Subinternship Medicine · Year 4 · from Subinternship Medicine
Case 1: High-Risk Discharge and Medication Reconciliation
Clinical Image
Source: Wikimedia Commons - Pharmacy - CC BY-SA 4.0
Case Presentation
A 74-year-old woman with heart failure, diabetes, COPD, and chronic kidney disease is admitted for acute heart failure exacerbation. During hospitalization, her medications undergo significant changes: her furosemide is increased from 40 mg daily to 80 mg twice daily, metoprolol is uptitrated from 25 mg to 50 mg twice daily, and a new medication (spironolactone 25 mg daily) is added. Her metformin is held due to acute kidney injury and is not restarted at discharge (creatinine improved but remains 1.8 mg/dL). Her pre-admission medication list includes 14 medications. The sub-intern performs medication reconciliation by comparing the admission medication list, current inpatient orders, and discharge plan. She identifies several issues: the patient was taking lisinopril at home that was never reordered (transcription error), her as-needed albuterol inhaler needs renewal, and she cannot afford the new spironolactone without insurance coverage review. The pharmacy team identifies a patient assistance program for spironolactone. The sub-intern creates detailed discharge medication instructions in plain language with large font (the patient has macular degeneration). She explains each medication change using teach-back: "Can you tell me in your own words why we increased your water pill?" The patient's LACE score (Length of stay 5, Acute admission, 4 Comorbidities, 2 ED visits in past 6 months) is 12, indicating high readmission risk. Enhanced discharge interventions are implemented: early PCP follow-up in 3 days, home health nursing for medication teaching and weight monitoring, and a transition phone call is scheduled for 48 hours post-discharge.
Key Learning Points
- Medication reconciliation requires comparing pre-admission, inpatient, and discharge medications; common errors include omissions, duplications, and unintentional changes
- High-risk medications at discharge include anticoagulants, insulin, diuretics, and opioids; these require specific attention and patient education
- LACE score predicts 30-day readmission risk (Length of stay, Acuity of admission, Comorbidities, Emergency visits); high-risk patients benefit from enhanced transition interventions
- Teach-back technique ("Tell me in your own words...") confirms patient understanding more reliably than simply asking "Do you understand?"