AHRQ’s Web M&M Examines Medication Discrepancies as Well as Hand Hygiene

The current issue of AHRQ Web M&M features a Spotlight Case describing an 80-year-old woman with a history of dementia who was admitted to the hospital with abdominal pain and diagnosed with a bowel obstruction, secondary to a new diagnosis of colon cancer. She underwent an uncomplicated surgical resection of the colon cancer with relief of the obstruction. Postoperatively she developed confusion and agitation consistent with acute delirium. A geriatric psychiatry consulting service at the hospital spoke with the family and reviewed the official medication reconciliation list, which a pharmacist had documented at admission. The family said the patient was on “memory medicine,” but the reconciliation list did not include medicine to treat dementia. The consulting service contacted the outpatient pharmacy and learned the patient was prescribed a cholinesterase inhibitor patch for dementia that was to be replaced weekly. In addition, the Perspective section of the issue features an article by Alexandre R. Marra, M.D., and Michael B. Edmond, M.D., M.P.H., M.P.A., that describes barriers to hand hygiene compliance in health care along with strategies to enhance and measure it. Also featured is a conversation about hand hygiene with Didier Pittet, M.D., M.S., director of the Infection Control Programme and WHO Collaborating Centre on Patient Safety at the University of Geneva Hospitals, Switzerland.