This is my presentation on Medical Reconciliation in the Hospitalized Patient

1. Reconciliation:
Prescriptions and Patients
A presentation
by Regina Holliday

2. What a case study does not show:
The Holliday Family Christmas 2007

3. Where did ourstorybegin?
Fred Holliday suffered at home from
January to March 2009.
We purchased medicationsfrom this CVS
or were given samples by Fred’s doctor.
For pain:
Heating Pad, Heat Packets, Bengay,
Tylenol, Advil, Hydrocodone-apap 5-500,
Naproxen Sodium and UltramER
Muscle relaxants:
Skelaxin and Cyclobenzaprine
High Blood Pressure: Atacand HCT32
Indigestion: AcipHex-rabeprazole
Laxatives: Senna, Miralax, Maalox and Dulcolax

4. On Friday March 13th, we went to the ER because Fred was in so much pain .
We waited three hours before being sent home
with a prescription for more pain medication.

5. Hospital 1:
Fred was hospitalized on March 25th2009for the administration of tests.
We did not know all the medicines he was taking. I put them in a bag and
brought them to the hospital. The nurse left them in Fred’s room.
On March 27th, he was told while alone that he had “tumors and growths’
throughout his abdomen and kidneys.
He was told all alone in a room with 44 tablets of opioid painkillers.

6. This is my husband’s medical record.
I was told it would cost
73 Cents per page
and we would have to wait 21 days to get a copy.
This document included all the things we needed to
help him including the MAR
(Medical Administration Record).

7. Throughout my husband’s stay he had a lidocaine patch.
Although he was supposed to have 12 hours on and 12 hours off, this did not happen.
The medication reconciliation report specifies that there were not sufficient breaks.
The patches were also frequently left without a marking for date and time. Upon transfer to a
new hospital the lidocaine patch Fred wore was unmarked and the transfer nurse remarked
upon the error.
The patches were also disposed of in
an open trash can although the
Medical Reconciliation Report specifies:
“Should be disposed of in such a ways to
prevent access by children or pets.”
My three year old and ten year old were
often in the same room with patches
in open view in the trash.

8. “Go After Them,
Regina.”
April 18, 2009

9. Hospital 2:
After waiting for 5 days for a transfer
to another hospital for a second opinion,
We were sent with an out of date
and incomplete medical record
and transfer summary.
The new staff spent 6 hours trying to
cobble together a current medical record
Using a telephone and a fax machine.

10. This is the
vital clinical information
from Fred’s electronic medical record.
Presented in the style of
the Nutrition Facts Label.
Then painted on the wall of
Pumpernickel’s Deli in
Washington, DC.

11. What about the chemotherapy?
We were told an order for Sutent had been placed.
It did not come. The hospital pharmacy kicked out the order
as it was too expensive.
I would have to order it from a specialty pharmacy and have
delivered to our apartment.
This painting is “Sutentin a Shadow Box.”
It is a mixed media piece of pills & paper.
It is priced at cost in homage of the
retail price of the pills alone.
17 pills $24,285.71

12. The Inpatient Rehab Center
Fred was sent to rehab to try to walk again.
I was told I would need pharmacy approval
to give him his new chemotherapy drug.
I waited three hours for the pharmacist to come to
Fred’s room, then I went search of the pharmacy.
It was in a quiet hallway on a lower level, the door
was closed with no window or buzzer.
I knocked. The pharmacist was very surprised
to see a patient caregiver.
She wrote out the permission slip.
We talked. Her son also had Autism
and later that week I would help her with her
son’s IEP.

13. Hospital 3.
We were transferred for a blood transfusion.
I asked for a copy of the MAR as I was very
experienced with medication errors during transfer.
I was secretly given a copy by the nurse.
By the time Fred was admitted to the floor there
were errors in the MAR that were rectified
by my copy.

14. Inpatient Hospice
We were in hospice for about 3 weeks,
then we were being transferred home.
I asked for a copy of the MAR to help give
Fred his medicines.
The nurse said she wasn’t supposed to do that.
She did any way.

15. Home Hospice
The home hospice nurse explained
Fred’s list of medicines.
The she gave me the
“Hospice Comfort Pack.”
She told me to place it in my fridge.
I said would not do that with young
children at home. Did it really need
refrigeration?
“No, she said. “That is just where we tell
people to place it.”

16. The Last Instructions
On June 16th the nurse wrote this medication note and I taped it to my kitchen cabinet.
Fred died the next day.
The note still hangs from the cabinet door 3 years later.

17. This is the CVS where are story began.
I still get coupons for Laxatives.
Facing the CVS is the painting
73 Cents.
Our story is the last thing a CVS customer
Sees as they leave the lot clutching their
Pharmacy bag.

18. True reconciliation does not consist
in merely forgetting the past.
-Nelson Mandela
There are speakers here today who will explain how to
prevent healthcare harm through better reconciliation.
I am here to tell you why.
Do not forget our story.
-@ReginaHolliday