Don't Leave the ER Guessing: How One Simple Step Can Prevent a Crisis

Six months ago, I sold a property and agreed to an extended visit with my 89-year-old dad in Florida. He had been living independently but was starting to show subtle signs of decline over the phone. I needed a pause from the hustle of my previous life, and this was a chance to get eyes on him, assess his ability to live on his own, discuss next steps, and spend some time together.

We fell into a rhythm that worked well for both of us. I travel frequently—sometimes for business, sometimes for pleasure—which gave us both some space and independence. He has a wonderful home health aide named Adriana who visits a few times a week to support him and provide some companionship. She has become a treasured ally on dad's journey.

On June 23rd, I traveled to California to attend a landmark event with Jack Canfield. I've been working with Jack since 2010 and he has been a longtime mentor, teacher, and client. Jack was holding his final live training and retirement send off. It was a beautiful reunion of people I love to spend time with. Jack's work has affected my life and my work in profound ways. I simply had to be there. It was a full-circle moment for me.

But while I was away, I got that call from my dad’s fall monitoring company: he’d been taken by ambulance to the hospital.

He fractured his shoulder and sustained soft tissue injuries. He was admitted to the hospital and once he was stable, the hospital planned to transfer him to a rehab facility for physical therapy. Adriana stepped up immediately to fill in for me, bringing comfort items and helping him settle into the hospital and then his rehab facility. My dad, being the fiercely independent man he is, told me to stay in California. He knew how much this trip meant to me and insisted he was okay. He seemed to be in good spirits and had resigned himself to the fact that he would be an inpatient for the long haul. I told him I would see him in a few days.

I am his health care advocate. I was in touch with his care team from the ER, through his hospital stay and to his rehab admission. I coordinated what I could from afar. I got report that he was medically stable and awaiting MRI results to map out a physical therapy plan. I felt confident about the plan and there wasn't anything I more I could do except to call my dad daily to check in. A few days later, I took the red-eye back to Florida and went straight from the airport to rehab to see him.

When I walked into his room he exhaled a sigh of relief. “It is so good to see you,” he said, with tears in his eyes. "Tell me all about your event in California." 
​
But something was off. He was trying to put on a good front, but something wasn't right. He didn’t look like himself. He looked extremely tired. He was shaky. He was teary. When I pushed him to tell me how he was doing, "strange," was all he could say to describe how he felt.  He pointed to his chest reporting discomfort. He talked about feeling dizzy and really tired with numbness and cramping in his legs. He rated his pain an 8 or 9 out of 10 and couldn't pinpoint exactly where he felt it. "I just don't feel good all over," he said. 

I’m a pharmacist. I tend to look at meds first as that is where elderly patients tend to have the most issues. So I excused myself for a minute, went straight to the nurse's station and asked to see his medication administration record. At first, the nurse was hesitant, but once I reminded her I was his healthcare power of attorney, she gave me the printout.

What I saw horrified me.

None of the medications listed on this medication administration record matched the meds he was on at home at the time of his fall. In fact, none of the meds they were giving him were not even indicated for his actual diagnoses. It was as if he had become an entirely different patient on paper. Not only were the meds incorrect, two of the meds they were giving him were potent cardiac meds and known to cause toxicity if not carefully monitored. I immediately instructed the nurse to hold all medications except for pain management until I could piece together what had happened during dad's ER admission, hospital stay, and rehab transfer.

The details of my findings were sent in a letter to the hospital administration, the admitting doctor, his primary care physician and several other providers who took part in his care. Dad's hospital stay did not indicate any reason for the change in his at home med regimen. After careful review of his record, I  determined that a major error was made upon admission to the ER.

In my dad's case, the meds that were prescribed for him upon this ER admission were the same meds he was being treated for an emergent cardiac event during his last hospital stay back in 2018 (7 years ago!!!) that was ultimately treated and resolved with open heart surgery.

The point I want to make here — for you — is this:

Medication errors are shockingly common during healthcare transitions. Any and all transitions. Transitions include ER visits, hospital admissions, hospital discharges, transfer of service from one physician to another, transfers from outpatient to inpatient facilities, at doctor's appointments ... the list goes on and on. The system has become more and more compartmentalized and sometimes, the picture of the whole patient's care plan is fractured. 

Med errors can be devastating. They can cause decline, confusion, pain, and even death. My guess is that if my dad's erroneous med regimen continued, the pulmonary symptoms he was experiencing would have resulted in acute pulmonary toxicity and death.

Many med errors are preventable with one simple tool:
An up-to-date list of home medications — clearly printed, shared, and visible.

Here's what I recommend every caregiver (and every person at any age with a daily med regimen) do:

🧊 Post a current medication list on the refrigerator.
Emergency Medical Services (EMS) are trained to look there when responding to 911 calls. Include other significant emergency paperwork (emergency contact, health care proxy, living will/DNR) along with the med list.

👛 Place a printed copy in your loved one’s wallet or purse.
It should be labeled “In Case of Emergency – Medication List.”

📱 Save a digital copy on their phone, if they have and use one. 
Either in the Notes app or via a health info lock screen if available.
(My dad's has a phone but it's never charged and sits, idle, beside his recliner ... so a list on the refrigerator and in his wallet is the best bet for him.)

👩‍⚕️ Share a copy of their updated medication list with their healthcare proxy, primary caregiver, and bring it to each medical appointment.
That way, you’re not scrambling when someone asks for the “med list” under pressure.

📝 Update the list regularly.
Every time a medication changes — even the dose — it should be updated across all versions.
💡 Include:

• Date updated
• Medication name (brand + generic if possible)
• Dose
• Frequency
• Reason for use
• Known allergies

We assume the system is tracking these things. But when someone is admitted through the ER, transferred to another unit, seen by multiple physicians, and handed off between facilities, errors happen — more often than we’d like to believe.

I'm still waiting for an explanation from all involved in his care about how the heck the med errors happened and why he was prescribed med from an outdated and inaccurate list. His declining status (drug toxicity) was well documented throughout his hospital stay, but they were so focused on his fall and his shoulder injury that no one noticed that he was displaying signs of drug toxicity.

He's been off the meds for four days now and has improved significantly. I shudder to think what might have happened if the med errors had gone unnoticed. 

You don’t have to be a pharmacist to catch a mistake. You just have to be informed, organized, and empowered to ask questions.

Final Thought
If you’re caring for an aging parent — or even just checking in from time to time — don’t wait for a crisis. Create your “emergency-ready” medication list now. Post it on the refrigerator, put a copy in their wallet and on their phone because EMS is trained to look in those places.

You can download a template for a medication list by clicking here.

You’ll never regret being prepared.
And it might just save your parent’s life.

For now, while I'm neck deep in caregiving mode on a daily basis,  I sense a series of blog posts about adult children stepping into a caregiving role will be forthcoming.
--
💛 From my heart to yours,
Trisha

P.S. If you’re navigating the overwhelm of caregiving, medical decisions, and all the emotional complexity that comes with it, my FREE Foundations for Heart-Centered Living course is a beautiful place to return to your center. Click here to access the course.

---