Medication Reconciliation at Hospital Discharge
An 82-year-old woman with heart failure, atrial fibrillation and osteoarthritis is discharged after a fall and a hip fracture. Her admission medicines were bisoprolol 5 mg daily, furosemide 40 mg daily, apixaban 5 mg twice daily, paracetamol as needed, and ibuprofen 400 mg three times daily. On discharge the surgical team has added oxycodone 5 mg four times daily and enoxaparin 40 mg daily for two weeks, and stopped ibuprofen. The discharge letter lists apixaban and enoxaparin together without comment. She lives alone, has mild cognitive impairment, and her daughter collects her medicines. The pharmacy is asked to complete reconciliation and counselling before she leaves.
1. Identify the medication-related risks in this discharge regimen and explain the reasoning.
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Several risks stand out. Combining apixaban with enoxaparin is anticoagulant duplication and markedly increases bleeding risk; enoxaparin bridging is sometimes intentional, but the letter gives no rationale, dose timing or plan, so it must be clarified with the prescriber before supply. The patient is 82 with recent falls and cognitive impairment, so anticoagulation and opioid use need careful review: oxycodone increases sedation, constipation and fall risk, and a laxative and falls advice are needed. Ibuprofen has correctly been stopped because NSAIDs worsen heart failure, reduce renal function and add to bleeding risk with anticoagulants. Furosemide and bisoprolol must be continued for heart failure and rate control, and stopping them abruptly could cause decompensation. Paracetamol remains the safer baseline analgesic but the total daily dose must not exceed 4 g, and less in frailty. Duplicate or omitted items, unclear stop dates for enoxaparin, and the daughter's role in administration all need to be addressed.
2. Describe how you would reconcile the list and what you would tell the patient and her daughter.
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Use a structured reconciliation: obtain the best possible medication history from the patient, daughter, community pharmacy records and repeat prescriptions; compare admission, inpatient and discharge lists; resolve discrepancies with the prescriber, especially the apixaban–enoxaparin overlap, and document the agreed plan including the enoxaparin stop date. Check doses against renal function and weight, confirm monitoring for anticoagulation, and ensure supplies and a compliance aid are arranged. Update the community pharmacy and GP record.
Counselling: explain what each medicine is for and when to take it; warn about bleeding signs (bruising, black stools, blood in urine, prolonged bleeding) and to seek urgent help for them; explain that oxycodone causes drowsiness and constipation, so take a laxative and avoid alcohol, and rise slowly to reduce falls; reinforce that ibuprofen must not be restarted; advise on paracetamol limits; and give a written schedule in large print. Involve the daughter in a teach-back session and provide a single updated list and contact number for questions.