Medication errors are costly and dangerous in any setting.
A recent position statement by the Hospice and Palliative Nurses Association (HPNA) highlighted the particular dangers of not following safety protocols in the hospice environment.
Per HPNA guidelines, providers need to exercise due diligence in regards to systematic medication error reporting and analysis. Most importantly, error reporting policies need to be non-punitive, according to the association.
At Hospice of Northeastern Illinois in suburban Barrington, IL, Denise Sample, BSN, RN, CMT, chief nursing officer said the most common error is patients not taking their prescribed medication.
"Very rarely do we see patients who are overdosing on purpose," she said.
"Even at the end of life, patients are very afraid of becoming addicted. They see the pink sheets with side effects from the pharmacy and really fear addiction."
As Sample noted, it's less common for hospice patients to overdose on medication. However, the substances are highly addictive so it's not unheard of.
In Kansas City, MO, nurses at Saint Luke's Health System Home Care Services said most overdosing errors are due to miscommunication with patients and families.
Often, overdoses are unintentional.
"When a doctor orders hospice, we know there will be a need for narcotics," said April Kimball, APN, ACHPN. "Finding the right dose and making the patient comfortable is the art of hospice nursing."
Although it's uncommon, nurses are trained to keep their radar on the potential for medications being taken by someone besides the intended. Narcotics and opioids have a high street commodity, said nurses at the soon-to-open Saint Luke's Hospice House.
"From a home health perspective, we send medications out in limited quantities with just enough for 2 weeks," said Kimball. "Nurses review medication at each home visit. Patients take medications two times per day and then as-needed for breakthrough pain. Breakthrough meds are where it gets tricky."
A medication journal gives nurses a black-and-white rendering of how much long-acting medication the patient's taking to ensure pain's being controlled. It also keeps families accountable. Sample said some patients she's encountered over the past 20 years are better about updating their medication diaries than the nurses.
Most families are forthcoming about a relative's prior substance abuse problems. If there's a relative with a history of drug abuse, Kimball said they store all medications in a locked box.
At Hospice of Northeastern Illinois, relatives at homes with known drug addiction histories are asked to show identification to pharmacy personnel when medication arrives. Hospice staff communicates with the pharmacy to ensure that no after-hours calls were made to order more medication.
Long-Term Care Factor
In home hospice, Sample said pharmacy error leaves a great deal of room for error.
"The majority of our care is conducted in patient's homes or senior living communities," she explained.
"Home patients use our pharmacy but senior living and long-term care patients have their own pharmacies. This leads to multiple people doing medical documentation."
Lately, she said the different regulations in long-term care environments and negative publicity has led to reluctance to administer Haldol, an anti-psychotic medication that's lately been found to cause death in patients with dementia.
"It's been listed as a chemical restraint in long-term care," Sample said.
"Long-term care is watched very closely in terms of restraint use," she said. "A lot of education needs to take place on why a patient would benefits from use of Haldol, not just for psychotic use but even for something like a urinary tract infection."
Another issue surrounding hospice patients residing in long-term care communities is the utilization of caregiving personnel who aren't allowed to administer medication.
"Unless the patient has a hired nurse, a routine home health aide can't draw medications," Sample explained.
"Depending on insurance or ability to pay, patients can get a nurse or LPN," she said.
"If the patient just can't remember when to take their medications, a hired caregiver can hand them to the patient in a cup if it's already been dropped into the cup. In the case of morphine, we have individual syringes the caregiver can hand to the patient to squirt in the mouth. If the patient's in crisis, we encourage them to come to the inpatient unit."
For patients discharged to their own home, there are no restrictions on medication distribution. But there are other potentially dangerous situations with medication administration.
At Saint Luke's, hospice staff works in close conjunction with social workers to ensure a safe discharge plan. Nurses said the always coordinate a Plan B of a different caregiver or nursing home placement if the original caregiver doesn't work out.
The goal, said Tricia Brashear, BSN, RN, CHPN, hospice manager at Saint Luke's, is for patients to know we're looking out for them". In some instances, that means devising a workaround, like color-coded medications for illiterate caregivers.
Social workers are an important part of the equation at Hospice of Northeastern Illinois as well. When patients can't remember if they've taken their medications, the team has found it very effective to provide pill boxes.
"An adult child may be at work during the day, but can come home in the evening and see which pills were taken or forgotten earlier," said Sample.
Additionally, Spanish speaking staff is on hand to answer questions from non-English speaking families and a language line for families that speak other languages.
In both facilities, social workers factor heavily into the equation when dealing with patients with cognitive impairment.
"If we can't rely on the patient, we need to work with someone who understands what we're saying," said Sample. "We don't release a patient to a relative until we determine which family member will be in charge of the medication."
Despite the best intentions, medication errors do occur. The HPNA encourages a non-punitive but thorough error reporting process.
At Saint Luke's, the priority is honesty.
"We're human and we make every attempt to learn from our mistakes," simplified Brashear.
In her 18 months at Hospice of Northeastern Illinois, Sample has seen an increase in error reporting, which she attributes partially to a new director of quality.
The hospice's error reporting policy is similar to acute care: file an incident report, track the error via a root cause analysis, ensure the patient is safe, analyze outcomes and tweak education for the patient and family, if necessary.
"We always make sure we're promoting a safe environment for staff to report. Obviously, we're looking into negligence if that occurs. The vast majority of medication error reports are non-punitive," she said. "Our nurses are really embracing error reporting, especially when it doesn't affect the patient, because we can make process improvements very quickly."
Robin Hocevar is senior regional editor at ADVANCE.