Discrepancies between home medications listed at hospital admission and reported medical conditions

How complete is the information on preadmission psychotropic medications in inpatients with dementia? A comparison of hospital medical records with dispensing data

OBJECTIVES

Reliable information on preadmission medications is essential for inpatients with dementia, but its quality has hardly been evaluated. We assessed the completeness of information and factors associated with incomplete recording.

METHODS

We compared preadmission medications recorded in hospital electronic medical records (EMRs) with community-pharmacy dispensations in hospitalizations with discharge code for dementia at the University Hospital of Udine, Italy, 2012-2014. We calculated: (a) prevalence of omissions (dispensed medication not recorded in EMRs), additions (medication recorded in EMRs not dispensed), and discrepancies (any omission or addition); (b) multivariable logistic regression odds ratio, with 95% confidence interval (95% CI), of ≥1 omission.

RESULTS

Among 2,777 hospitalizations, 86.1% had ≥1 discrepancy for any medication (Kappa 0.10) and 33.4% for psychotropics. When psychotropics were recorded in EMR, antipsychotics were added in 71.9% (antidepressants: 29.2%, antidementia agents: 48.2%); when dispensed, antipsychotics were omitted in 54.4% (antidepressants: 52.7%, antidementia agents: 41.5%). Omissions were 92% and twice more likely in patients taking 5 to 9 and ≥10 medications (vs. 0 to 4), 17% in patients with psychiatric disturbances (vs. none), and 41% with emergency admission (vs. planned).

CONCLUSION

Psychotropics, commonly used in dementia, were often incompletely recorded. To enhance information completeness, both EMRs and dispensations should be used.

Amiodarone and risk of death in contemporary patients with atrial fibrillation: Findings from The Retrospective Evaluation and Assessment of Therapies in AF study

BACKGROUND

There are limited data on mortality outcomes associated with use of amiodarone in atrial fibrillation and flutter (AF).

METHODS

We evaluated the association of amiodarone use with mortality in patients with newly diagnosed AF using complete data from the Department of Veterans Affairs national health care system. We included patients seen in an outpatient setting within 90 days of a new diagnosis for nonvalvular AF between Veterans Affairs fiscal years 2004 and 2008. Multivariate analysis and propensity-matched Cox proportional hazards regression were used to evaluate the association of amiodarone use to death.

RESULTS

Of 122,465 patients (353,168 person-years of follow-up, age 72.1 ± 10.3 years, 98.4% males), amiodarone was prescribed in 11,655 (9.5%). Cumulative, unadjusted mortality rates were higher for amiodarone recipients than for nonrecipients (87 vs 73 per 1,000 person-years, P < .001). However, in multivariate and propensity-matched survival analyses, there was no significant difference in mortality (multivariate hazard ratio 1.01, 95% CI 0.97-1.05, P = .51, and propensity-matched hazard ratio 1.02, 95% CI 0.97-1.07, P = .45). The hazard of death was not modified by age, sex, heart failure, kidney function, β-blocker use, or warfarin use, but there was evidence of effect modification among patients diagnosed with AF as an inpatient versus outpatient.

CONCLUSION

In a national health care system population of newly diagnosed AF, overall use of amiodarone as an early treatment strategy was not associated with mortality.

Impact of incorporating pharmacy claims data into electronic medication reconciliation

PURPOSE

The potential value of adding pharmacy claims data to the medication history in the electronic health record (EHR) to improve the accuracy of medication reconciliation was studied.

METHODS

Three medication history sources were used for this evaluation: a gold-standard preadmission medication list (PAML) created by reviewing all available medication history information, an EHR-generated PAML, and pharmacy claims data. The study population consisted of patients from the Partners Medication Reconciliation Study with medication history information available from all three medication history sources. The aggregated medication list from each medication history source was compared with the gold-standard PAML to identify and categorize missing medications, additional medications, and discrepancies in the various attributes of a medication order, including dose, route, and frequency. McNemar's test was used to compare paired proportions of medication entries across each source to the gold-standard PAMLs.

RESULTS

Fifteen patients had medication histories in all three medication history sources. Medication entries across all three sources included 169 from the gold- standard PAMLs, 158 from the EHR-PAMLs, and 351 from pharmacy claims data. The EHR-PAMLs and pharmacy claims data correctly reflected 52.1% and 43.2% of the gold-standard PAMLs, respectively. Combining the EHR-PAMLs and pharmacy claims resulted in 69.2% of the gold-standard PAMLs correctly reflected (p < 0.0001). Combining these two data sources increased the accuracy of medication history by 17.1%.

CONCLUSION

Combining the EHR-PAML and pharmacy claims data resulted in a significant increase in the number of medications correctly reflected in the gold-standard PAML compared with the EHR-PAML or claims data separately.

An evaluation of a collaborative, safety focused, nurse-pharmacist intervention for improving the accuracy of the medication history

OBJECTIVE

To evaluate the impact of a standardized approach to collecting a medication history on the accuracy of the admission medication list.

METHODS

Pharmacists and nurses developed and implemented a structured, systematic assessment tool for use by nurses in obtaining a medication history. The tool was first evaluated with nursing students in an educational setting using mock patients and simulated scenarios. The number and type of medication errors (omissions) were compared between controls and those using the tool. Based on the findings from this phase of the study, we refined the tool and then implemented it on four medical/surgical units in a large academic teaching hospital and a smaller, affiliated community hospital. We compared medication error rates using hospital safety report records and discrepancies (i.e., delays in ordering, omissions) before and after implementation of the tool.

RESULTS

Accuracy of the medication history improved significantly with student nurses who used the tool versus those who did not (87% versus 74%, P = 0.010). We were unable to evaluate the numbers of medication discrepancies in the academic medical center because of a lack of availability of electronic admission history and physical reports during the study period. At the community hospital, there was a significant increase in the percentage of patients without medication discrepancies (before = 20% versus after = 42%, P = 0.017), a significant reduction of minor medication omissions during the hospital stay (1.10 versus post 0.60, P = 0.003) and a trend toward the reduction of important drug omissions in the discharge summary (pre 0.43 [0.71] versus post 0.18 [0.44], P = 0.053). The most common agents involved in a delay or omission were multivitamins, laxatives, antidepressants, antidiabetic agents, platelet inhibitors, and acid-suppressing agents.

CONCLUSIONS

The use of a structured tool to systematically obtain a medication history produced a measurable improvement in the accuracy of the admission medication list by student nurses and a reduction of medication errors in a community hospital.

Perseverant, non-indicated treatment of obese patients for obstructive lung disease

Background

Bronchodilators are a mainstay of treatment for patients with airflow obstruction. We hypothesized that patients with obesity and no objective documentation of airflow obstruction are inappropriately treated with bronchodilators.

Methods

Spirometric results and medical records of all patients with body mass index >30 kg/m² who were referred for testing between March 2010 and August 2011 were analyzed.

Results

155 patients with mean age of 52.6 ± (SE)1.1 y and BMI of 38.7 ± 0.7 kg/m² were studied. Spirometry showed normal respiratory mechanics in 62 (40%), irreversible airflow obstruction in 36 (23.2%), flows suggestive of restriction in 35 (22.6%), reversible obstruction, suggestive of asthma in 11 (7.1%), and mixed pattern (obstructive and restrictive) in 6 (3.9%). Prior to testing, 45.2% (28 of 62) of patients with normal spirometry were being treated with medications for obstructive lung diseases and 33.9% (21 of 62) continued them despite absence of airflow obstruction on spirometry. 60% (21 of 35) of patients with a restrictive pattern in their spirometry received treatment for obstruction prior to spirometry and 51.4% (18 of 35) continued bronchodilator therapy after spirometric testing. There was no independent association of non-indicated treatment with spirometric results, age, BMI, co-morbidities or smoking history. All patients with airflow obstruction on testing who were receiving bronchodilators before spirometry continued to receive them after testing.

Conclusion

A substantial proportion of patients with obesity referred for pulmonary function testing did not have obstructive lung disease, but were treated nonetheless, before and after spirometry demonstrating absence of airway obstruction.

Estimating the information gap between emergency department records of community medication compared to on-line access to the community-based pharmacy records

Objective

Errors in community medication histories increase the risk of adverse events. The objectives of this study were to estimate the extent to which access to community-based pharmacy records provided more information about prescription drug use than conventional medication histories.

Materials and methods

A prospective cohort of patients with public drug insurance who visited the emergency departments (ED) in two teaching hospitals in Montreal, Quebec was recruited. Drug lists recorded in the patients’ ED charts were compared with pharmacy records of dispensed medications retrieved from the public drug insurer. Patient and drug-related predictors of discrepancies were estimated using general estimating equation multivariate logistic regression.

Results

613 patients participated in the study (mean age 63.1 years, 59.2% women). Pharmacy records identified 41.5% more prescribed medications than were noted in the ED chart. Concordance was highest for anticoagulants, cardiovascular drugs and diuretics. Omissions in the ED chart were more common for drugs that may be taken episodically. Patients with more than 12 medications (OR 2.92, 95% CI 1.71 to 4.97) and more than one pharmacy (OR 3.85, 95% CI 1.80 to 6.59) were more likely to have omissions in the ED chart.

Discussion

The development of health information exchanges could improve the efficiency and accuracy of information about community medication histories if they enable automated access to dispensed medication records from community pharmacies, particularly for the most vulnerable populations with multiple morbidities.

Conclusions

Pharmacy records identified a substantial number of medications that were not in the ED chart. There is potential for greater safety and efficiency with automated access to pharmacy records.

Ascertaining problems with medication histories

BACKGROUND

Accurate and complete medication histories are not always obtained in clinical practice.

OBJECTIVE

This qualitative research study was undertaken to explore the barriers to and facilitators of obtaining accurate medication histories.

METHODS

Individual interviews, based on a structured interview guide, were conducted with 25 patients from both inpatient and ambulatory care clinic settings. Focus groups, based on a semistructured interview guide, were conducted with pharmacists, medical residents, and nurses. Transcribed data were analyzed by forming coded units and assessing these units for emerging themes.

RESULTS

Major themes that emerged from the patient interviews included patient ownership of health and medication knowledge (with knowledge of medications and their side effects and how to take medications being seen as important), patient-specific strategies to improve medication histories (e.g., use of regularly updated medication lists), and suggestions for system-level facilitators to improve medication histories (e.g., centralized databases of medication histories, increased patient education regarding the use and purpose of medications). Major themes also emerged from focus groups with health care professionals, including shared responsibility for medication history-taking among all 3 health care professions, perceptions about the barriers to medication history-taking (including patients not knowing their medications and not bringing their medication lists), and suggestions to improve medication histories (e.g., educating patients to bring medication vials to hospital admissions and appointments, using a centralized computer database for medication histories).

CONCLUSIONS

Key recommendations resulting from this study include using standardized documentation techniques for medication histories, recording of medication history information in centralized electronic databases, educating patients to bring medications to every health care visit, and establishing criteria for pharmacist referral for cases involving complex medication histories.

Polypharmacy and food-drug interactions among older persons: a review

Polypharmacy is generally defined as the use of 5 or more prescription medications on a regular basis. The average number of prescribed and over-the-counter medications used by community-dwelling older adults per day in the United States is 6 medications, and the number used by institutionalized older persons is 9 medications. Almost all medications affect nutriture, either directly or indirectly, and nutriture affects drug disposition and effect. This review will highlight the issues surrounding polypharmacy, food-drug interactions, and the consequences of these interactions for the older adult.

How reliable are patient-completed medication reconciliation forms compared with pharmacy lists?

OBJECTIVES

Medication reconciliation is a Joint Commission for the Accreditation of Healthcare Organizations requirement to reduce medication errors. This study evaluated the reliability of patient-completed medication reconciliation forms (MRs) compared with pharmacy-generated lists and determined if there was a difference in concordance when patients completed the forms from memory compared with when they brought a separate list or pill bottles.

METHODS

We prospectively enrolled patients with completed MRs. Research assistants contacted the patient's pharmacy to determine medications filled in the prior 3 months, which was compared with the MR. Discrepancies and the method by which the patient completed the MR (memory, list, or pill bottles) were recorded.

RESULTS

Three hundred fifteen patients were enrolled. Thirty-three percent made errors of omission (reported by pharmacy, but not on MR), 12.7% made errors of addition (reported on MR, but not by pharmacy), 18.1% made both types of errors, and 36.3% made no errors. Patients with errors were on 5.6 medications compared with 3.6 medications for those without errors (P < .0001). Those completing the MR from a list made 2.3 errors compared with 1.2 for those completing from memory and 1.8 for those completing from their pill bottles (P < .001). Of 390 medications omitted from patient lists, 16% were cardiac medications, 13% were neuropsychiatric agents, and 9.5% were narcotics.

CONCLUSIONS

Thirty-six percent of patients were able to provide a medication list that matched their pharmacy-prescribed drugs. More errors were noted from patients taking more medications and from those completing their MR from a separate list.

Potential risk of medication discrepancies and reconciliation errors at admission and discharge from an inpatient medical service

BACKGROUND

Medication discrepancies, defined as unexplained variations among drug regimens at care transitions, are common. Some are unintended and cause reconciliation errors that are potentially detrimental for patients.

OBJECTIVE

To determine the prevalence of medication discrepancies and reconciliation errors at admission and discharge in hospitalized patients and explore risk factors for reconciliation errors and their potential clinical impact.

METHODS

An observational prospective study was conducted at a general teaching hospital. Patients who were admitted to the internal medicine service and were receiving chronic preadmission treatment were included in the study. Preadmission treatment was compared with the treatment prescribed on admission (first 48 hours) and at hospital discharge, and discrepancies and reconciliation errors were identified. The primary endpoint was the presence of reconciliation errors at admission and/or discharge. Potential risk factors (patient-, medication-, and system-related) for reconciliation errors were analyzed using a multivariate logistic regression model.

RESULTS

Of the 120 patients enrolled in the study between April and August 2009, 109 (90.8%) showed 513 discrepancies. The prevalence of patients with reconciliation errors was 20.8% (95% CI 13.6 to 28.1). Intended medication discrepancies were more frequent at admission (96.6%) than at discharge (75.5%), while reconciliation errors were more frequent at discharge (24.5%) than at admission (3.4%). The prevalence ratio (admission vs discharge) was 2.4 (95% CI 1.9 to 3.0) for discrepancies and 0.65 (95% CI 0.32 to 1.32) for reconciliation errors. The logistic regression analysis revealed an association between the number of discrepancies at admission (OR 1.21; 95% CI 1.01 to 1.44) and age (OR 1.05; 95% CI 0.99 to 1.10) and an increased risk of reconciliation errors.

CONCLUSIONS

Medication reconciliation strategies should focus primarily on avoiding errors at discharge. Since medication discrepancies at admission may predispose patients to reconciliation errors, early detection of such discrepancies would logically reduce the risk of reconciliation errors. Medication reconciliation programs must implement a process for gathering accurate preadmission drug histories and must submit this information to a critical assessment of patients' needs.

Medication use across transition points from the emergency department: identifying factors associated with medication discrepancies

BACKGROUND

As patients move across transition points of care, medication discrepancies are likely to occur. In the emergency department (ED), patients are vulnerable to medication discrepancies because they are in an environment in which rapid decisions need to be made under high levels of stress.

OBJECTIVE

To identify the patient-, environment-, and medication-related factors involving unexplained medication discrepancies across transition points after ED presentation.

METHODS

Using a retrospective chart review design, a stratified, random sampling of data was undertaken over a 12-month period. Information was obtained from an electronic administrative database and medical records as patients moved from the ED to another transition point of care. Medication discrepancies were classified into 2 outcome groups: (1) no discrepancies and situations in which discrepancies were adequately explained and (2) discrepancies that had no adequate explanation.

RESULTS

For the 12-month period, 210 randomly selected patients were included; 73 (34.8%) had at least one unexplained medication discrepancy. Binary logistic regression modeling showed 4 factors that were statistically significant in determining the incidence of at least one unexplained medication discrepancy. Benefit card holders (individuals who receive benefits from government insurance programs comparable to the US-based Medicare and Medicaid initiatives, which include the elderly, the disabled, low income earners, and unemployed persons) had 3.73 greater odds of experiencing an unexplained medication discrepancy (95% CI 1.72 to 8.07; p = 0.001). Patients prescribed 5 or more drugs at discharge from the ED had 12.22 greater odds of having at least one unexplained medication discrepancy (95% CI 5.52 to 27.08; p < 0.001). Patients who were first seen by a physician within 1 hour of a change in working shift had 3.70 greater odds of having an unexplained medication discrepancy (95% CI 1.67 to 8.18; p = 0.001). For each additional minute of wait time for a physician, the odds of having an unexplained medication discrepancy increased by a factor of 1.01 (95% CI 1.00 to 1.01; p = 0.042).

CONCLUSIONS

Patient-, environment-, and drug-related factors contribute to the risk of medication discrepancies across transition points from the ED.