Table 1 Protocols used for the steps shown in figure 2.
Steps | Protocols used consists of |
|---|---|
1 | Questions asked: allergies, presence of relative during patient counselling at discharge, marital status, birth country patient and parents, education, readmission rate previous six months |
2 | Check: - Matching of medication at admission with pre-admission medication regarding drug, dose, route and frequency |
3 | Check: - Matching of medication at discharge with pre-admission medication regarding drug, dose, route and frequency - Whether temporally discontinued medication and substituted medication (due to hospital formulary policy) should be resumed |
4 | Check: - Continuing need: discontinue not indicated (temporally prescribed) medication - Consider right dose (e.g. for geriatric patient), simplify drug regimen (e.g. modified release product in stead of plain drug), duration of therapy (e.g. antibiotic prescribed too long, gradually reduce prednisolone) - Laboratory values: international normalized ratio, glomerular filtration rate, glucose, sodium and potassium blood levels to adjust medication if necessary. - Identify suboptimal treatment (e.g. laxative with opioid, gastroprotection with NSAID and risk factors, rescue medication with inhaled corticosteroid, bisfosfonate with long-term prednisolone, isordil with ACS, statin with diabetes mellitus type II) - Drug-drug interactions (pharmacokinetic and pharmacodynamic) and contra-indications (e.g. NSAID with heart failure, COX-2 inhibitor with ischemic heart disease) - Consider cost (e.g. brand to generic drug) - Consider monitoring (e.g. therapeutic drug monitoring, electrolytes, creatin) |
5 | Check: - Appropriateness of new medication - Documentation of (reasons for) changes between discharge prescriptions and pre-admission medications |
7 | Check: - How medication is used by the patient and at what time point. - Continuing need: discontinue not indicated (temporally prescribed) medication or restart medication if patient does not agree with discontinuation (e.g. patient still has pain) - Other medication usage (e.g. over-the-counter medication or herbals) to evaluate whether there are contra-indications or interactions with the medication prescribed at discharge |
8 | Check: - Practical problems with medication use: check whether patient is capable of using his medication (e.g. big tablets, type of inhalator) - Occurrence of adverse drug reactions: check whether these could be prevented or minimized - Forgetting of medication: check whether patient is compliant and what the possible reasons are for non-adherence. Problems with adherence are further explored and possible tools, such as pill boxes, are discussed. |
9 | Check: - Understanding of new prescribed medication - Knowledge of side effects (e.g. bloody or black tarry stools with anticoagulants to recognize bleeding, risk of fracture and prednisolone, increase of blood sugar and prednisolone, rapid heart beats and bronchodilators, sore throat and inhalalation corticosteriods to rinse mouth, stomach pain and NSAID, headache and nitrates/beta-blockers, muscle pain and lipid-lowering medicines, orthostatic hypotension and antihypertensives, diarrhoea and antibiotics, risk of falls/drowsiness and hypnotics, muscle weakness and paraesthesia to recognize low/high potassium) - Written information need: give patient information leaflet for new prescribed medication - Whether there are questions - Which medication the patient still has in stock at home and which medication should be dispensed. |
11 | Register on the medication discharge overview: changes in medication and reasons, possible drug-related problems and follow-up procedures (e.g. therapeutic drug monitoring). This information is automatically registered on the medication summary for the patient also. |