Epic Medication Reconciliation Fail: A True Story

pills isolated on white background

pills isolated on white background

Today I want to share a true story that I’ve been mulling over recently, as I ask myself when will we start to see more substantial gains in health care quality.

It’s the story of a 94 year old woman who was sent from her memory-care residential unit to the emergency room, due to nausea and vomiting. She ended up being hospitalized for about 48 hours, for UTI.

(Sad but true aside: her family has asked for hospitalization to be avoided unless absolutely necessary for comfort. But the facility feels they have to send her to the ER if she falls, vomits, or otherwise looks seriously ill. Argh.)

Before hospitalization, she was only taking vitamin D and a daily aspirin and a multivitamin. She’d been in the memory unit for years due to dementia, and on minimal meds since “graduating” from a stint in hospice a few years ago. Because she’s chair-bound and it’s hard for her to leave the facility, she hasn’t been to her PCP’s office in years. Instead, I come and see her at the facility once or twice a year.

Guess how many medications she was discharged from the hospital on? Fourteen.

As in, fourteen new daily medications to be taken indefinitely! (There was also a course of antibiotics for UTI plus a few new PRN medications.)

I thought I was hallucinating when I saw her med sheet at the facility.

Unsurprisingly, the medications were putting her at risk. There was Paxil, which is anticholinergic and really our last choice if we have to use an SSRI in an elderly person. There was an iron supplement and a calcium supplement, both of which are constipating. There was a beta-blocker, an ACE-inhibitor, a statin, and a loop diuretic too for good measure.

And there was also Plavix (along with the aspirin) and also a directive to apply clotrimazole/betamethasone twice a day. Indefinitely.

Which is perhaps why I discovered huge ecchymoses on her shins, when I saw her four months after her hospital discharge.

How could this happen, I wondered?

After consulting with the family, I stopped some meds but really felt I had to first learn more about why they were started before proceeding further. So I requested the ED and hospital records to try to understand the reasoning of my medical colleagues.

The Medication Reconciliation That Wasn’t

Here’s what I learned by reviewing the ED and hospital records:

ED clinical note: This says: “Reconciled Medications For This Visit as Completed by EDRN:
No medications the patient reported taking on file as of [date]
NON Reconciled Medications on File:
No hospital prescriptions on file as of [date].”

This document also notes that the patient is unable to provide history, and so “history from family member and nursing home.”

I am left wondering why the ED didn’t have the med list from the facility, which would have listed her three medications. The family member also could have provided this information.

Hospitalist history & physical note: This note includes a huge long list of medications in a table titled “Prior to Admission Medications.”

  • The column headings are “Prescription” “Last Dose” “Informant” “Patient Reported?” and “Taking?”
  • The “Prescription” column includes just about everything the patient was later discharged on.”
  • The “Informant” and “Last Dose” columns are blank.
  • The “Patient Reported?” column reads “No” for everything other than aspirin and one other medication (which the patient was not taking as far as I know).
  • The “Taking?” column reads “No” for everything.
  • At the end of the table, it says “Facility-Administered Medications: None”

Yikes. All this information technology in hospitals and doctors’ offices — and there’s medication management software at the facility too — and this is what we get??

Presumably, the computer pulled an old list from somewhere. Who knew old medication lists could come back in this way?

And what did the hospitalist think of this? Not nearly enough, I fear. She notes that the patient’s current hypertension might due to “missing medications today.” She also notes that the reason for Plavix are unclear but as patient “has been on it for years” they will continue and check with PMD.

Hospitalist discharge summary: This note is signed by a different hospitalist. It repeats the line re Plavix.

It discharges the patient on 19 medications, of which one is an antibiotic and four are PRNs.

It says to follow up in 2 weeks with PCP.

Small bonus record: At the very end of the records sent to me is a small item that somehow got printed along with the rest. It’s dated a few months later, says “Telephone encounter”. It seems to be a record of receiving and executing a refill request for Vitamin D.

At the end it reads:
“Last Visit with [PCP name] on [date in early 2012]

No Future Appt with [PCP name]

What Went Wrong with This Medication Reconciliation?

Obviously, just about everything.

I wish I found it remarkable that this could happen, but in truth the only thing that surprised me what this hospital’s computer was able to dig up a list that was at least 3.5 years old.

You’d think they’d program EMRs to not insert anything older than a year or some kind of shorter window, because if it’s been too long since someone checked the meds, someone ought to be forced to do it. Don’t get me wrong, accessing medication history is useful. But computers should not be allowed to insert anything beyond a certain time period as “current medications.”

It’s discouraging but not surprising that neither the admitting hospitalist nor the discharging hospitalist didn’t think “Why the heck is a 94 year old woman with dementia on so many medications?” and try to look into that. The facility — or the pharmacy supplying the facility — could’ve told them that the patient hadn’t taken those meds for years.

But you know, hospitalists are very busy these days. They are being pressured to see a lot of patients, and most are not forming unions in response. Plus they have lots of computers and little admin tasks sucking away at their attention.

Did the hospital team talk to the patient’s family and review medications at discharge? I don’t know if they were able to be present at discharge. Maybe they were and figured the doctors must have a good reason for all those meds? Maybe they were at work? It can be hard for a family to stay on top of all these details, when an older person has been hospitalized.

And what about the patient’s usual pharmacy team? Couldn’t they notice that “wow, she’s been on three piddly meds for years and now look, she’s been discharged on 19 medications!” One wishes they’d call the prescribing doctors when there’s a big change like that, but they too, are probably very busy.

Whose responsibility was it to make sure the patient was seen by her PCP for follow-up?

Why don’t hospitalists notice when a person hasn’t been in to see their PCP for over three years? (That would seem to have implications related to getting follow-up with the PCP, no?)

I do believe that information technology is important in healthcare. But this story is a sobering example of how far we can still fall short, when it comes to providing patients with the right care at the right time.

[I’m very grateful to the families I work with, for allowing me to share de-identified versions of their experiences so that we can all learn and improve.]


  1. Sorry for being a hard=*$$ about this, but I need to ask the question of how much were the doctors receiving for each prescription? There are major problems with most hospitalists that they answer to the hospital and follow directions from the hospitals. If something will make the hospital money, they are often required to do that. Computer systems at most hospitals are programmed to follow administration orders and often override common sense.
    I know two doctors that left a hospital because of this and are now in private practice. They have related some real horror stories about what the computer changed in records that the doctors had not entered or then could not change back.

    • Leslie Kernisan, MD MPH says:

      Interesting thoughts.

      I had not heard of hospitalists having a financial incentive for putting patients on medication. (I’ve assumed that they are mainly being pressed to keep length-of-stay down, and also to see a lot of patients in a single day.)

  2. genie deutsch says:

    It doesn’t surprise me. We have become just a billing code to most of our health providers. Perhaps if one has a serious health problem that the provider think can be treated successfully the patient becomes more memorable.

    The only provider I feel knows me is my PT person…but that person has spent several hours alone with me.

    As a relatively healthy 84 year old I seek mainly to maintain my physical strength and mental powers, not to see how long I can live.

    QUESTION: When I have been sitting for an hour or more, when I get up my feet and legs feel stiff and walking is difficult. Is this caused by physical problems, ie circulation? or is it a nervous system or brain problem? Is there anything I can do to alleviate it while I am sitting? I would appreciate any suggestions you have. thanks, genie

    • Leslie Kernisan, MD MPH says:

      Thanks Genie for following this blog.

      Your question re stiff legs is better suited to my blog at BetterHealthWhileAging.net (formerly known as GeriatricsForCaregivers.net). You can post it in the comments here and I will post an answer soon….I know feeling stiff after sitting is a fairly common complaint so many people who read that blog are likely to be interested.

  3. The sad reality is that elders are over-medicated in America. Period. Unless families are actively engaged in and closely monitoring their parents or grandparents situation, or the patient has a PCP or geriatrician who does the same, elders remain vulnerable. As a chemist and former pharmaceutical executive, I know better than most the consequences of prescription drugs. As a daughter who supported a parent who lived with Alzheimer’s for 17 years at home, I know the reason she had cognition at the end was because we kept her physically and cognitively active and minimized the number and dosing of prescription Rx she took. My challenge to you, Leslie, is how can you use your voice through video, interviews and other media to advise families about these dangers? And why aren’t the physicians or nurses who attend to people living in assisted living communities raising the alarm?

    • Leslie Kernisan, MD MPH says:

      Well, probably all demographic groups are over-medicated in the US, but older adults are especially likely to be harmed in the shorter-term by this.

      Re clinicians who work in residential facilities, I think they are overwhelmed and also used to the status quo.

      As for using my voice…I have relaunched my other website as BetterHealthWhileAging.net and am working on launching a podcast for families and older adults. I hope it will help to provide a source of education for families but we’ll see…families are overwhelmed too, as you know so well.

  4. Norman Bauman says:

    I assume you read this article in which the author’s healthy, intellectually active mother was unnecessarily hospitalized, unnecessarily given cyclobenzaprine, developed delerium, given other unnecessary drugs, and died as a result.

    Perspective | September 2015 Less Is More
    “Mom, You Have to Trust Me”
    Mary K. Brennan-Taylor
    JAMA Intern Med. 2015;175(9):1441. doi:10.1001/jamainternmed.2015.3659.

    • Leslie Kernisan, MD MPH says:

      Had not seen that particular story but sadly, it’s not surprising as this kind of thing happens fairly frequently 🙁

      This story illustrates how many apparently healthy older adults are actually physiologically vulnerable. So it’s important to be careful about what stresses we expose older adults too.

      Also important to be double-checking on what the hospital and the doctors are doing.

      Thanks for bringing the story to my attention.

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