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Achieving Medication Reconciliation for Heart Failure Patients Through the Use of a System to Catch Physician Dictation Errors Marianne Morrissey BSN, RNVictoria Abud BSN, RNRochelle Bakker BSN, RN Spectrum Health Heart Failure Quality Program Identify greatest opportunities for improvement  Medication Reconciliation Discharge Summary Discrepancies  Discharge Summary Including Patient List of Medications  Review Heart Failure Charts for EXACT Medication Match-Up Problem - Medication Errors Not Impacting Patient Safety He said “Levothyroxine” They heard “Levofloxacin” She said “Furosemide” They heard “Torsemide” He said “Valsartan” They heard “Losartan” Problem - Medication Errors Impacting Patient Safety  Medication Omission From Patient’s Take Home List  Unclear Instructions For Medications / Dosing  Correctional Measures Given to Providers *List of Medications Sent Home with Patient*

Medication Name
Dose, Route, How Often
Tylenol 500 mg Tab (acetaminophen)
aspirin (aspirin)
Lipitor (atorvastatin)
20 mg, By mouth, Every evening - at bedtime Bumex (bumetanide)
Coreg (carVEDILOL)
Colace (docusate)
100 mg, By mouth, Twice a day As Needed for as needed for constipation dutasteride 0.5 mg oral capsule (dutasteride)
glimepiride (glimepiride)
hydrALAZINE 25 mg oral tablet (hydrALAzine)
isosorbide dinitrate (isosorbide dinitrate)
nitroGLYCERIN (nitroGLYCERIN)
0.4 mg, Under the tongue, Every five minutes As Needed for as needed for chest pain Nitro-Dur 0.4 mg/hr Patch (nitroGLYCERIN)
See Instructions 1 patch(es), Topical, Every morning, apply in the morning and remove at bedtime potassium chloride (potassium chloride)
Ranexa PO (ranolazine)
tamsulosin 0.4 mg oral capsule (tamsulosin)
*Medications in Dictated Discharge Summary*
1. Tylenol 500 mg 2 tablets daily. 2. Aspirin 81 mg daily. 3. Lipitor 20 mg at bedtime. 4. Bumex 2 mg b.i.d. 5. Coreg 25 mg b.i.d. 6. Colace 100 mg b.i.d. 7. Avodart 0.5 mg daily. 8. Glimepiride 1 mg daily. 9. Hydralazine 50 mg b.i.d. 10. Imdur 60 mg t.i.d. 11. Nitroglycerin 0.4 mg sublingually as needed for chest pain. 12. Potassium 20 mEq b.i.d. 13. Ranexa 500 mg b.i.d. 14. Tamsulosin 0.8 mg daily. *List of Medications Sent Home with Patient*
Novolog with meals based on blood sugar reading before meals as written Sugar Novolog

amiodarone 400 mg oral tablet (amiodarone)
400 mg 1 tab(s), By mouth, Twice a day, For 10 days then decrease to 1 tablet daily amiodarone 200 mg oral tablet (amiodarone)
200 mg 1 tab(s), By mouth, Daily, start 7/22/11. aspirin 81 mg oral tablet (aspirin)
citalopram 10 mg oral tablet (citalopram)
divalproex sodium 250 mg oral delayed release tablet (divalproex sodium)
Lovenox 120 mg/0.8 mL subcutaneous solution (enoxaparin)
120 mg 0.8 mL, Under the skin, Every twelve hours, may stop when INR at 2.0 or higher. As directed, Under the skin, Three times a day, less than 70 mg/dL do not take Novolog 71-150 mg/dL Novolog 15 units 151-200 mg/dL Novolog 17 units 201-250 mg/dL Novolog 19 units 251- NovoLog 100 units/mL subcutaneous solution (insulin aspart)
300 mg/dL Novolog 21 units 301-350 mg/dL Novolog 23 units 351 mg/dL or greater Novolog 25 units and call the physician Spec. Instr. = with meals insulin glargine 100 units/mL subcutaneous
solution (insulin glargine)
55 unit(s), Under the skin, Every morning Spec. Instr. = Lantus 100 units/mL subcutaneous solution (insulin Please dispense insulin syringes Sig: I months. Patient to
glargine)
lisinopril 10 mg oral tablet (lisinopril)
meclizine 25 mg oral tablet (meclizine)
25 mg 1 tab(s), By mouth, Three times a day As Needed for dizziness metoprolol tartrate 100 mg oral tablet (METOPRolol)
pantoprazole 40 mg oral enteric coated tablet (pantoprazole)
simvastatin 10 mg oral tablet (simvastatin)
10 mg 1 tab(s), By mouth, Every evening - at bedtime warfarin 7.5 mg oral tablet (warfarin)
7.5 mg 1 tab(s), By mouth, Every evening - at bedtime *Medications in Dictated Discharge Summary*
1. Amiodarone 400 mg 1 pill twice a day for ten days and 200 mg a day thereafter. 2. Aspirin 81 mg a day. 3. Citalopram 10 mg daily. 4. Divalproex sodium 250 mg twice a day. 5. Lovenox 120 mg subcutaneous b.i.d. until INR is greater than 2. 6. Glyburide 5 mg twice a day. 7. Insulin 10 units daily. 8. Lisinopril 10 mg daily. 9. Meclizine 25 mg 3 times a day. 10. Metformin 500 mg twice a day. 11. Metoprolol tartrate 100 mg twice a day. 12. Protonix 40 mg daily. 13. Simvastatin 10 mg daily. 14. Coumadin as directed by West Michigan Heart. *List of Medications Sent Home with Patient*
ASA (aspirin)
Tricor (fenofibrate)
FUROsemide 80 mg (FUROsemide)
metoprolol tartrate 50 mg oral tablet (METOPRolol) 50 mg 1 tab(s), By mouth, Twice a day
multivitamin (autosub) PO (multivitamin with
minerals)
Crestor 40 mg oral tablet (rosuvastatin)
Spiriva 18 mcg inhalation capsule
(tiotropium)
Diovan 160 mg oral tablet (valsartan)
*Medications in Dictated Discharge Summary*
1. Multivitamin 1 daily. 2. Aspirin 81 mg daily. 3. Tri-Cor 145 mg daily. 4. Lasix 80 mg as needed. 5. Metoprolol 50 mg b.i.d. 6. Crestor 40 mg daily. 7. Diovan 320 mg daily. 8. Dabigatran 150 mg b.i.d.   *List of Medications Sent Home with Patient*
acetaminophen-HYDROcodone 500 mg-5 mg PO Tablet
1 tab(s), By mouth, Every four hours As Needed for moderate pain (acetaminophen-hydrocodone)
ALPRAZolam 0.25 mg oral tablet (ALPRAZolam)
0.25 mg 1 tab(s), By mouth, Three times a day As Needed for anxiety See instructions, By mouth, Twice a day Spec. Instr. amiodarone 200 mg oral tablet (amiodarone)
= Take two (2) tablets twice a day for 14 days, then take one (1) tablet daily. aspirin buffered 81 mg oral tablet (aspirin)
brimonidine 0.2% Ophth Soln (brimonidine ophthalmic)
carvedilol 3.125 mg oral tablet (carVEDILOL)
3.125 mg 1 tab(s), By mouth, Twice a day 150 mg 1 cap(s), By mouth, Twice a day, blood Pradaxa 150 mg oral capsule (dabigatran)
thinner You will be on this indefinitely. Spec. Instr. = digoxin 250 mcg (0.25 mg) oral tablet (digoxin)
fluorometholone 0.1% Ophth Susp (fluorometholone
ophthalmic)
FUROsemide 40 mg oral tablet (FUROsemide)
lorazepam 0.5 mg oral tablet (LORazepam)
0.5 mg 1 tab(s), By mouth, Every evening - at bedtime potassium chloride 20 mEq oral tablet, extended release
(potassium chloride)
pravastatin 20 mg oral tablet (pravastatin)
20 mg 1 tab(s), By mouth, Every evening - at bedtime AndroGel 5 g/packet transdermal gel (testosterone)
venlafaxine 75 mg oral tablet (venlafaxine)
zolpidem PO (zolpidem)
10 mg, By mouth, Every evening - at bedtime *Medications in Dictated Discharge Summary*
1. Acetaminophen/hydrocodone 500 mg/5 mg 1 tablet p.o. every 4 hours. 2. Alprazolam 0.25 mg 1 tablet p.o. t.i.d. p.r.n. anxiety. 3. Aspirin 81 mg 1 tablet p.o. daily. 4. Brimonidine 0.2% ophthalmic solution 1 drop in the right eye t.i.d. 5. Carvedilol 3.125 mg 1 tablet p.o. b.i.d. 6. Digoxin 0.25 mg 1 tablet p.o. daily. 7. Fluorometholone 0.1 ophthalmic suspension 1 drop in the right eye every other day. 8. Furosemide 40 mg p.o. q.a.m. 9. Potassium chloride 20 mEq p.o. daily. 10. Lorazepam 0.5 mg p.o. nightly. 11. Pravastatin 20 mg 1 tablet p.o. nightly. 12. AndroGel 5 g/packet transdermal gel 2 each topical daily. 13. Venlafaxine 75 mg 1 tablet p.o. b.i.d. 14. Zolpidem 10 mg p.o. nightly.
 This has been an effective way for our HF program to address medication documentation discrepancies until an electronic solution can be found

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