“This is a major breakthrough for patient safety in California,” said Rita Shane, PharmD, Cedars-Sinai vice president and chief pharmacy officer. Shane helped craft the new law’s language regarding medication reviews when high-risk patients are discharged from a hospital.  

Shane said it is essential to review the discharge medication list to make sure that the medications patients take home are correct since the medications they were on prior to hospitalization may need to be changed or discontinued if new treatments have been added.

The new law closes a gap in patient safety and will lead to pharmacist-led medication reviews for high-risk hospital patients when they are discharged. Studies of the medication review practice at discharge—already implemented at Cedars-Sinai for years—demonstrate dramatically lower errors, by as much as 60%.

A Personal Experience With Medication Error

The issue of patient safety has always been a priority for Shane, but it became personal in 1998 when her father was admitted to a hospital for cancer that had metastasized to his brain.

As his condition worsened, Shane’s father was transferred from one hospital to another. In this transition of care, the new hospital did not review his medication list, leading to the abrupt discontinuation of a medication, which triggered an extreme side effect.

“I saw firsthand the negative impact medication reconciliation errors could have on patient care,” Shane said. “From then on, I made it my mission to prevent this from happening to other families.”

Advocacy in Action

In 2018, 20 years after her father’s passing, Shane helped draft and pass a state bill that requires pharmacy staff to review medication profiles for high-risk patients upon admission at acute-care hospitals with more than 100 beds.

The new legislation focusing on medication reviews when patients are discharged serves as a bookend to her original advocacy work.

When combined, the two laws are expected to better protect patients and minimize the risk of medication errors, which present a growing risk due to what Shane calls the “poly problem.” The term refers to the increasing number of patients who have multiple chronic diseases and who often need treatment by multiple physicians and are prescribed multiple drug therapies. 

“These errors are not intentional,” Shane said. “But there are so many moving parts, the errors can, unfortunately, be introduced, which threatens patient safety and can lead to what should be avoidable hospital readmissions.”

Shane said she is already receiving inquiries about the legislation from hospital pharmacists at healthcare centers outside California who want similar measures adopted in their home states. She hopes to someday see these policies enacted nationwide.

Read more from Cedars-Sinai Magazine: How to Manage Multiple Prescriptions

Wildfires across Los Angeles County have forced hundreds of thousands of people to flee their homes, leaving many without critical medications.

But patients can access vital medications using a variety of resources, according to Cedars-Sinai pharmacists.

“There are options for those in need of medications during all types of natural disasters,” said Rita Shane, PharmD, vice president and chief pharmacy officer at Cedars-Sinai.

Shane, alongside Vipul Patel, PharmD, executive director of Pharmacy and Oncology Services; Douglas Malcolm, PharmD, associate director of Ambulatory Pharmacy; and Rachel Vaystub, PharmD, manager of Pharmacy Services, offered advice for navigating medication access during a disaster.  

How can patients refill medications without access to their prescriptions or their regular pharmacy?

Patients have a few options. If they use a chain pharmacy, they can go to any other location, which will be able to access their medication records and provide refills. Or they can visit a local pharmacy, explain their situation, and the pharmacy might be able to determine the patient’s medications by checking with the patient’s insurance company.

Patients can call their insurance provider to get their medication list and ask for a recommended pharmacy. Or they can contact their medical provider and get their prescriptions sent to another pharmacy. Online tools like RxOpen track which pharmacies have remained open during emergencies.

Will pharmacies refill prescriptions early?

Pharmacies can—in good faith—provide a reasonable supply of medications without a prescription during a federal, state or local emergency. Under their professional judgment, pharmacists can refill prescriptions if failing to do so could interrupt ongoing care or create a significant, adverse impact on a patient’s wellbeing. The pharmacist will need to contact the patient’s physician as soon as possible to explain what was provided.

Do patients need to find pharmacies covered by their insurance provider?

Patients can go to any pharmacy in an emergency, especially in a declared state of emergency. Out-of-network pharmacies might cost more up front, but patients might be able to submit a claim to their insurer for reimbursement. Patients should call their insurance company to determine which pharmacy they recommend and whether a reimbursement will be provided.

What should patients do if they are uninsured?

The federal government has activated the Emergency Prescription Assistance Program for specific zip codes in California to help uninsured residents replace prescription medications and certain medical equipment lost or damaged during the wildfires. Call the program’s hotline at (855) 793-7470 to find out if you are eligible and to register. Visit the program’s website to review a list of participating pharmacies. Free clinics also might be able to help with critical medications, and certain local pharmacies might be willing to waive payment during emergencies.

Can patients get controlled substances without a prescription in an emergency?

Controlled substances would be very difficult to access without any proof of prescription. Having a medication list or information from insurance companies helps pharmacies when these medications are needed during emergencies/disasters. Strict regulations require additional steps and may result in delays.

What else should patients know?

For self-administered injectables, appropriate storage, and access to supplies like needles and syringes are major considerations. Many of these medications require refrigeration, but some can remain at room temperature. It is best to consult a pharmacist about how long the medication will last outside a fridge. Local pharmacies can also provide supplies in emergency situations. 

To arrange an interview, contact:
Marni Usheroff | 323-317-0556 | marni.usheroff@cshs.org

For the Cedars-Sinai Newsroom team's complete coverage of the Los Angeles County wildfires, please click here.  

“The key to good outcomes with enoxaparin is careful selection of candidates,” said Lee D. Lam, PharmD, who monitors heart pump patients in the Mechanical Circulatory Support Program at the Cedars-Sinai Comprehensive Transplant Center. “For instance, patients must have a certain level of kidney functioning and lack a history of bleeding, blood clots or allergic reactions to drugs. Due to potential bleeding risks, enoxaparin should not be used within 30 days after the initial surgery to implant the heart pump.”

Lam is the first author of the new study. Oksana Volod, MD, professor of Pathology and Laboratory Medicine at Cedars-Sinai, is the corresponding author.

For the study, investigators analyzed medical records from 85 heart failure patients who had been implanted with left ventricular assist devices (LVADs) to boost the heart’s performance. They found that enoxaparin, which a patient can inject at home, is a treatment strategy that can be achieved at a small fraction of the cost of treatment in a hospital setting while improving quality of life. Use of this drug also was correlated with longer patient survival over a three-year period without major bleeding or blood clot events when compared with in-hospital bridging.

Other Cedars-Sinai authors include Lawrence S. Czer, Carmelita Runyan, Ieeshiah Otarola, Jason Jang, Jason Lau, Mignon Gau, Katrina Hernandez, Tram Ngo, Mario Aguillon, Newman Huie, Julie W. Chen, Robert Cole and Jaime Moriguchi.

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The plan, published in the peer-reviewed journal Neurology® Clinical Practice, covers all aspects of the complicated medication regimen, from guidelines for emergency management of patients on lecanemab, and biweekly patient assessments, to a comprehensive informed consent process, including a provision for an authorized surrogate for adult patients who may lack the cognitive ability to manage their own care.

Lecanemab, recently approved by the Food and Drug Administration (FDA), is a complex therapy requiring biweekly infusions, periodic imaging and laboratory tests, clinical patient assessment, and drug interaction screening. Rita Shane, PharmD, vice president and chief pharmacy officer at Cedars-Sinai, said the guidelines will help guide the management of future complex therapies.

“With an increasing number of FDA approvals of these types of high-cost, innovative therapies, a comprehensive, multidisciplinary planning process not only supports access, but also safety for patients,” Shane said. “The process design we implemented for lecanemab can serve as a blueprint to support safe and effective management of these new, complex neurologic therapies at institutions across the country.”

Additional authors: Sarah Kremen, MD; Zaldy S. Tan, MD, MPH; Hai Tran, PharmD; Thanh G. Tu, PharmD; Nancy L. Sicotte, MD.

Funding: The authors report no targeted funding.

Conflict of interest: S. Kremen was a consultant for Eli Lilly and Company relating to donanemab.

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The findings are published in JAMA Network Open.

The development and use of medications to treat acute and chronic health conditions has improved longevity and quality of life. But for some older adults, taking multiple medications can do more harm than good. Polypharmacy—the use of five or more medications—is associated with a higher risk for falls, fractures, hospitalizations, along with functional and cognitive decline for some aging patients.

“Polypharmacy, especially harmful or inappropriate polypharmacy, is bad. But the research community hasn’t figured out how to consistently move the needle on hospitalizations, quality of life, mortality and other adverse outcomes associated with being on several medications at once,” said corresponding author Michelle Keller, PhD, a health services scientist in the Department of Medicine at Cedars-Sinai.

Investigators analyzed 14 studies that systematically evaluated various tactics used to address the risks of taking five or more medications. They could not find a clear set of practices that consistently helped polypharmacy patients, but some approaches showed promise.

“Intensive, face-to-face interventions were effective in some studies. In those cases, having a healthcare provider review the patient’s medical record, go over the drugs with them to discuss medication adherence or whether a drug was still appropriate, and providing patient education all appeared to reduce hospitalizations,” said senior author Joshua Pevnick, MD, co-director, Division of Informatics at Cedars-Sinai.

Adults 65 and older tend to take more medications. According to a report by the Centers for Disease Control and Prevention, about a third of adults in the U.S. who are in their 60s and 70s take five or more prescription drugs. Medications to control cholesterol, high blood pressure and diabetes are the most common.

“We must weigh the benefit of prescribing a new medication against the possible risk it may present. Can it interact with other medications the patient is taking or impact the disease course in the older adult? For example, a new medication may effectively treat a specific condition but make the person drowsy, putting them at higher risk for a fall or impair their cognitive abilities. The more tools we develop to help us assess the risk-benefit of medications for our patients, the better care we can give them,” said  Sonja Rosen, MD, chief, Section of Geriatric Medicine at Cedars-Sinai.

While time spent discussing medication use with a healthcare provider, in person, did reduce some negative polypharmacy consequences in a few studies, a simple consult with a pharmacist also proved protective in some cases.

“Older adults often develop a good rapport with their pharmacists, and in some of the studies we reviewed, relatively short consults with them were very helpful to polypharmacy patients—especially those who may be at risk for falls or cognitive decline. I think a lot of health systems are recognizing the important role a pharmacist can play in the overall healthcare of their patients,” Keller said.

Identifying who is at higher risk for adverse polypharmacy outcomes is critical in order to develop effective interventions and is the focus of a pilot program in development at Cedars-Sinai.

“We want to create a risk-prediction model using data from the electronic health records of patients seeing primary care physicians. For the polypharmacy patients we identify as being at high risk for health problems associated with their medication regimen. As a first step, we can flag the record and send a message to their physician recommending a consult with a pharmacist, as a first step,” Keller said.

The Cedars-Sinai pilot program is expected to begin this spring.

Funding: This work was supported by National Institutes of Health grant numbers K01AG076865 and K24AG047899.

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Read more on the Cedars-Sinai Blog: The Balancing Act of Fall Prevention