Annals of Long Term Care

The evidence in support of medication reconciliation has increased rapidly in recent years, while the need for an improved medication-use system in the LTC setting remains. This article describes the essential elements of medication reconciliation and its application to the LTC setting. First, a case presentation depicts some of the typical clinical problems involving medications that face residents and clinicians in this setting and during transitions of care. Second, a brief literature review of medication reconciliation follows, with a special emphasis on the LTC setting. Third, a practical real-life example of adopting this service in several facilities in one state, the Nursing Home Medication Safety Project in Massachusetts, is reviewed. Finally, suggested strategies for implementation are presented, including implications for clinicians. (Annals of Long-Term Care: Clinical Care and Aging 2009;17[11]:36-40)

Clinical Scenario

Mr. H is an 88-year-old white man who lives by himself in the house he shared with his wife of over 50 years, until her death two years ago. He is generally alert and oriented and can make his immediate needs known. He is fiercely independent. Despite being forgetful and occasionally confused, Mr. H refuses to accept much help from his two sons and daughter, who live nearby. He is not fond of seeing doctors and often misses appointments. He reluctantly takes medications and may skip them for several days in a row because he feels he is taking too many pills. Mr. H’s medical problems include congestive heart failure, atrial fibrillation, hypertension, chronic obstructive pulmonary disease, degenerative joint disease, falls, dizziness, insomnia, and depression. His prescribed medications include: regularly-scheduled digoxin, warfarin, metoprolol, albuterol metered-dose inhaler, and fluoxetine, as well as trazodone as needed for sleep.

One day, Mr. H’s daughter comes to pick him up for an appointment but he does not answer the door. She finds him lying on the floor moaning. She calls 911, and he is taken to the emergency room, where he is diagnosed with a right hip fracture and mild dehydration. He is admitted and undergoes an open-reduction internal fixation procedure that night. His post-operative course is mostly uneventful, but he becomes confused on post-op day 2; he is administered haloperidol intravenously with good results. He also develops a low-grade temperature. The next day, he is discharged from the hospital and admitted to a skilled nursing facility (SNF) for rehabilitation. His discharge medications include: (1) haloperidol as needed for delirium; (2) a higher dose of digoxin, since on hospital admission, his digoxin level was < 0.1; and (3) meclizine as needed for dizziness because Mr. H’s daughter told the hospital staff about her father having been lightheaded at home prior to his admission.

Mr. H arrives on the subacute unit at the nursing home at 5:00 PM on Friday evening; he is the fourth admission that afternoon. He had been in the hospital for 3 days and is now more confused. He is taking 10 medications, including a proton pump inhibitor, ibuprofen, meclizine, senna, docusate, and haloperidol. Mr. H has an unsteady gait and complains of dizziness upon standing.

Mr. H’s confusion increases, and he has a fall related to weakness on his fourth day in the SNF. Laboratory studies reveal a digoxin level of 3.5 (reference range, 0.8-2.4 ng/mL), Hgb/Hct of 8/25 (reference range, 14-18 g/dL/ 39-54%), INR of 5.1 (reference range, 2.0-3.0), and BUN of 70 (reference range, 6-23 mg/dL). He is transferred back to the hospital and diagnosed with an upper gastrointestinal bleed, dehydration, and digoxin toxicity. After 3 days, he is stable and transferred back to the SNF.

Clinical Scenario Questions: