R E V I E W S & A N A LY S E S Patients Taking Their Own Medications While in the Hospital Matthew Grissinger, RPH, FISMP, FASCP INTRODUCTION Manager, Medication Safety Analysis Pennsylvania Patient Safety Authority The medications prescribed for and administered to patients while they are hospitalized are typically provided by the hospital’s pharmacy department. However, there are times when it may be necessary for a patient to bring his or her own medications into the hos- pital. For example, patients are often asked to bring their medications with them so that ABSTRACT an accurate medication list can be generated for medication reconciliation. If the drug Pennsylvania facilities submitted 879 the patient needs is not on the hospital’s formulary and the hospital has no alternative medication error reports from July 1, therapy, the patients’ personal medications may be used to avoid an interruption in 2004, through January 31, 2011, to therapy.1 Some patients also may bring their medications from home to the hospital in the Pennsylvania Patient Safety Author- hopes of saving money. Many patients desire to self-medicate with their own medicines ity involving patients taking their own while in the hospital to ease anxiety over the loss of self-control of their care.2 medications while in a hospital. Cat- Hospitals of all sizes face challenges in managing patients’ personal medications. Larger egorization of the reports by harm score institutions and government hospitals generally maintain larger inventories of medica- shows that 77.7% of the events reached tions and have closed formularies. Smaller community and rural hospitals may not the patient and 2.1% of the events have the space or funds to maintain a large inventory of medications and, therefore, resulted in patient harm. Almost 300 may be more likely to allow patients to use their own medications. A survey of directors different medications were mentioned of pharmacy at small hospitals (300 beds or less) found that a majority (90.9%) of the in the reports, and 18.7% of the reports hospitals allowed patients to use their own medications while in the hospital. Of the revealed that patients took multiple hospitals not allowing the use of personal medications, 42.9% sent the medications medications. One or more controlled home with the patient’s family member or friend, 28.6% stored them on the nursing substances were involved in 40.3% of unit until the patient was discharged, and another 14.3% stored them in the pharmacy the events, and more than 25% of the until the patient was discharged.1 reports mentioned a medication con- sidered to be a high-alert medication. The Joint Commission addresses the issues involving patients’ medications in standard Employing strategies to prevent harm MM.03.01.05, which states, “The hospital safely controls medications brought into the from patients taking their own medica- hospital by patients, their families, or licensed independent practitioners.” This stan- tions can be prioritized by proactively dard includes the following elements of performance:3 assessing the risk associated with — The hospital defines when medications brought into the hospital by patients, patients bringing in their own medica- their families, or licensed independent practitioners can be administered. tions, developing a screening process — Before use or administration of a medication brought into the hospital by a for patients admitted to the facility who patient, his or her family, or a licensed independent practitioner, the hospital have a previous history of bringing in identifies the medication and visually evaluates the medication’s integrity. their own medications, and provid- — The hospital informs the prescriber and patient if the medication brought into ing patient and family education upon the hospital by patients, their families, or licensed independent practitioners is admission to the facility about the facil- not permitted. ity’s policies in regard to patients’ use of their own medications. (Pa Patient Saf Pennsylvania facilities have submitted a number of reports to the Pennsylvania Patient Advis 2012 Jun;9[2]:50-7.) Safety Authority mentioning errors with the use of patients’ own medications, many indicating staff have found medications in a patient’s room that were brought from home without the hospital staff’s knowledge. There is scarce literature that addresses situations in which patients bring in their own medications, and a comprehensive search found no literature that discussed patients taking their own medications unbe- knownst to the healthcare staff. Analysis of events reported to the Authority in which patients used their own medications has determined the most common types of events, patient populations involved, medications involved, and reasons why patients bring their medications to the hospital, as reported in Pennsylvania. Page 50 Pennsylvania Patient Safety Advisory Vol. 9, No. 2—June 2012 ©2012 Pennsylvania Patient Safety Authority AGGREGATE ANALYSIS OF Table 1. Predominant Medication Error Event Types Associated with Patients Taking Their PATIENTS BRINGING THEIR Own Medications (n = 746, 84.9% of total reports), July 1, 2004, to January 31, 2011 OWN MEDICATIONS INTO THE NUMBER OF PERCENTAGE OF TOTAL HOSPITAL EVENT TYPE REPORTS REPORTS (N = 879) While reviewing reports submitted to Unauthorized drug 422 48.0% the Authority, analysts have the oppor- Extra dose 70 8.0 tunity to further classify reports, using Wrong dose/overdosage 20 2.3 a “monitor code,” for future querying Monitoring error/other 16 1.8 opportunities. Analysts queried the Wrong drug 15 1.7 Authority’s database for reports assigned Other 203 23.1 the monitor code “PE1,” representing reports identified as errors involving patients using their own medications. In Medications Brought in by to nearly 5,500 people per day.6 The addition, the event descriptions were que- Patients unprecedented rise in overdose deaths ried for phrases such as “own meds” to in the United States parallels a 300% Nearly 300 different medications were identify reports that may involve patients increase since 1999 in the sale of opioid listed in the 879 reports submitted to the taking their own mediations that were painkillers. These drugs were involved in Authority, and in 164 reports (18.7%), not assigned the “PE1” monitor code. 14,800 overdose deaths in 2008, more patients took multiple medications, for The query yielded 879 medication error than cocaine and heroin combined.7 The a total of nearly 1,300 medications men- reports that had been submitted to the misuse and abuse of prescription painkill- tioned in all reports. This does not include Authority from July 1, 2004, through ers was responsible for more than 475,000 reports where no medications were men- January 31, 2011. Categorization of the emergency department visits in 2009, a tioned (n = 114, 13%). reports by harm score, which is adapted number that nearly doubled in just five from the National Coordinating Council Patient found unresponsive. Emer- years.8 Authority analysts found, through for Medication Error Reporting and Pre- gently intubated and appropriate review of event descriptions reported vention harm index,4 shows that 77.7% intervention for symptoms provided. to the Authority and in response to the (n = 683) of the events reached the patient During treatment, two prescription patients taking their own medications, (harm index = C to I) and 2% (n = 18) of bottles, both empty, were found in that nearly 8% (n = 70) of the reported the events resulted in patient harm (harm patient’s bed. Both bottles had refill events resulted in a transfer of the patient index = E to I). dates that occurred during inpatient to a higher level of care, with 67% (n = hospitalization. Family will be ques- 47) of these cases involving patients taking More than 60.8% of the reports (n = 534) tioned in regard to who provided the their own controlled substances. involved the adult population, while medications to the patient. 36.6% (n = 322) involved the elderly. Patient did not disclose presence Only 2.6% (n = 23) of reports involved One or more controlled substances were of home medications, including the pediatric population. involved in 40.3% (n = 354) of events Soma® and Valium, upon admis- reported to the Authority, and 15 of sion when asked by admitting nurse. The predominant medication error event the top 25 mentioned drugs involved Patient took the Soma and Valium types reported by facilities (see Table 1) controlled substances. (A controlled by crushing the medications and included unauthorized drug (48%, n = [scheduled] drug is one for which use self-administering via her gastroin- 422), other (23.1%, n = 203), extra dose and distribution is tightly controlled testinal tube. The medications were (8%, n = 70), and wrong dose/overdosage because of its abuse potential or risk.5) discovered in the patient’s personal (2.3%, n = 20). The problem with controlled substance belongings along with a syringe and Events took place in 68 different care abuse, including opioids (e.g., Percocet®, pill crusher. The patient was found areas, as selected by facilities. The most Vicodin®) and benzodiazepines (e.g., to be lethargic, with minimal response common care areas cited in these events Valium®, Ativan®) in the United States to verbal stimuli. Patient was trans- included medical/surgical units (29.5%, is well documented. In 2010, two million ferred to the intensive care unit n = 259), telemetry units (12.3%, n = 108), people reported using prescription pain- for monitoring. and medical units (5%, n = 44). killers for nonmedical purposes for the first time within the last year—this equates Vol. 9, No. 2—June 2012 Pennsylvania Patient Safety Advisory Page 51 ©2012 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S A patient confused and with slurred Table 2. Top 25 Medications Involved in Medication Errors in Events in which Patients Took speech was found standing in urine Their Own Medications (n = 526, 59.8% of total reports) on the floor. Two pills, Benadryl® NUMBER OF PERCENTAGE OF TOTAL and Ambien®, were found on the MEDICATION REPORTS REPORTS (N = 879) floor. In addition, empty bottles for OxyCODONE*,† 77 8.8% [containing] Zanaflex®, Vicodin, ClonazePAM* 44 5.0 and Darvocet® were found in the patient’s drawer. The pills were ALPRAZolam* 43 4.9 brought in by the patient’s wife, HYDROcodone*,† 41 4.7 but the patient denies taking the LORazepam * 36 4.1 medications. Insulin† 34 3.9 Patients also brought in over-the-counter Metoprolol 25 2.8 medications, as mentioned in 108 reports Methadone*,† 21 2.4 (12.3%), including Tylenol®, Zantac®, Zolpidem * 19 2.2 aspirin, Pepcid®, and diphenhydrAMINE. Diazepam* 19 2.2 A patient with a fever refused the Acetaminophen 19 2.2 hospital-supplied Tylenol. The Propoxyphene with acetaminophen*,† 16 1.8 patient’s parent brought in the Aspirin 14 1.6 patient’s home supply, and the nurse Warfarin† 13 1.5 said the child could take that because MetFORMIN† 11 1.3 the fever needed to be treated. The Morphine*,† 11 1.3 nurse went out to get an oral syringe, Carisoprodol* 11 1.3 and when he came back to the room, DiphenhydrAMINE 10 1.1 the mother said she gave the child FentaNYL*,† 10 1.1 what “seemed like a lot of Tylenol.” Temazepam* 10 1.1 The nurse asked how much, and the parent said 20 mL, which would be Nitroglycerin 9 1.0 640 mg. The doctor was notified and Sertraline 9 1.0 labs were obtained, which showed Fioricet®* (i.e., acetaminophen, 8 0.9 an acetaminophen level of 30 and butalbital, and caffeine) liver functions tests [serum glutamic HYDROmorphone*,† 8 0.9 oxaloacetic transaminase and serum Lisinopril 8 0.9 glutamate pyruvate transaminase] * Controlled substance (categories II through V) increased significantly. † High-alert medication More than 25% (n = 220) of the reports mentioned a medication that would be Reasons Patients Bring Their organizations were intentionally using considered to be a high-alert medication in either the acute or ambulatory care Own Medications patients’ own medications. settings.9,10 Of the 25 most commonly Analysts also reviewed event descriptions A nurse gave an extra dose of feno- mentioned medications (see Table 2), 10 to determine if reporting facilities men- fibrate [which was the patient’s (40%) were high-alert medications. Most tioned the reasons why patients felt the own medication] instead of the of these high-alert medications were opi- need to bring in and self-administer their thalidomide that was scheduled. oids, but two medications, insulin and own medications. Most of the reports The patient’s thalidomide [also her warfarin, were not. Forty percent (n = submitted to the Authority involved home medication] was later found in 28) of the 70 events involving high-alert situations in which the patients brought another patient’s drawer. The next medications resulted in patients being in their medications without inform- dose of fenofibrate was held and tha- transferred to a higher level of care. ing facility staff and self-administered lidomide was administered. them. However, at least 45 reports (5.1%) Vytorin® [a combination tablet of described errors that occurred in which ezetimibe 10 mg and simvastatin Page 52 Pennsylvania Patient Safety Advisory Vol. 9, No. 2—June 2012 ©2012 Pennsylvania Patient Safety Authority 20 mg] was ordered for the patient. contained clonidine 0.2 mg. The were “tired of waiting” for their medica- The pharmacy substituted Zetia® patient said, “I thought it was nerve tion, or that their disease was not being [ezetimibe] 10 mg and Zocor® [sim- medicine.” Physician was informed, adequately treated while in the hospital. vastatin] 20 mg to use for Vytorin, and orders [were] received to continue The nurse discovered that the patient and that was printed on medication Klonopin for [the patient’s] anxiety. had medicated himself with insulin, administration record. The nurse was The patient told the physician that indicating that he was concerned that unfamiliar with that drug. The patient he took his own Coumadin® because staff did not medicate him in a timely brought in Vytorin, and all three medi- he thought we forgot to order it. The manner. The patient had Humalog® cations were taken by the patient. medication was actually on hold. insulin along with insulin syringes in The physician wrote an order for Robi- A nurse found the patient’s husband his room, apparently from home. The nul® for a three-year old child to “use administering home medications medication and syringes were removed home med as ordered.” The bottle was via a peg tube. The medications from the patient’s room. sent to the pharmacy and identified, administered included Zanaflex® A five-year-old patient was seizing for the order entered into the pharmacy 8 mg, Coumadin 5 mg, and docu- about six to seven minutes, with the system, and the bottle returned to floor. sate sodium 100 mg. The patient’s doctor in the room. The patient was The nurse misinterpreted directions husband had been instructed not to apneic, and two nurses were bagging on the bottle [to dilute two tablets administer any medications. The the patient. The mother took the of Robinul in 20 mL of water and physician had ordered Coumadin to medication Diastat® [diazepam] out administer 4 mL orally every six hours] be held; no negative outcome was of a bag and gave [the patient] the and administered two tablets [2 mg] reported due to unauthorized dose. medication, saying there was no time versus 0.4 mg [4 mL] for two doses. for a third party to retrieve When preparing the morning medica- A large portion of the reports (44.5%, tions for the patient, she stated that [the medication]. n = 391) did not specifically state the she already took her medication that The patient’s father was upset with reasoning as to why the patient took morning. She stated that her husband the delay of medications reaching their own medications, while almost 10% brought them in and that she took the nursing unit for his daughter. He (9.8%, n = 86) of the reports indicated “everything, Dilantin®, phenobar- proceeded to administer her Imuran® some level of miscommunication between bital, Colace®, all of them.” The [azathioprine] brought in from her the patient and staff, for example: doctor was notified and order was home. This medication was not — Patients were unaware of which given to hold the medications. approved by pharmacy. medications were prescribed or given The lab alerted the staff that the A patient was agitated about their to them. patient had open bottles of medica- elevated glucose readings for the past — Patients were unaware that their tion on her bed with some of them two checks. Adjustments were made medications were temporarily spilled on the floor. When the patient to NovoLog® scale during the day stopped (i.e., hold order). was asked what she was doing, she shift; however, following the last — Patients were unaware that the direc- stated she didn’t get enough medicine elevated glucose reading, the patient tions for a particular medication so she was taking her own. When expressed concerns about inadequate were different in the hospital com- asked what she took, she stated that treatment. Calls were made to the pared with at home. she took baby aspirin, heart pills, and resident to explain the situation; — Patients were simply unaware that Synthroid®. All of the medications patient was assured that a sliding they should not take their own medi- were removed from the patient’s room scale order would be entered for the cations while in the hospital. and sent to the pharmacy. elevated reading, but no order was The patient used the call bell and Over 12.6% (n = 111) of the reports indi- received. Upon explanation of this asked to speak to the med nurse. cated that patients self-administered their to the patient, she stated, “I already Upon entering the room, the patient own medications because they were not took my own insulin.” She stated, stated, “I took one of my Klonopin® completely satisfied with the care they were “I took Humalog 10 units.” Review [clonazepam]”. The patient held up receiving. For example, patients stated that of glucose level was 95 and, when their bottle of pills, which actually their pain was poorly controlled, that they rechecked again, the glucose was 65. Vol. 9, No. 2—June 2012 Pennsylvania Patient Safety Advisory Page 53 ©2012 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S RISK REDUCTION STRATEGIES Review current organization policies and medications. Specify that procedures to ensure the following items the pharmacist is the health Many institutions are confronted with are addressed: professional who will identify managing the patient’s own medications that are brought in from home, and orga- — Identify the types of personal the medications, and include nizations can have procedures in place medications that are allowed and guidelines for another health for the control and administration of not allowed for use and in which, if professional to identify these these medications. Consider the strategies any, circumstances they are allowed medications if the pharmacist described in this section, which are based to be used while the patient is in the is unavailable. In one pub- on a review of events submitted to the hospital. Examples of circumstances lished account of a hospital’s Authority and observations at the Insti- allowing for personal medication use assessment of medications that tute for Safe Medication Practices: could include the following: patients brought to the hospital, The medication is not available pharmacists were able to identify Proactively assess the risk associated with 95% of the medications, with the use of patients’ own medications. For on the hospital’s formulary, including those medications that 1 in 15 containers of these example, consider performing a failure medications being mislabeled mode and effects analysis to assess the are part of a restricted distribu- tion system, compounded by or unlabeled.11 risk associated with the various scenarios an outside specialty pharmacy, Develop a process to ensure the in which the facility may need to use a investigational medications, and proper labeling of any patient’s patient’s own medications. controlled substances. personal medications that are Develop a screening method for patients allowed for use in accordance There are no therapeutic alter- admitted to the facility who have a pre- with state regulations, making natives on the formulary. vious history of bringing in their own sure that the medications are medications, and take proactive steps to The patient is on a continuous identifiable, in good condition, deter this process. parenteral infusion of such medi- and not expired. Specific chal- cations as Flolan®, Remodulin®, Provide patient and family education lenges to be addressed include or an insulin pump.1 upon admission to the facility about the the following: — Develop an alternative plan to pro- facility’s policies in regard to patients’ use a. Changes in the frequency of vide the medication to the patient if of their own medications. administration. For exam- the pharmacy is unable to supply it — If patients are asked to bring in ple, if a patient was taking before the next dose is due. medications only for reconciliation their medication from home — Determine if the patient should once daily but the directions purposes, explain to the family why be allowed to self-administer his or the medications were needed and have changed in the hospital her own medications. For example, to two times a day. encourage them to take the medica- stating that if a patient’s home medi- tions home. cation must be used, it should be b. The use of bar codes. If the — If the facility does not need to use administered by a nurse. organization uses bar coding a patient’s medications, explain to — Address the pharmacy’s role in this at the point of care, the phar- the patient and family the policy on process, including the following: macy will need to apply a bringing in prescription, over-the- bar code to each medication If the medications are not to counter, and herbal or homeopathic brought in by the patient for be allowed for use, return them medications into the facility. use within the facility. to the patient’s family or care- Review medication administration records givers. If this is not possible, Before medications are sent to (MARs) to determine how the direc- securely store the medications the nursing unit, place stick- tions for patients’ own medications are in a safe location (e.g., the phar- ers or some other means of expressed. For example, some organiza- macy). Ensure a process is in notification on containers for tions simply state “use home meds” on place to return the medications the medications that have been the MAR, which does not reflect the to the patient or family on dis- reviewed by a pharmacist. actual dosage or frequency of administra- charge from the facility. Use a documented tracking tion for those medications. mechanism to communicate Ensure proper verification procedures of patients’ own the use of patients’ personal Page 54 Pennsylvania Patient Safety Advisory Vol. 9, No. 2—June 2012 ©2012 Pennsylvania Patient Safety Authority medications, especially when with the use of patients’ personal unbeknownst to healthcare practitioners. patients bring in controlled medications. One or more controlled substances were substances or investigational — Ensure procedures are in place to involved in over 40% of these events medications. return patients’ personal medica- reported to the Authority, and more than tions before discharge, and note the 25% of these reports mentioned high- If controlled substances are final disposition of the medications alert medications. Employing proactive allowed, dispense them in unit- in the pharmacy records. strategies to address situations in which dose form. patients may bring in their own medica- CONCLUSION tions and implementing a screening — Develop a standardized approach in regard to the storage of patients’ own In Pennsylvania, almost 900 medication method for patients admitted to the facil- errors have been reported from July 1, ity with a previous history of bringing in medications in the patient care area. 2004, through January 31, 2011, involving their own medications can be steps that — In accordance with hospital policy, patients taking their own medications are prioritized to prevent potential harm report any adverse events associated while in healthcare facilities, many times to patients. NOTES 1. Norstrom PE, Brown CM. Use of April 20]. Available from Internet: http:// national estimates of drug-related emer- patients’ own medications in small hos- www.tsbp.state.tx.us/consumer/broch2. gency department visits. Rockville (MD): pitals. Am J Health Syst Pharm 2002 Feb htm. Center for Behavioral Health Statistics 15;59(4):349-54. 6. Substance Abuse and Mental Health and Quality, SAMHSA; 2010. 2. Jones L, Arthurs GJ, Sturman E, et al. Services Administration. Results from 9. Institute for Safe Medication Practices. Self-medication in acute surgical wards. the 2010 national survey on drug use Results of ISMP survey on high-alert J Clin Nurs 1996 Jul;5(4):229-32. and health: summary of national find- medications: differences between nurs- 3. Joint Commission. Standard MM.03.01.05. ings [online]. NSDUH Series H-41, ing, pharmacy, and risk/quality/safety In: Comprehensive accreditation manual for HHS Publication No. (SMA) 11-4658. perspectives. ISMP Med Saf Alert 2012 Feb hospital: the official handbook, update 2 2011 [cited 2012 April 2]. Available 9;17(3):1-4. (CAMH). Oakbrook Terrace (IL): Joint from Internet: http://oas.samhsa.gov/ 10. Institute for Safe Medication Practices. Commission Resources; 2011 Sep. NSDUH/2k10NSDUH/2k10Results. ISMP list of high-alert medications in com- 4. National Coordinating Council for Medi- htm#2.16. munity/ambulatory healthcare [online]. cation Error Reporting and Prevention. 7. Centers for Disease Control and Preven- 2011 [cited 2012 April 15]. Available NCC MERP index for categorizing medica- tion. Vital signs: overdoses of prescription from Internet: http://www.ismp.org/ tion errors [online]. 2001 [cited 2012 April opioid pain relievers—United States, 1999- communityRx/tools/ambulatoryhighalert. 2]. Available from Internet: http://www. 2008. MMWR Morb Mortal Wkly Rep 2011 asp. nccmerp.org/medErrorCatIndex.html. Nov 4;60(43):1487-92. 11. Kostick J, Chidlow J, Plihal T. A program 5. Texas State Board of Pharmacy. Con- 8. Substance Abuse and Mental Health for controlling medications brought to trolled drugs: what is a controlled Services Administration. Drug Abuse the hospital by patients. Am J Hosp Pharm (scheduled) drug? [online]. [cited 2012 Warning Network: selected tables of 1973 Sep;30(9):814-6. (See Self-Assessment Questions on next page.) Vol. 9, No. 2—June 2012 Pennsylvania Patient Safety Advisory Page 55 ©2012 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S LEARNING OBJECTIVES SELF-ASSESSMENT QUESTIONS — Recognize the types of medication The following questions about this article may be useful for internal education and errors that occur when patients assessment. You may use the following examples or come up with your own questions. bring their own medications into the 1. Examples of miscommunication between patients and staff that may lead to hospital. patients taking their own medications while in the hospital include all of the fol- — Recall the most common types lowing EXCEPT: of drugs involved in medication a. Patients are unaware of which medications are prescribed or given to them. errors when patients use their own b. Patients are informed that their medications are temporarily stopped (i.e., hold medications. order). — Identify reasons frequently men- c. Patients do not realize that the directions for a particular medication are differ- tioned in case reports indicating why ent in the hospital compared with at home. patients bring their medications into d. Patients are not told that they should not take their own medications while in the hospital. the hospital. — Select risk reduction strategies for e. Patients are not completely satisfied with the care they are receiving. healthcare organizations to proac- 2. Which of the following statements reflect standards from the Joint Commission? tively address the safe use of patients’ a. The hospital defines when medications brought into the hospital by patients own medications. or their families cannot be administered. b. After the use or administration of a medication brought into the hospital by a patient, the hospital identifies the medication and visually evaluates the medi- cation’s integrity. c. The hospital informs the prescriber and patient if the medication brought into the hospital by patients is permitted. d. The hospital safely controls medications brought into the hospital by patients, their families, or licensed independent practitioners. 3. Reasons why a patient may feel the need to bring their medications into the hospi- tal include all of the following EXCEPT: a. To obtain an accurate medication list for medication reconciliation. b. To provide a drug that is on the hospital’s formulary. c. To avoid an interruption in therapy. d. To save money. e. To ease anxiety over the loss of self-control of their care. 4. According to the event reports submitted to the Pennsylvania Patient Safety Authority involving patients taking their own medications, all of the following statements in regard to the types of medications brought into the hospital by patients are true EXCEPT: a. Fifteen of the top 25 drugs mentioned involved controlled substances. b. Almost 20% of the reports mentioned patients taking more than one medication. c. Patients also brought in over-the-counter medications, including Tylenol®, Zantac®, aspirin, Pepcid®, and diphenhydrAMINE. d. Insulin and warfarin were the types of high-alert medications mentioned most often in the reports. Page 56 Pennsylvania Patient Safety Advisory Vol. 9, No. 2—June 2012 ©2012 Pennsylvania Patient Safety Authority SELF-ASSESSMENT QUESTIONS (CONTINUED) While in the hospital, a patient self-administered atenolol 50 mg from her own supply. The patient brought in her medication from home because she thought that it was okay to take her high blood pressure medicine. However, the patient’s attending physician had not ordered this medication for the patient. 5. What proactive strategies may help to prevent these types of errors? a. Develop a screening method for patients admitted to the facility who have a previous history of bringing in their own medications. b. Inform the patient and family upon admission to the facility about the facil- ity’s policies in regard to patients’ use of their own medications. c. If the medication was brought in for reconciliation purposes, ask the patient’s family to take the medication home. d. All of the above are true. e. Only B and C are true. Vol. 9, No. 2—June 2012 Pennsylvania Patient Safety Advisory Page 57 ©2012 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 9, No. 2—June 2012. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2012 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s An Independent Agency of the Commonwealth of Pennsylvania website at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for more than 40 years, ECRI Institute marries experience and indepen- dence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions. Scan this code with your mobile device’s QR reader to subscribe to receive the Advisory for free.