Medication Reconciliation Across Cancer Prescribers

AHRQ's Patient Safety Network gives the formal definition. It is "the process of avoiding such inadvertent inconsistencies across transitions in care by reviewing the patient's complete medication regimen at the time of admission, transfer, and discharge and comparing it with the regimen being considered for the new setting of care."

In plain terms, someone compares what you were really taking against what is now written down, then fixes the gaps. It is boring work. It is also one of the highest-value things anyone does with your chart.

AHRQ names three points in a hospital stay where the list must be checked.

• Admission.
• Transfer between units inside the hospital.
• Discharge.

AHRQ explains why these moments go wrong. Hospital clinicians "might not be able to easily access patients' complete pre-admission medication lists." The result is omissions, duplications, or incorrect dosages.

It also notes that unintended changes occur frequently, and that harm from medicines is one of the most common problems after a hospital discharge.

Cancer care multiplies every part of the problem.

You may have five prescribers at once: medical oncology, primary care, surgery, radiation oncology, and pain or palliative care. None of them sees the full picture by default.

Ask specifically whether any of your medicines come from a specialty pharmacy rather than your usual one. Oral anticancer drugs often do. If so, they may be missing from the record other clinicians look at.

Ask too about the medicines that change shape over time. A steroid dose that steps down over ten days is almost never written correctly on a standing list. Neither are anti-sickness drugs taken only as needed. Neither are drugs taken on days one to five of a cycle and not the rest.

Do not build the list from what you remember. Build it from things you can hold.

Bring the actual bottles and boxes. A bottle carries the strength, the prescriber, the fill date and the pharmacy. Memory carries none of that reliably.

Add your pharmacy printout, your last discharge summary, and anything a specialty pharmacy sent you.

MedlinePlus suggests keeping it simple and physical: "Make a medicine chart. List each medicine and the time that you take the medicine."

Give each medicine its own line, and put all of this on it.

• The drug name, both brand and generic.
• The strength, per tablet, capsule or millilitre.
• How many, how often, and at what times.
• What it is for.
• Who prescribed it.
• Which pharmacy fills it.
• Whether you actually take it as written.

That last item is the one most lists get wrong. If you skip the evening dose because it keeps you awake, that belongs on the list. A list that records the intention rather than the reality is the one that causes harm.

Ask the pharmacist to check for duplicates directly. AHRQ names duplications as one of the three classic errors, and a brand name and a generic name for the same drug are an easy way to get two of something.

NCI's guidance on keeping cancer records includes "other supportive or complementary care received." Supplements are not a side note.

NCCIH is direct about the best-known example. "It has been clearly shown that St. John's wort can interact in dangerous, sometimes life-threatening ways with a variety of medicines."

NCCIH also names cancer drugs specifically. St. John's wort can weaken the effects of many medicines, "including irinotecan, imatinib, and docetaxel."

Read that carefully, because it inverts the usual worry. The danger is not only that a supplement might add a side effect. It is that it can make your cancer treatment weaker while everything looks fine.

FDA requires warnings on some drugs against grapefruit and grapefruit juice.

The mechanism is worth knowing. Grapefruit juice blocks an enzyme called CYP3A4 in the small intestine. As FDA puts it, "the juice lets more of the drug enter the blood. When there is too much drug in the blood, you may have more side effects."

FDA lists affected groups, including statins such as Zocor and Lipitor, some blood pressure drugs, transplant anti-rejection drugs, an anti-anxiety drug, certain corticosteroids, heart rhythm drugs, and one antihistamine.

It can also work the other way. With fexofenadine, grapefruit juice "can cause less fexofenadine to enter the blood."

MedlinePlus adds a simpler point that people miss. "Some medicines need to be taken when your stomach is empty." Ask your provider or pharmacist which of yours are affected by food.

The list you go home with is not the list you came in with. Something almost always changed.

Do not restart a medicine the hospital stopped without asking why it was stopped. It may have been paused for a scan. It may have been stopped for good because of a kidney result.

Ask these four questions before you leave.

• Which of my medicines were stopped, and permanently or temporarily?
• Which had the dose changed?
• Which are brand new?
• Which bottles at home should I now stop using?

Then ask for the answers written on the discharge paperwork, not spoken at the door.

Reconciliation only works if one person resolves the conflicts. Ask who that is, by name and role. It is often a pharmacist, and a pharmacist is usually the best person for it.

If nobody owns it, four prescribers will each assume another one is handling it, and none of them will.

NCI's guidance on tracking cancer care says to record:

• Dates of each medical visit.
• Tests and procedures received, with dates and results.
• Treatments received, with dates.
• Side effects and symptoms you have had, with dates.
• Any medicines prescribed.
• Other supportive or complementary care received.

Keep copies of treatment plans and results too. NCI suggests a file folder, or photos saved on your computer. Either works. What does not work is relying on a portal you may lose access to when you change insurance or centers.

• Who is the one person who reconciles my medicine list?
• Are any two of these the same drug under different names?
• Does anything on this list interact with my cancer treatment?
• Do any of my supplements need to stop, and when?
• Which of these must be taken with food, and which without?
• What should I do if I miss a dose of the oral cancer drug specifically?

That last question deserves its own answer from oncology, not from a general leaflet. The rule for a missed dose is not the same for every drug.

• Medication Reconciliation — AHRQ Patient Safety Network
• Managing Cancer Costs and Medical Information — National Cancer Institute
• St. John's Wort and Depression: In Depth — National Center for Complementary and Integrative Health
• Grapefruit Juice and Some Drugs Don't Mix — U.S. Food and Drug Administration
• Taking medicines as prescribed — MedlinePlus Medical Encyclopedia
• Managing Cancer Care — National Cancer Institute