Improving Medication Reconciliation with Comprehensive Evaluation at a Veterans Affairs Skilled Nursing Facility.

BACKGROUND: Unintentional medication discrepancies due to inadequate medication reconciliation pose a threat to patient safety. Skilled nursing facilities (SNFs) are an important care setting where patients are vulnerable to unintentional medication discrepancies due to increased medical complexity and care transitions. This study describes a quality improvement (QI) approach to improve medication reconciliation in an SNF setting as part of the Multi-Center Medication Reconciliation Quality Improvement Study 2 (MARQUIS2). METHODS: This study was conducted at a 112-bed US Department of Veterans Affairs SNF. The researchers used several QI methods, including data benchmarking, stakeholder surveys, process mapping, and a Healthcare Failure Mode and Effect Analysis (HFMEA) to complete comprehensive baseline assessments. RESULTS: Baseline assessments revealed that medication reconciliation processes were error-prone, with high rates of medication discrepancies. Provider surveys and process mapping revealed extremely labor-intensive and highly complex processes lacking standardization. Factors contributing were polypharmacy, limited resources, electronic health record limitations, and patient exposure to multiple care transitions. HFMEA enabled a methodical approach to identify and address challenges. The team validated the best possible medication history (BPMH) process for hospital settings as outlined by MARQUIS2 for the SNF setting and found it necessary to use additional medication lists to account for multiple care transitions. CONCLUSION: SNFs represent a critical setting for medication reconciliation efforts due to challenges completing the reconciliation process and the concomitant high risk of adverse drug events in this population. Initial baseline assessments effectively identified existing problems and can be used to guide targeted interventions.

Acyclovir-induced renal failure in an obese patient.

PURPOSE: A case of acyclovir-induced acute renal failure in an obese patient is described. SUMMARY: A 60-year-old white man arrived at the emergency department complaining of confusion and disorientation. He was 5 ft 7 in tall and weighed 108.9 kg. His medical and surgical histories included chronic obstructive pulmonary disease (COPD), sleep apnea not requiring biphasic positive airway pressure, obesity, oxygen supplementation, and appendectomy. He also had a history of cyst drainage on the back of his neck, with recent drainage emitting a foul odor, and suffered recurrent herpes cold sores on his chin. A lumbar puncture revealed abnormal cerebral spinal fluid. A diagnosis of herpes encephalitis was considered, and the patient was empirically treated with i.v. acyclovir 1 g over 60 minutes every eight hours, with the dosage based on actual body weight. He was also given moxifloxacin 400 mg i.v. daily for possible COPD exacerbation and doxycycline 100 mg i.v. twice daily for possible leptospirosis meningitis. On hospital day 3, his serum creatinine (SCr) and blood urea nitrogen (BUN) concentrations rose to 2.8 g/dL and 32 mg/dL, respectively. Acyclovir was subsequently discontinued, as were all i.v. antibiotics. On day 7, hydration therapy was initiated, as was therapy to alkalinize the urine, and his neurologic status began to improve. At discharge, the patient's SCr and BUN levels were 3.1 g/dL and 38 mg/dL, respectively. His discharge diagnoses included encephalitis with possible viral origin and acyclovir-induced nephrotoxicity. CONCLUSION: An obese man receiving excessive doses of i.v. acyclovir developed acute but reversible renal failure.

Thermodynamic profiles for CO photodissociation from heme model compounds: effect of proximal ligands.

Here we present a comprehensive study of the thermodynamic parameters (enthalpy, entropy, and volume changes) associated with carbon monoxide photodissociation and rebinding to Fe(II) microperoxidase-11 (Fe(II)MP11) and Fe(ll) tetrakis(4-sulfonatophenyl)porphine complex (FeII4SP) with water and 2-methylimidazole as proximal ligands. CO photodissociation from FeII4SP complexes is accompanied by a positive volume change of approximately 17 mL mol(-1). A smaller volume change of approximately 12 mL mol(-1) was observed for CO dissociation from Fe(II)MP-11. We attribute the positive volume change to cleavage of the Fe-CO covalent bond and to solvent reorganization due to the low-spin to high-spin transition. CO binding is an exothermic reaction with an enthalpy change of -17 kcal mol(-1) for the CO-FeII4SP complexes and -13 kcal mol(-1) for the CO-Fe(II)MP11 complex. In all cases, the ligand recombination occurs as a single-exponential process indicating that CO dissociation is followed by direct CO rebinding to a high-spin five-coordinate complex without concomitant dissociation of the proximal base. In addition, observed negative activation entropies and volumes for ligand binding to (2-Melm)FeII4SP and MP-11, respectively, suggest that CO rebinding can be described by an associative mechanism with bond formation being the rate-limiting step.