Medication Safety: A Short Call Could Make the Difference


July / August 2006

Medication Safety

A Short Call Could Make the Difference

I may not be cheap, but I still drive a 10-year-old car with almost 200,000 miles on it. Everything works on it, but when something breaks, I quickly make an appointment to go to the dealership and get it fixed. I have been doing that and tending to regular oil changes and maintenance checkups for the last 10 years. Within a week of a visit for service, Jeannie from the dealership always calls to make sure my car was delivered to me clean, my problem was taken care of, and I was highly satisfied. I feel very good about this, especially since my car has so many miles on it. I feel good about the experience and will continue to go back to the dealership.

Fran is a family friend who is in her 80s. She has made regular visits to her family physician for many years. Though she is generally in good health, she has her share of aches along with medications for her heart, thyroid, and blood pressure. She recently had a sinus infection and was prescribed an antibiotic. I am confident the pharmacist at the local chain pharmacy counseled her to make sure she finished all of the capsules during the next 10 days, told her to call the pharmacy if she had any problems, and probably gave her a sheet of paper with these instructions on it. At the very least, a warning label was affixed to the prescription bottle. But she stopped taking her antibiotic after 4 days because she was feeling better and thought the pills had started to upset her stomach. A week later, Fran was coughing, had a fever, and made another trip to her physician who admitted her to the hospital with a possible pneumonia.

Mollie, the mother of a business associate of mine, is diabetic and has been maintained on oral medication for more than 15 years. She recently had a hospital stay for surgery to remove a non-malignant growth from her thyroid and was discharged on new medications along with her hypoglycemic drugs. Her surgeon told her to return to the office in 1 week for a checkup. But a few days after discharge, she was readmitted to the hospital with a possible broken hip after falling in her home. Upon admission, her blood pressure was 95/60; she was disoriented and dehydrated.

Ambulatory Challenge
At first glance, my car, Fran, and Mollie do not appear to be related, and frankly, they aren’t. But hear me out.

We all know the focus in our industry has been on medication errors, safety, and overall quality management. We have all come to realize that, though we strive to be careful in our daily practice and to instill quality into every interaction we have with every patient, errors occur in spite of our best efforts. We go to great lengths to implement technologies that monitor the Five Rights in the acute care setting. But we all know that the majority of medications are administered in the ambulatory setting, and more importantly, by patients and not by healthcare professionals. The vast majority of prescribed medications (complex, expensive chemicals, some with a variety of annoying or harmful side effects) are administered by a population in our society who are sometimes forgetful, think the medications are too expensive, don’t understand how one medication impacts another, or just don’t think of telling their physicians that “I take aspirin, too.” How do we monitor the Five Rights in this other environment?

We will assume the pharmacist followed all of the correct procedures when Fran’s prescription for the antibiotic was filled in the pharmacy. We know there is good reason she should take the full 10 days worth of antibiotic. But she was feeling better, the pills were upsetting her, and she decided to stop taking her medication. If she had been contacted after a few days to see how she was feeling and asked if she was taking her antibiotic medication or having side effects, she may not have required a hospital stay. A short follow-up call could have prevented her pneumonia.

Mollie may also have benefited from a short follow-up call. A simple check to see how she was doing, how she was feeling, or if she had any questions, might have helped. Perhaps the caller would have realized Mollie wasn’t doing well and that something had to be done; perhaps a close contact could have been called to check in on her; perhaps Mollie’s hip would not have been broken.

I don’t want to believe the outcomes would have been different if Mollie and Fran were old cars rather than elderly patients.

Larry Pawola is associate professor on the faculty in the College of Applied Health Sciences at the University of Illinois at Chicago. He has more than 35 years of experience in technology, clinical practice, and executive management. He is president of his own healthcare information technology and clinical services consulting firm, Lincolnshire Consulting Associates LLC. As a respected industry consultant for over 25 years, Pawola has worked with a variety of ambulatory clinics, community hospitals, and academic medical centers. His work has focused on assessing clinical systems needs, operational improvements, strategic planning, and education. He has also consulted with healthcare companies for the strategic positioning of their technology products. Pawola may be contacted at