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19 Fitzgerald Health Education Associates, Inc., August 2015 fhea.com NP Firsts Avoiding Malpractice: A Case Analysis Reconciliation of Medications The nature of the problem at the heart of this case is easily recognized: reconciliation of medications. The Joint Commission describes medication reconcilia- tion as follows: "Medication reconciliation is the process of com- paring a patient's medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug in- teractions. It should be done at every transition of care in which new medications are ordered or exist- ing orders are rewritten. Transitions in care include changes in setting, service, practitioner, or level of care. This process comprises five steps: (1) develop a list of current medications; (2) develop a list of med- ications to be prescribed; (3) compare the medica- tions on the two lists; (4) make clinical decisions based on the comparison; and (5) communicate the new list to appropriate caregivers and to the pa- tient." 1 Unless there is another explanation that has not been made available in this case, the NP either did not review the hospital medication list or did review the list, saw that the patient had refused the medica- tion for 24 hours, and let the matter drop. One could argue that an astute clinician, seeing this patient's hospital course—multiple lower extremity surgeries and orders for bed rest—would recognize the risk for thromboemboli and consider anticoagulation thera- py as necessary, whether or not a surgeon had or- dered it. In any event, heparin did not appear on the list of discharge medications and the patient did not take hep arin for 3 days before his cardiac arrest. It is true that the thromboemboli may have been formed prior to discharge, and it is true that heparin is not always effective at preventing thromboemboli, but there is no way to prove those arguments. The fact remains that the patient should have been on heparin after his discharge from the hospital. Take-Home Messages for NPs The take-home messages for NPs are multiple: 1. Read the clinical expectations outlined by The Joint Commission on discharge medication rec- onciliation. 1-3 2. If the patient took medications prior to admis- sion, but which were not received (refused or withheld) during the hospital stay, check with the patient's primary care provider or applicable specialist to determine whether the patient needs orders to resume the medications at dis- charge. 3. If there is a medication ordered for the patient during his or her hospi- tal stay, check with the surgeon to determine whether the medication should be continued af- ter discharge. 4. If a medication is indi- cated to avoid a surgical complication, and the surgeon hasn't ordered it, contact the surgeon and discuss the matter. 5. Avoid writing discharge summaries and orders for patients who are not known to you. Taking on this important task without either knowing the patient or spending the time necessary to learn about the patient is putting the patient, the NP, and the NP's employ- er at risk. Medicare Rules on Discharge There is another issue to consider that is unrelated to malpractice. Medicare pays surgeons for the dis- charge service as part of the global fee for surgery. 4 According to Medicare's rules, the discharge day services include a face-to-face evaluation and man- agement service between the attending physician and the patient, and only the attending physician of record can report the Hospital Discharge Day Man- agement Service. Thus, it is Medicare's intention that C ontinued from page 17 Avoid writing discharge summaries and orders for patients who are not known to you.