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Todays newspaper had an article in the “health” section that really was worthy of front page news. But, because of whatever reason, in this small town in west Texas, the article was buried in section D, second page. The story is repeated in small towns all across the country. Big towns, too. The story should be an isolated incident, yet it is all too familiar. Loved ones are dying because of human error in their medical care, specifically their medication.

This particular death occurred at one of the most dangerous junctures in medical care: when patients leave the hospital. This patient had her prescription phoned into a pharmacy and the person transcribing the medication wrote it down wrong. It was a “high-alert” medication with consequences so “devastating” that they warrant special safeguards against incorrect dispensing. However, they made it into the hands of the patient; and caused her death. In all honesty there were several stages where the error should have been caught.
But problems can occur at any point in patient care. For instance, problems can occur: 1) At hospitals, where federal data show that fewer than half of patients say they confidently understood the instruction of how to care for themselves after discharge. 2) In nursing homes, where case managers are carrying too heavy a workload or just simply come up short. A 2013 government report found more than a third of facilities did not properly assess patients’ needs, devise a plan for their care, and then follow it through. 3) At pharmacies. A 2012 study found that half of patients had a clinically significant medication error within a month of discharge from two highly regarded academic medical centers. The study found that these errors persisted even when pharmacists took a more active role in counseling the patient and reviewing the prescription. 4) At home health agencies, where failure to create and execute a care plan are the most common issues government inspectors identify, followed by deficient medication review, according to KHN’s analysis.
As sophisticated as we think our health care system is, it still boils down to human interaction and personal responsibility for our actions.
I am proud to work for an agency who pushes back and fights for the patient; often at the chagrin of the physician because they are so busy. “Pardon me, we really would like to know if this is the medication you intended to have the patient receive” should have been a question that the home health nurse asked of the physician while on her first visit with this patient.
No one is perfect, far from it. However, it is imperative that a home health agency have a clearly communicated plan of care in place and that they follow protocols for each and every patient, every time. This is one of the ways we differentiate ourselves and continue to consistently out-perform competing agencies.
No one should die from a prescription that they believe the physician ordered for their health and well-being. It happens all too often (at least once a day according to the FDA). That is one too many.

Other reading which discusses the risks associated with taking prescription drugs. http://www.collective-evolution.com/2013/11/20/how-pharmaceuticals-came-to-be-the-4th-leading-cause-of-death-in-america/

Lori Jo has been in sales and marketing for most of her adult life and joined the San Angelo Home Health team in 2015. She will be a regular contributor to our "blog" section, along with Joanne Poynor, RN who is also part owner of the agency.

Lori Jo Thomas, Marketer