2) Medication Reconciliation Sheets.

#2. The Med Rec Sheet.

Medication reconciliation is another one of the many things that make pharmacists irate. Perhaps a bit of background is required.

Sometime back a long time ago (I'm not really sure when...before my time, anyway) someone in academia and Joint Commission decided it would be a great idea to have a prepared document that was able to be generated listing a patient's medications they take at home and the list of medications they are taking while in the hospital. With this list, practitioners would then decide whether or not each med would be ordered, continued, discontinued, whatever. And if a patient is on, say, two statins, the physician can note this and tell them they only have to take one of them. A sheet is thus filled out upon admission, transfer, discharge, etc.

Now while I admit that this all sounds rosy...and it's probably needed... it unfortunately gets executed in a way that causes the average hospital pharmacist to want to just end it all and jump into the nearest volcano.

In fact, personally, if I were given the choice between dealing with a med rec sheet and stabbing myself in the eye with 25 years worth of Rossanne Barr's blood red tampon drippings frozen into the shape of a giant 25 foot tall, razor-sharp icicle...I'd make sure my vision insurance is up to date and stab away.

So where do I start.

Well, it should be understood that every initiative that is started and, later, required in hospital pharmacy practice is started by people in academic teaching hospitals. As such, all initiatives are designed and created with these types of facilities in mind. So, in these humongous hospitals, they employ 50 bazillion pharmacists. And, as such, one or two of them are freed up to go around and compile medications to be placed on med rec sheets, analyze them, and THEN give them to a physician for review. I'm sure the whole thing works dandy in this setting. Keep that all in mind.

Now that I think about it...this is a pointless tangent, children...whenever I was on rotation at the hospital that was attached to the school I graduated from...I'd see dozens and dozens of pharmacists every day...but I swear to God, I never saw any of them doing any actual....work. The IV pharmacist is the only exception I can think of. In fact, the ED pharmacist I hung out with just stood around the ED all day doing nothing, then went up to the surgery satelite he was also responsible for and played on the internet for a few hours.

Yeah...

Anyway...in the real world, there aren't that many damned pharmacists laying around.

Let's take my institution for example.

I typically work afternoon shifts from 1-11 (mostly because I still sleep until 11:30 most days...) As such, and being that I work in a locale where something like 80% of the people are on Medicaid, there are only 7 full time day/afternoon pharmacists for a hospital with a census of 150-200. That's all we can afford.

That means that I am there, alone, between the hours of 5:30-9PM. Not to mention that our hospital can't afford to give their employees a typical prescription insurance card that can be used at an actual retail pharmacy...so we actually have to dispense prescriptions for every hospital employee, too...which is total balls.

So, yeah, one dude, alone, with 150 patients and a mini-CVS on the side. So that one pharmacist is dealing with the mountains of post-op admission orders (which, yes, have med recs of their own) and regular admissions that the first shift nurses were too damn lazy to send down during their shift, so they punted it to second shift...which starts at about 4:30.

All of this together means that there is no way in hell I'm going to be able to go down, interview a patient, and compile an accurate med rec sheet.

So, in these non-utopian hospitals...who does the compiling of info for med rec sheets? And it's the damnedest thing...I actually had no clue. In fact, none of the pharmacists did. So I looked into it one day when it was slow. Turns out that it's rather random based upon which floor it is. But USUALLY, it's a nursing aide. And that should frighten you.

Personally, this doesn't surprise me at all. It explains why I get orders for drugs such as "Zopenex 0.31mg" and "hydracompatyazime 25mg". And they'll write down any stupid ass thing the patient tells them, too.

I swear to God this is true...one time we got a med rec sheet that had "Cannabis" listed as a home med. (the physician ordered it because he was a "liner"...I'll get to "liners" here in a bit...) The pharmacist on duty called the physician to "clarify"...of course putting the phone on speaker so we could all hear the mass hilarity...our buyer offered to drive up to Homewood (Pittsburgh ghetto) to try to get some if Cardinal was out of stock.

I few weeks ago I had one that listed "whiskey" as a home med.

I swear to God this is real.


Now one might think...well...that's no big deal...right? I mean the physician checks them and knows what's wrong....right? ....uh...right...?

Ha. Haha...hahahahaha. No.

As I've discovered, either way too many physicians know jack about drugs or way too many are too lazy to actually read the things. So what happens is that they will order drugs that are jotted down wrong. Then we get it. We notice that it's wrong...however...yippee...we don't have prescriptive authority...so that means we get to CLARIFY all of this shit.

Say some crazy patient tells the clerk that they take "Phoslo 125mg one cap TIDAC" (this happened yesterday). The physician orders it. Well, sumbitch, it only comes in one strength, 667mg. So that means we have to clarify it. If we just put it in for 667mg TIDAC, an idiot nurse that thinks they are more of a drug expert than a pharmacist will call you and threaten to write you up because you are trying to overdose a patient with 5 times the ordered dose. Not to mention the patient's calcium is like 13 and they suffer from renal failure, so they shouldn't be taking it, anyway.

So to avoid this, we call the ordering physician and do the song and dance of "clarifying" the med rec sheet. Usually this means we tell them what it should be and they agree with us.

Sometimes we get physicians that are privy to the whole stupid ass system and humor us to the "importance" of our phone call. We know it's stupid, they know it's stupid, but we just get it over with and that's that. I can deal with those people.

But there are "those."

The ones that actually know what Phoslo is will scold you for wasting their time as Phoslo only comes in one strength. No, they don't care about JCAHO regs. They care that their golf game was interrupted. They will call you an idiot, tell you "Yes, MORON, make it 667mg"...and then you hear the words "stupid f'ing pharmacists" faintly in the distance...right before you hear the click of them hanging up on you.

Then you have the ones that have no idea what the hell Phoslo does, they just ordered it because it was one of the options on the home med list. You'll tell them "Well, not only is the dose wrong, but the Ca/Phos product is above 55...which has been shown to increase risk of mortality in these patients. After about a 5 second pause, they'll just say.."Uh...yeah...let's cut that one and I'll consult Renal about that." Of course, I could tell them that Renagel is a great alternative, but being given advice from a pharmacist is like a 15 year old kid getting scored on by a 3rd grader in a game of neighboorhood pickup ball to these people. So they kinda avoid it at all costs. Plus, they play golf with the nephrologists, so consulting them gives their friends a reason to bill the insurance companies.

Then we have my most hated brand of med rec sheets. The ones filled out by the "liners".

So what, pretail, is a "liner?"

A liner is when a physician is too damned lazy to actually read their med rec sheets and they just draw a giant ass line down the "Order" column of the sheet. They get away with this because they know that the pharmacist will have to make sure everything is kosher...plus the nurses wait until 4:30 to fax down new admits as they don't want to deal with them on their shift...and by then, they are already long gone and some random hospitalist has already taken over call for that patient.

"Of course I read it. Honest." A classic example of a "Liner." Due to the lack of a defined insulin sliding scale for the above patient, we had to call the physician on call to get it corrected. Not to mention the fact that Vicodin doesn't come in 7/750 (that's 7.5/750). The dude that wrote the order slipped out right after signing off on the order. It probably wasn't a coincidence.

So anyway....to put this into perspective. About 10-70% of med rec sheets have issues that need to be corrected depending on what day it is and who's in the ED/OR/whatever.

At 5PM when the nurses from first shift fax all of the new admissions they've gotten since 1PM, then run out of there as fast as they can upon hitting the "send" button...and like 30 of them do that at the same time...which means I get a stack of like 20 admissions and med rec sheets. And they start coming over and collecting at about the same time the army of first shift pharmacists start to leave...

...and of these, like 5 are wrong.

2 are so f'd up that I have to call the pharmacy to figure out what the hell that patient takes.

Meanwhile, there is a nurse that's addicted to Vicodin at the door demanding her bi-weekly candy.

I have three nurses on hold demanding meds that found their way to the mysterious black hole...

Then I find out that the patient's pharmacy is Caremark mail order (God help me)...next thing I know, I'm sitting on hold with Caremark on speaker phone, talking to a nurse about why her Phoslo 125mg hasn't been sent up to the floor yet on another phone, checking a script for Vicodin my tech so kindly typed in and filled for me...then another nurse shows up at the window wanting to know why she can't get through to the pharmacist because both lines are tied up and she needs her now dose of Maalox...

...all at the same time...

...and it all piles up there because the entire implementation and existence of med rec sheets in the typical community hospital is so poorly executed...and so relentlessly dumped onto the the laps of helpless pharmacist...that it makes all of us so damned irate. And there is no way to make it any better because, again, in the real world...there are restrictions on manpower...

And I'm not even going to go into the situations where a physician discontinues a medication on the "current medications" sheet (which is one section of the med rec sheet), then reorders the same damned drug with the same damned direction on the home med list (the other part of the med rec sheet). Does he want it...is he just testing us to see what we'd do? How the hell should we know.

But when I get in a med rec-caused situation that stymies me from accomplishing anything...yeah...sometimes I curse...sometimes I throw things...sometimes I bang my head against the wall...and sometimes I just cry.

But at the same time, at least it shows me how needed we apparently are. Because if we weren't there, I'm pretty sure that an only moderately-opiate tolerant patient would die from taking 300mg of OxyIR (like I had one med rec say...those pesky extra digits...) And saying that we legitimately save patients from harm can seriously be drawn just off of the strength of the organizational abortions that are med recs alone. Job security...right? At least that's what we tell ourselves.

And that's why med rec sheets are one of the things that make hospital pharmacists irate.