Organizing Discharge Medicines After Cancer Hospitalization

You come home with a printed discharge list. In the kitchen there is a cabinet full of the bottles you were taking before you went in. The two do not match, and nobody has said which one wins.

That gap is the whole problem, and two specific errors live inside it.

The duplicate: you keep taking the old bottle and start the new one, and end up with a double dose of the same drug under two different names. The omission: a medicine was quietly stopped or quietly started during the stay, and nobody at home knows it happened.

Sort this out in the first day home, not in week three.

Clear a table and lay out all three:

1. The discharge medicine list the hospital printed for you.
2. Every bottle, box, inhaler, patch, cream, and injection pen in the house. Include the bathroom cabinet and the bedside drawer.
3. Everything you take that is not a prescription: pain relievers you buy yourself, vitamins, minerals, dietary supplements, and herbs. The National Cancer Institute is blunt about this. Talk to the doctor or nurse before you take any over-the-counter or prescription drug, vitamin, mineral, supplement, or herb.

Now build one table. For each medicine write four things: the name of the drug, the reason you take it, how much you take, and how often you take it. Those four items are what NCI asks patients to record.

Add allergies and any past bad reaction to the same page.

Work bottle by bottle. Every one has to land somewhere.

• Continue. Same drug, same dose, same timing as before the hospital.
• Changed. Same drug, new dose or new schedule. This pile causes the double doses, because the old bottle and the new bottle look the same.
• Stopped. Do not take it. It should leave the cabinet today.
• New. Started during the stay.

If a bottle does not appear on the discharge list at all, that is not permission to stop it. It may simply have been missed. Call and ask.

Ring the discharging team or the oncology clinic. Say it plainly: "I am reading the discharge list against the bottles at home, and I have questions about six of them."

For each unclear medicine, ask:

• Is this continued, changed, stopped, or new?
• What is it for?
• How long should it go on, and who decides when it stops?
• Does it need a blood test to stay safe, and who orders that test?
• Who refills it, and at which pharmacy?

Write the answers on the same sheet as your table. One page, at the front of the folder.

Before a prescription is filled, the pharmacy and the drug plan run safety checks for drug interactions, wrong doses, and unsafe amounts of opioid pain medicine.

If the patient has a Medicare drug plan, ask about Medication Therapy Management, or MTM. Plans must offer it to people who meet certain requirements or who are in a drug management program. If you qualify, you get it at no cost. A pharmacist or other provider reviews every medicine with you and what it is for. Afterwards you receive written documents, including a Medication List and a Recommended To-Do List. That is exactly the paperwork a family needs after a hospital stay. Call the number on the drug plan card and ask if the patient qualifies.

Two Medicare opioid rules are worth knowing. A first opioid prescription is limited to seven days or less. Taking opioids at the same time as benzodiazepines, a group of sedative medicines, is restricted. If the hospital sent you home with seven days of pain medicine and the pain is not finished, call before the last tablet.

MedlinePlus puts the goal in one line: medicine safety means you get the right medicine and the right dose, at the right times.

At the pharmacy counter, and again at home:

• Check the label shows the right name, the right drug, the right dose, and how often to take it.
• Check the pill looks like the last one you took. Generic makers change and pills do change color, but ask before you swallow something that looks different.
• Read the label every time. Do not work from memory.

Never take an expired medicine. Never crush or split a pill unless the prescriber says you may, because some are built to release slowly. Never take a medicine prescribed for somebody else.

And never stop, restart, double, or shift a dose on your own. If a dose was missed, call and ask what to do about that dose.

Use anchors that are already in the day. Take medicines with meals and keep the pillbox near the kitchen table. Tie a dose to feeding the dog or brushing teeth. Set alarms on the phone. Ask one friend or relative to be the check-in. Keep a written chart with tick boxes. Keep all the medicines in one place.

Tell the team if doses are being missed. That is information they need in order to plan, not a confession.

Do not leave stopped medicines in the cabinet. That is where next month's duplicate comes from, and it is a risk to children, visitors, and pets.

The Food and Drug Administration gives three options, in this order:

1. Drug take-back. Drop the medicine at a take-back location. Many pharmacies and police stations have one. You can also use a pre-paid mail-back envelope. The Drug Enforcement Administration website finds locations by ZIP code.
2. The flush list. A small group of medicines, including some opioids, are dangerous enough that one dose could harm a child or a pet. If take-back is not available, check the FDA flush list and flush only what appears on it.
3. Household trash. For everything else, mix the medicine with something unappealing such as dirt, cat litter, or used coffee grounds. Seal the mixture in a plastic bag and put it in the trash. Do not crush the pills. Scratch your personal details off the label first.

If you think someone has taken too much opioid pain medicine. Call 911 and give naloxone if you have it. CDC lists these signs of an overdose:

• Unconscious, or cannot be woken
• Slow or shallow breathing, or choking, gurgling, or snoring sounds
• Discolored skin, especially the lips or nails
• Small, "pinpoint" pupils that do not react to light

If you are not sure it is an overdose, treat it as one. Keep the person on their side so they do not choke, and stay with them until help arrives.

Signs of infection during cancer treatment. NCI states that infections during cancer treatment can be life threatening and need urgent medical attention. Call the cancer team right away, including nights and weekends, for:

• Fever of 100.4°F (38°C) or higher
• Chills
• Cough or sore throat
• Diarrhea
• Ear pain, headache, sinus pain, or a stiff or sore neck
• Skin rash
• Sores or white coating in the mouth or on the tongue
• Swelling or redness, especially where a catheter enters the body
• Bloody or cloudy urine, or pain when passing urine

Confirm your own fever number with your own team. NCI gives 100.5°F; CDC gives 100.4°F, and your own team may set a different number for you.

Do not sit waiting for a call back. If nobody picks up within a few minutes, or the person is shaking, breathing fast, drowsy or confused as well as hot, go straight to an emergency department or call 911. CDC calls a fever during cancer treatment a medical emergency, because an infection can turn dangerous within hours when blood counts are low.

Signs that two medicines are fighting each other. A bad interaction usually announces itself the same way an overdose does, so treat it the same way. Call 911 or go to an emergency department if the person cannot be roused, breathes slowly or shallowly, becomes suddenly confused or cannot speak properly, has a seizure, bleeds and it will not stop, or passes black or bloody stools. Do the same for swelling of the lips, face or tongue, a spreading rash, or sudden trouble breathing after any new tablet. Bring the one-page medicine sheet with you — it is the fastest thing you can hand the emergency team.

• Chemotherapy and You: Support for People With Cancer — National Cancer Institute
• Infection and Neutropenia During Cancer Treatment — National Cancer Institute
• Medication Errors — MedlinePlus, National Library of Medicine
• Medicine safety: filling your prescription — MedlinePlus Medical Encyclopedia
• Taking medicine at home: create a routine — MedlinePlus Medical Encyclopedia
• Safety checks, drug management programs, and Medication Therapy Management — Medicare.gov
• Disposal of Unused Medicines: What You Should Know — U.S. Food and Drug Administration
• What to Do If You Think Someone Is Overdosing — Centers for Disease Control and Prevention
• Fever During Cancer Treatment — Centers for Disease Control and Prevention
• Drug allergies — MedlinePlus Medical Encyclopedia
• Your Discharge Planning Checklist — Centers for Medicare & Medicaid Services