Fourteen Bottles on the Kitchen Table: Medication Reconciliation and Polypharmacy at the First Home Health Visit
Student Name
Master of Science in Nursing Program, Aspen University
N684: Case Management and Home Health Nursing
Instructor Name
Month Day, Year
Fourteen Bottles on the Kitchen Table: Medication Reconciliation and Polypharmacy at the First Home Health Visit
Older adults returning home after a hospital or rehabilitation stay often take many medications, and their lists change at every transition. Home health nurses are frequently the first clinicians to see what patients actually take once they are home, and the first visit is the best opportunity to find errors before they cause harm. This paper describes the problem of medication discrepancies after discharge, the risks of polypharmacy in older adults, and the process of reconciliation and review at the first home health visit, applied to a composite patient.
The Size of the Problem
Discrepancies between what patients are supposed to take and what they take after discharge are nearly universal. In a study of 184 older adults taking at least five medications who went home from post-acute care facilities, 98% had at least one medication discrepancy a week later, with a median of seven per person, and a median of four involved potentially inappropriate medications for older adults (Vasilevskis et al., 2024). Discrepancies include medications omitted, added or taken at the wrong dose, often because patients resume old prescriptions at home or do not understand changes. Cognitive impairment compounds the risk; a pilot study of older adults discharged home from a community hospital linked cognitive impairment with errors in medication self-management (Hain et al., 2012).
The Patient
Mrs. Albright is a composite 81-year-old woman who returned home yesterday after a hip fracture repair, three days in hospital and 16 days in a skilled nursing facility. She lives with her husband, who has mild memory problems. Her conditions include atrial fibrillation, hypertension, type 2 diabetes, osteoarthritis, insomnia and depression. The facility's discharge list includes 14 medications, prescribed by her primary care physician, cardiologist and the facility physician. She has a home health referral for nursing and physical therapy.
Reconciliation at the Kitchen Table
The nurse asks Mrs. Albright and her husband to bring every medication in the house to the kitchen table, including over-the-counter products, supplements and anything in the bathroom or bedside drawer. The nurse then compares each container with the facility discharge list and with the list from her primary care office, asking her how she takes each one. The comparison finds five discrepancies. She has resumed her old metoprolol dose from bottles at home in addition to the new, higher dose started at the facility. She is not taking the calcium and vitamin D prescribed after her fracture, because she did not know it was new. A nighttime pain reliever bought at the pharmacy, which contains the antihistamine diphenhydramine, sits on her nightstand and appears on no list. Her anticoagulant was held around surgery and restarted at the facility, but her home bottle has a different dose. And she takes ibuprofen for hip pain, which raises the risk of bleeding with her anticoagulant.
The nurse sorts the medications into those that match, those that need clarification and those that should not be taken, removes duplicate bottles with the patient's agreement, and contacts the primary care physician the same day with a concise list of the discrepancies and questions. The duplicate beta blocker and the anticoagulant dose are clarified within hours.
Polypharmacy Review
Reconciliation establishes what the patient takes; review asks whether each medication is still right. National criteria for potentially inappropriate medications in older adults identify drugs to avoid or use with caution, including older sedating antihistamines, diphenhydramine among them, which cause confusion and raise fall risk, and nonsteroidal anti-inflammatory drugs combined with anticoagulants because of bleeding risk (American Geriatrics Society Beers Criteria Update Expert Panel, 2023). For Mrs. Albright, who has just broken her hip, sedating medications are especially dangerous.
A structured collaboration between home health nurses and a clinical pharmacist has been tested in a randomized trial. Among Medicare patients with at least one targeted medication problem, such as therapeutic duplication or use of drugs with adverse effects in high-risk patients, medication use improved for 50% of patients in the program compared with 38% with usual care (Meredith et al., 2002). The composite agency uses a similar approach: the nurse sends the reconciled list to the agency's consultant pharmacist, who recommends stopping the diphenhydramine product, replacing ibuprofen with scheduled acetaminophen and reviewing the continued need for her sleeping medication, and the nurse brings these recommendations to her prescribers.
Deprescribing decisions belong to the prescribers and the patient, so the nurse's role is to present the findings clearly and to ask Mrs. Albright what matters to her. She says her priority is to walk without falling again, which makes the case for stopping sedating drugs easier to discuss with her and her physicians.
Supporting Safe Self-Management
A correct list is useful only if the patient can follow it. The nurse assesses whether Mrs. Albright can read labels, open containers and remember doses, and whether her husband can help. Because his memory is impaired, the nurse arranges for the pharmacy to provide prepackaged multi-dose blister packs, simplifies the schedule to two times a day with the prescribers' agreement, and teaches with teach-back, focusing on the anticoagulant and signs of bleeding. The daughter, who visits weekly, receives a copy of the updated list. The nurse updates the list at every visit and checks the blister packs against it.
The nurse also plans for the next transition. Because Mrs. Albright sees three prescribers, the nurse asks her primary care physician to act as the single point of reconciliation, sends the updated list to all three offices and to her pharmacy, and gives her a wallet card with the current list to show at every appointment or emergency visit. At discharge from home health, the nurse repeats the reconciliation so that the list she keeps matches what she actually takes.
Conclusion
Medication discrepancies after discharge are almost universal among older adults, and the first home health visit is the moment to find them. Reconciliation with the actual containers, followed by review against criteria for inappropriate medications and in collaboration with a pharmacist, turns a list of 14 medications into a safer regimen. For Mrs. Albright, one visit found a duplicate beta blocker, a missed supplement, a sedating nighttime antihistamine and a dangerous combination of pain reliever and anticoagulant, each of which could have led to a fall, a bleed or a readmission.
References
American Geriatrics Society Beers Criteria Update Expert Panel. (2023). American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 71(7), 2052-2081. https://doi.org/10.1111/jgs.18372
Hain, D. J., Tappen, R., Diaz, S., & Ouslander, J. G. (2012). Cognitive impairment and medication self-management errors in older adults discharged home from a community hospital. Home Healthcare Nurse, 30(4), 246-254. https://doi.org/10.1097/NHH.0b013e31824c28bd
Meredith, S., Feldman, P., Frey, D., Giammarco, L., Hall, K., Arnold, K., Brown, N. J., & Ray, W. A. (2002). Improving medication use in newly admitted home healthcare patients: A randomized controlled trial. Journal of the American Geriatrics Society, 50(9), 1484-1491. https://doi.org/10.1046/j.1532-5415.2002.50402.x
Vasilevskis, E. E., Trumbo, S. P., Shah, A. S., Hollingsworth, E. K., Shotwell, M. S., Mixon, A. S., & Simmons, S. F. (2024). Medication discrepancies among older hospitalized adults discharged from post-acute care facilities to home. Journal of the American Medical Directors Association, 25(7), Article 105017. https://doi.org/10.1016/j.jamda.2024.105017
How this N 684 Module 6 example is structured
Aspen does not publish N684 module prompts, so check your classroom for the exact instructions. This example sizes the discrepancy problem with evidence, introduces a composite patient, walks through reconciliation with actual containers, reviews appropriateness against national criteria with a pharmacist, and supports safe self-management.
N684 Module 6 questions, answered
What does N684 Module 6 usually ask for?
Aspen's N684 description includes home health nursing care, so a paper on medication management, reconciliation and polypharmacy in the home is a typical assignment. Check your classroom for the prompt.
What is the difference between medication reconciliation and medication review?
Reconciliation establishes an accurate list by comparing sources and what the patient actually takes; review evaluates whether each medication is appropriate, effective and safe for the patient.
Why reconcile with the actual containers?
Because patients often keep old bottles, take over-the-counter products not on any list and misunderstand changes, discrepancies that only appear when the containers are examined.
Write yours, or have the desk draft it
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