Description of clinically important unintended medication variances and the impact of the reconciliation
| Case description | Timing of variance | Description of variance | Impact of reconciliation |
|---|---|---|---|
| (1) Patient admitted for myocardial infarction | Admission | Patient was taking metoprolol 25 mg bid at home.Patient ordered metoprolol 75 mg bid on admission. After first dose, patient was hypotensive and bradycardic | Patient experienced hypotension and bradycardia. Dose decreased after reconciliation. |
| (2) Patient with a history of CHF and angina admitted for hypertension | Admission | Patient was taking clonidine at home.Patient was ordered half of usual dose | Patient experienced severe hypertension. MD changed dose of clonidine after reconciliation and started additional antihypertensives |
| (3) Patient admitted for CHF and pneumonia | Admission | Patient was on metoprolol 12.5 mg bid at home.Metoprolol 50 mg bid ordered in hospital | Dose reduced |
| Admission | Patient had discontinued using spironolactone before admission. Spironolactone 50 mg daily was ordered on admission: 3 doses given | Dose reduced | |
| (4) Patient admitted for total hip replacement | Discharge | Patient was taking ketorolac at home. Ketorolac held while in hospital as patient was started on warfarin. Patient discharged on warfarin but not instructed at discharge to discontinue ketorolac | Patient informed to discontinue ketorolac |
| (5) Patient with history of CHF admitted for pneumonia | Admission | Furosemide used at home but not ordered at admission | Furosemide restarted |
| (6) Patient with metastatic cancer | Admission | Patient was taking hydromorphone as needed at home. Patient was started on morphine as needed(at half the equipotent narcotic dose). Patient’s pain score was 7/10 | Physician chose to continue morphine. Later changed to hydromorphone as patient continued to have pain |
| (7) Patient admitted for hepatic encephalopathy | Admission | Patient used fluticasone/salmeterol Diskus at home. fluticasone/salmeterol was not ordered | No new order |
| Discharge | Spironolactone increased in hospital from 50 mg daily to 50 mg bid. No written instructions or prescriptions | Patient informed of increase in dosage | |
| Discharge | fluticasone/salmeterol held while in hospital. Patient not informed whether to restart fluticasone/salmeterol upon discharge | Patient informed to restart fluticasone/salmeterol | |
| Discharge | Estrogen held while in hospital. Patient not informed whether to restart estrogen upon discharge | Patient informed to restart estrogen | |
| (8) Patient admitted for bowel obstruction. Ileostomy performed | Admission | Patient had discontinued hydrochlorothiazide at home. Ordered at admission but patient refused medication | Hydrochlorothiazide discontinued |
| Discharge | Patient was on salbutamol before admission but was changed to Combivent in hospital.Patient not informed to discontinue salbutamol at home | Patient informed to discontinue salbutamol | |
| (9) Patient with history of stroke admitted for COPD exacerbation | Discharge | ASA held while in hospital as patient was on ketorolac. Patient not informed to re-start ASA upon discharge | Patient informed before discharge |
| (10) Patient admitted for bowel surgery | Admission | Patient was taking lorazepam daily at bedtime at home. Medication was not ordered at admission | Doctor did not restart lorazepam |
| (11) Patient with diabetes admitted for hypoglycaemia, CHF and renal failure | Admission | Nifedipine XL used at home but omitted from medication history. Patient started on metoprolol in hospital | Physician chose to continue metoprolol and hold nifedipine XL |
| Discharge | Furosemide was increased while in hospital, but discharge prescription was for pre-admission dose | Prescription changed | |
| Discharge | Insulin dose reduced significantly in hospital.Discharge prescription for insulin did not indicate dose. Patient resumed pre-admission dose | Missed opportunity to prevent harm. Patient readmitted with hypoglycaemia | |
| Discharge | Patient’s metformin was discontinued in hospital. No instructions provided. Patient restarted metformin at home | Missed opportunity to prevent harm. Patient readmitted with hypoglycaemia | |
| Discharge | Nifedipine XL discontinued and metoprolol ordered in hospital. Metoprolol prescribed at discharge. Patient restarted nifedipine XL at home | Missed opportunity, no clear impact on patient |