Spotty Medication Management in Home Health Causes Dire Results

A significant number of home health agencies may be doing a woefully inadequate job of medication management, contributing to serious and sometimes fatal hazards that people are facing as they transition from hospitals to other settings.

In the period between January 2010 and July 2015, about 3,000 home health agencies inadequately tracked or reviewed new patients’ meds, according to a Kaiser Health News analysis of federal inspection records. That represents about a quarter of all HHAs examined by Medicare, KHN reporter Jordan Rau noted in an article published Monday.

In one example of a medication management lapse, 66-year-old Joyce Oyler was erroneously given methotrexate rather than the diuretic metolazone following a hospitalization for congestive heart failure in 2013, Rau reported. Methotrexate is a cancer drug that can cause “devastating” effects when taken incorrectly—and in the case of Oyler, it caused mouth and throat sores, bleeding from the nose and bowels, and ultimately destroyed her ability to create blood cells. Oyler died of multiple organ failure caused by the medication.


The home health agency caring for Oyler failed to catch the medication error.

“Less than a year before, Missouri state inspectors had cited the agency for inadequately reviewing medications for three patients, and the agency had pledged to make improvements, records show,” Rau wrote. “Still, neither of two agency nurses who visited Oyler at home stopped her from taking the wrong drug.”

Yet, the home health agency was not the only player that contributed to this fatal sequence of events. Workers at the local Hy-Vee pharmacy provided the methotrexate, possibly because a pharmacy technician mis-transcribed the prescription order. A jury awarded Oyler’s family $2 million in damages from the pharmacy, although that later was reduced to $125,000 due to caps in place in Missouri. The hospital involved, Heartland Regional Medical Center, also has paid the family $225,000 in a settlement, according to records cited by KHN.


Overall, hospital-to-home transitions place patients in jeopardy because of systemic issues involving all types of providers, experts told Rau. One major contributing factor is that post-acute providers were excluded from the federal government’s subsidies for implementing electronic medical records, meaning that interconnected digital communications systems are lacking. While more coordinated care has been one stated aim of health care reform, that is not yet a reality for many patients leaving the hospital, according to Don Goldmann, chief medical and scientific officer at the Institute for Healthcare Improvement, a nonprofit.

“This episodic care at different places at different times is not designed to keep the overall safety of the patient in mind,” Goldmann told Rau.

Written by Tim Mullaney

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