specialist hospitals, such as the recent increase in oral cancer treatments in haematology and oncology settings (see Case study 1).² Oral treatments pose the same risks of error and toxicity as intravenous anticancer treatments.² And management at home can increase the chances of error/toxicity. This includes supportive medicines such as anti-infective prophylaxis.² Management at home can also mask self-ceasing of medicines as well as patient confusion over either medicines to be taken and/or ceased and the reasons why (see Case Study 2). 

Box 1 – Tips

AP spoke to two hospital pharmacists about detecting these anomalies.

SOPHIE HINDLEY MPS 

Haematology and Oncology Clinical Pharmacist Western Haematology and Oncology Clinics Perth, Western Australia

Case 1

Mr SJ, 58 years, has been taking idelalisib for follicular lymphoma for the past year. Other than some initial bouts of neutropenia he has been stable and responding well to treatment. 

He is currently supplied these medicines from his local pharmacy: 

• Idelalisib 150 mg bd 
• Trimethoprim/sulfamethoxazole 160 mg/800 mg bd twice a week on Mondays and Thursdays only 
• Valaciclovir 500 mg once daily.

 Mr SJ does not need to attend the clinic for any infusion treatment. 

He lives remotely and struggles to attend monthly appointments. And due to his stability on the medicines, Mr SJ’s haematologist review appointments have recently been spaced to every 3 months. He calls to request help getting another idelalisib script from his haematologist.

 A clinical review ensued including recent blood results, doctor’s clinic notes and questions about adverse effects. It emerges that Mr SJ has not been taking his trimethoprim/sulfamethoxazole and valaciclovir prophylaxis medicine. He also reveals he’s had moderate to severe diarrhoea over 2 weeks and loperamide has not helped. 

When asked, he tells me he thought the other two medicines could be ceased because he was doing well on the idelalisib and when repeats for idelalisib were dispensed at his community pharmacy, his other medicines were not mentioned, so he assumed it was ok. 

I explain, as he had forgotten what the haematologist had initially told him, that these medicines are used to prevent pneumocystis jirovecii pneumonia and cytomegalovirus infections from occurring/ reoccurring and this treatment would only cease on the haematologist’s discretion.³

Due to the new onset of diarrhoea, I organised a review of Mr SJ’s case by the haematologist. Idelalisib is known to potentially cause severe diarrhoea and colitis.^3-4 Infectious causes of the diarrhoea need to be considered and treatment interruption might be warranted.^3-4

After discussion with the haematologist it was decided to re-start anti-infective prophylactic medicines. As his non-adherence with the prophylaxis medicine was picked up, he quickly recommenced his anti-infective prophylactic medicines with nil incident. 

Screening for infective causes of the diarrhoea was carried out, and a plan for management and follow-up was made. 

TATENDA CHINOMONA MPS 

Western New South Wales Health District Virtual Clinical Pharmacist

Case 2

Ms SW, 67 years, lives with hypertension, chronic kidney disease Stage 3, chronic obstructive pulmonary disease (COPD), obstructive sleep apnoea, migraine, depression, obesity and restless legs syndrome. 

Her regular medicines on admission were: 

• temazepam 10 mg at night 
• fluticasone furoate 100 micrograms, umeclidinium 62.5 micrograms, vilanterol 25 micrograms daily 
• beclometasone 100 micrograms, formoterol 6 micrograms, glycopyrronium 10 micrograms daily 
• salbutamol 100 micrograms 2 puffs Q4H PRN
• amitriptyline 50 mg at night
• irbesartan 300 mg daily 
• pantoprazole 40 mg daily 
• paracetamol 1 g PRN. 

Ms SW lives in a rural town in western New South Wales, which has a hospital but no on-site hospital pharmacist. She was admitted to this local hospital with an exacerbation of her COPD. On admission, the patient was reviewed via video conference by me, a virtual clinical pharmacist, and a best-possible medication history was taken.

 During the interview Ms SW reported taking three puffers at home – fluticasone furoate with umeclidinium and vilanterol, beclometasone with formoterol and glycopyrronium, and salbutamol. 

A review of the electronic medical record revealed Ms SW had recently been reviewed by a respiratory physician as an outpatient with instructions to cease fluticasone furoate with umeclidinium and vilanterol due to insufficient inspiratory capacity, and initiate beclometasone with formoterol and glycopyrronium. 

Unfortunately, Ms SW had not understood these instructions, continued both and subsequently both had been charted on her admission to hospital. 

During the interview Ms SW also reported she had recently self-ceased felodipine 5 mg MR and furosemide 40 mg due to frequent bathroom visits. The increased fluid load was thought to also be contributing to her shortness of breath. 

I followed-up the issues identified with a Medication Management Plan and had a discussion with the Local Medical Officer covering the facility. 

Fluticasone furoate with umeclidinium and vilanterol was ceased and beclomethasone with formoterol and glycopyrronium was continued. Felodipine and furosemide were restarted. 

I provided counselling to Ms SW on the use of only one preventative puffer and the indication for felodipine and furosemide and how ceasing these may have contributed to her admission. 

She was encouraged to speak with her community pharmacist and GP in future before making any medicine changes herself. Ms SW was given a patient-friendly medication list on discharge.

References

1. Mazjar F, Haider N, Al-Osaimi YA, et al. Prevention of medication errors at hospital admission: a single-centre experience in elderly admitted to internal medicine. Int J Clin Pharm 2018;40(6):1601–13.
2. Cancer Therapy Medication Safety Working Group. COSA guidelines for the safe prescribing, dispensing and administration of systemic cancer therapy. Sydney: Clinical Oncology Society of Australia.
3. Gopal AK, Kahl BS, de Vos S, et al. PI3Kδ inhibition by idelalisib in patients with relapsed indolent lymphoma. N Engl J Med 2014;370(11):1008-18.
4. National Comprehensive Cancer Network. Prevention and Treatment of Cancer-Related Infections. [Updated 2022 Aug 19].