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Op-Ed Contributor

Many Drugs and Many Doctors Lead to Many Mistakes

Credit...Dingding Hu

I am a home hospice nurse, and when I get new patients after they have been discharged from the hospital, the list of drugs included in their paperwork is always wrong. Some mistakes are minor: The list includes a relatively harmless drug the patient no longer needs or it leaves off a minor dose adjustment. But other mistakes are more serious — the list may include an important prescription the patient never knew to fill or may have the patient on two medications that can be dangerous when taken together.

Sometimes, in desperation, a patient will bring me plastic bags bulging with prescription drugs and ask me to sort them out. Many are confused by the generic and brand names of drugs, and find doses difficult to remember. For some, their knowledge of their own medications is limited to “I take the orange pill in the morning, the blue one in the evening and the white ones twice a day.” I create a list for them by going through their bottles one by one.

The abundance of errors in medication lists put patients at risk. A 2010 article in the Journal of General Internal Medicine found that the 651 hospital patients studied had 309 errors on their medication lists, and over half those errors had the potential to cause harm.

To avoid these problems, we need a single drug list unique to every person that would be stored online and could easily be available to patients and their doctors.

This is harder than it sounds because most patients have a number of health care providers. A cardiologist prescribes the patient’s beta blocker, a family nurse practitioner the treatment for acid reflux, and a dermatologist the topical cream for a rash. These three providers — and their computer systems — may or may not communicate with one another, and the drugs could come from various suppliers: a mail-order pharmacy, the local drugstore and a free sample given out in the physician’s office. Thus, no complete and easily accessible record of the patient’s medications exists.

When a patient is admitted to a hospital, the current system tries to resolve this chaos through a process called medication reconciliation. The doctors compile a medication list by relying on computer records, if there are any, or more often on the patient’s memory. That information is entered into the hospital’s computer system, as are the new drugs that are inevitably prescribed, again by a number of different doctors.

Despite the use of electronic records, errors creep in. The beta blocker was stopped on admission. Should the patient restart it after discharge? He wasn’t told. He goes home with two medications for reflux: the old one he had been on and the new one he started in the hospital. Does he need both? And the patient takes nutritional supplements but doesn’t consider them medications and so didn’t mention them to the hospital staff. They are left off the list, even though supplements can alter the effectiveness of some drugs.

Much of this confusion could be relieved if there was a simple way for patients or their caregivers to list all their medications and if clinicians could easily obtain and refer to that list, with both entering updates as needed.

Introducing MyRxCloud: a cloud-based, free, ad-free, voluntary, nonprofit mobile app (also available online) that can exchange information with existing electronic health records and does nothing more than keep accurate lists of all patient medications, including prescription and over-the-counter drugs, implants, nutritional supplements, IV solutions and injectables, such as insulin and heparin.

MyRxCloud exists only in my imagination, but it’s a simple solution to the problem of mistakes in medication records. Some existing apps already include medication lists as part of managing family members’ health care (CareZone) and helping patients locate low-cost prescriptions (GoodRx). Some even pretty much do what MyRxCloud would do (MyRxList). The difference is that those apps intend to help patients but are not available to clinicians, or they are available to some clinicians but only those within a particular network. So while they may make the keeping of medication lists easier, they cannot reduce the number of medication errors caused by poor communication between patients and their doctors, or among doctors themselves.

The tricky part of implementing MyRxCloud would be “interoperability” — ensuring it is able to communicate with the computer systems in doctors’ offices and hospitals. Existing electronic health record systems are not good at talking to one another, so importing information from one system to another is at best difficult and at worst impossible. The Department of Health and Human Services wants these record systems to be interoperable by 2024, but many people think that is optimistic.

But what if the Centers for Medicare and Medicaid set up MyRxCloud and gave incentives to hospitals and prescribers to use it? What if MyRxCloud could smoothly import medication information from electronic health records? What if patient safety advocates pushed the idea of “One patient, one list” to cajole the makers of the record systems to work with MyRxCloud?

I’m not a software developer. But if we begin with the idea that the patient — not the pharmacy, hospital or prescriber — owns her list of medications and work backward from that, for the sole purpose of creating and then curating a singularly accurate drug list to keep her safe and healthy, I imagine it could be done.

Theresa Brown, a hospice nurse, is the author of “The Shift: One Nurse, Twelve Hours, Four Patients’ Lives.”

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