Many years ago, a woman in her 80s died of a preventable upper gastrointestinal (UGI) bleed. As the facility’s Medical Director, I became involved in this case after the disaster. This resident was at our facility for rehab and a community PCP was her attending physician. The facility podiatrist diagnosed acute gouty arthritis and prescribed the nonsteroidal anti-inflammatory medication indomethacin, which at the time, was a standard treatment option. However, this woman had a history of prior peptic ulcer disease, which the PCP was aware of and would not have permitted this Rx had he been aware of it. She died about 5 days later of a massive UGI bleed. This upsetting event resulted in a policy that all new prescriptions by other providers would require the approval of an attending physician. 

This kind of event is even more likely to occur today. My rehab patients commonly see consultants, but I rarely see reports from these visits in my in-box. During a follow-up visit, I was surprised to find a new order for the direct oral anticoagulant (DOAC) apixaban for one of my patients in the active medication part of the facility EHR. Fortunately, she was not on other meds that increased her bleeding risk, but I could have prescribed one without realizing the heightened bleeding risk. In this case, a brief progress note from the consultant was scanned into the facility EHR documents file but was not placed in my inbox. I would hope that the prescriber reviewed my recent rehab progress note that included current medications and past/current medical problems. 

Medication reconciliation is another area of concern. In the hospital records I review as a part of my H&P, I find little evidence that medication reconciliation has occurred. I recently received a patient who had been on a trial of high-dose prednisone for a cutaneous inflammatory disorder, who had been hospitalized for an acute injury. She reported the dose had been reduced to 40 mg daily, and she hoped further dose reductions would resolve her new corticosteroid-induced “moon facies.” However, the hospital records did not mention this medication and transferred her to my facility without it. In this case, I faxed the treating surgeon a typed request (with my mobile number) for their guidance while prescribing 30 mg daily. After no response by the next day, I called the office and was notified he wasn’t in the office this week but was available on his mobile. My question was quickly addressed by texting his mobile. A physician friend who reviewed this case has also found messaging through the Doximity app to be a helpful option. 

My community has SNF learning collaboratives with Sutter and Providence hospitals. I hope that we can explore ways to improve medication safety through collaborative prescribing with prompt or synchronous, optimal bi-directional provider communication.