The Joint Commission has rigorous standards for hospitals during all phases of medication management from prescribing and administering to reconciliation at discharge. Because of this, the Medical Center has a comprehensive medication safety program, which quickly noticed a trend in the fall of 2020. An increase in safety events and anecdotal reporting led the Unit Advisory Committees and Nursing Pharmacy Committee to find that often medications, some of which were delivered to patient care units from the Professional Office Building (POB) Pharmacy and others were the patients’ own, were being left behind at discharge.
After trialing several other options in response, such as making notes on the whiteboards in patient rooms or using Epic reminders, nursing suggested using a bright green wristband to be placed on the patient when POB Pharmacy medications were delivered (often prior to the day of discharge) or when a patient brought a medication from home to be used. In collaboration with our partner in the pharmacy, Ann Jankiewicz, PharmD, a pilot was conducted with 6 Kellogg and 7 North Atrium nurses to try to reduce these errors by implementing the use of the green wristbands to alert discharging nurses that the patient had POB Pharmacy medications or their own medications stored in the patient-specific area of the medication-dispensing machine. This practice has improved their discharge workflow and reduced the number of medications left behind at discharge. The pilot has been so successful that this practice is now used hospital-wide as of July 2021. The pharmacy continues to monitor safety event reports related to medication management at discharge.