Post-Hospital Medication Discrepancies at Home: Risk Factor for 90-Day Return to Emergency Department

Patient Performance of Care Tasks During Acute Hospitalisation: A Scoping Review

BACKGROUND

Patient self-care is established as improving outcomes, yet acute care in hospitals is provided such that patients tend to be passive recipients of care. Little is known about the extent and type of patient participation in treatment care tasks in acute hospital settings.

AIMS

To map and synthesise available literature on self-performance of care tasks in acute hospital settings.

DESIGN

A scoping review was conducted guided by JBI methodology.

METHODS

A literature search was conducted in July 2021 and updated in March 2024 across five databases: Scopus, PubMed, CINAHL, Embase and Web of Science. Studies were screened using predefined eligibility criteria. Full-text screening and data extraction were performed independently by two researchers. Data were collected using a template specifically designed for this review. Reporting followed the PRISMA-ScR guideline.

RESULTS

Of the 31,361 articles identified, 35 were included. Most of the articles were experimental (n = 20) and conducted in Europe (n = 13), North America (n = 10) and Australia (n = 3). Studies were classified according to investigation of the performance of care tasks (n = 6) or of the outcomes of the performance of the self-care task (n = 29). Most tasks performed involved self-administration of medication (n = 31), only 4 articles referred to other care tasks. Most articles focused on acute tasks (n = 18), while 15 articles referred to chronic care tasks. Ostomy self-care (n = 2) was a separate category, being an acute task that continued into chronic self-care.

CONCLUSION

Performance of care tasks by patients in acute care settings are predominantly related to chronic and pain medication administration.

IMPLICATIONS FOR CARE

Patient preferences and competency to self-perform care tasks during hospitalisation should be assessed and monitored and supported accordingly. Utilising hospitalisation time to observe and assess self-care practices could provide additional teaching opportunities to patient self-care and improve overall care continuity.

REPORTING METHOD

The PRISMA-ScR guideline was followed.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

TRIAL AND PROTOCOL REGISTRATION

This review was registered on Open Science Framework before running the final search: (https://doi.org/10.17605/OSF.IO/D8KS2).

Unintentional medication discrepancies at care transitions: prevalence and their impact on post-discharge emergency visits in critically ill older adults

BACKGROUND

Unintentional medication discrepancies during care transitions pose a significant risk for medication errors, particularly in critically ill older patients. This study aimed to investigate the prevalence of such discrepancies during care transitions and their impact on post-discharge emergency department (ED) visits in this patient population.

METHODS

This retrospective cross-sectional study included patients aged 65 and older who were on chronic medications and admitted to the intensive care units of emergency departments (ED-ICUs) between 2019 and 2020. We evaluated unintentional medication discrepancies, including omissions or changes in medication type, dose, frequency, formulation, or administration route without clear clinical justification during care transition. The association between these discrepancies and post-discharge ED visits was analyzed using a multivariable Cox-proportional hazard model.

RESULTS

Of the 339 patients analyzed, 68% encountered unintentional medication discrepancies at some point during care transitions, with prevalence of 35% at admission, 20% during transfer, and 49% at discharge. After adjusting for confounding factors, patients with unintentional medication discrepancies had a twofold higher risk of ED visits within 30 days of discharge (HR = 2.13, 95% CI = 1.06-4.30).

CONCLUSION

This study demonstrated a substantial prevalence of unintentional medication discrepancies among critically ill older adults during care transitions, significantly increasing the risk of ED visits within a month of discharge. The findings highlight the crucial need for systematic identification and management of medication discrepancies throughout the care transition process to enhance patient safety.

Effectiveness of Clinical Pharmacists-Led Medication Reconciliation to Prevent Medication Discrepancies in Hospitalized Patients: A Non-Randomized Controlled Trial

Aim

Medication discrepancies are a major safety concern for hospitalized patients and healthcare professionals. Medication Reconciliation (MR) is a widely used tool in different practice settings to ensure the proper use of medications.

Objective

This study aimed to assess the effectiveness of the clinical pharmacists-led MR process in identifying, preventing, and resolving medication discrepancies among hospitalized patients.

Patients and Methods

This was a prospective study with an observational and interventional part, conducted at the Internal Medicine Department of a tertiary Hospital in Sudan from January to September 2023. The enrolled patients were divided into two groups, the observation group, in which the routine MR process was performed by doctors (usual care), and the intervention group, in which clinical pharmacists led the MR process.

Results

Compared to the usual care, the clinical pharmacists were more efficient in identifying and preventing medication discrepancies (P=0.001). From a total of 1012 medications, clinical pharmacists' interventions contributed to the detection of (39%) equivalent to 2.2 discrepancies per patient, resolving 325 (83%) and preventing (55%) clinically significant discrepancies. Dose discrepancy (43%) was the most common type of identified discrepancies. These interventions were accepted by (98%) of doctors and implemented in (86%) of the total cases. The main predictors of medication discrepancies (P ≤0.05) for patients were the length of hospital stay, patient-hospital transfer, high number of medication histories, and increased number of medications used during hospitalization.

Conclusion

Through the implementation of the MR process, the clinical pharmacist's interventions substantially contributed to the detection and resolution of medication discrepancies among hospitalized patients. It is recommended that this intervention be disseminated in more hospitals in Sudan to encourage the implementation of appropriate practices.

Effect of frailty on medication deviation during the hospital-family transition period in older patients with cardiovascular disease: An observational study

Studies have shown that frailty increases cardiovascular disease (CVD) incidence in older patients and is associated with poor patient prognosis. However, the relationship between medication deviation (MD) and frailty remains unclear. This study aimed to explore the influence of frailty on MD during the hospital-family transition period among older patients with CVD. Between February 2022 and February 2023, 231 older people CVD patients were selected from a class III hospital in Nantong City using a multi-stage sampling method. A general information questionnaire was used to collect the socio-demographic characteristics of the participants prior to discharge, the frailty assessment scale was used to assess the participants frailty, and a medication deviation instrument was used to assess the participants MD on the 10th day after discharge. Propensity score matching was used to examine the effect of frailty on MD in older patients with CVD during the hospital-family transition period. The incidences of frailty and MD were 32.9% (76/231) and 75.8% (175/231), respectively. After propensity score matching, the risk of MD in frail patients with CVD was 4.978 times higher than that in non-frail patients with CVD (95% CI: [1.616, 15.340]; P = .005). Incidences of frailty and MD during the hospital-family transition period are high in older patients with CVD, and frailty has an impact on MD. Medical staff in the ward should comprehensively examine older patients with CVD for frailty and actively promote quality medication management during the hospital-family transition period to reduce MD occurrence and delay disease progression.

The value of incorporating patient-consulted medication reconciliation in influencing drug-related actions in the outpatient rheumatology setting

Background

Unintentional changes to patients’ medicine regimens and drug non-adherence are discovered by medication reconciliation. High numbers of outpatient visits and medication reconciliation being time-consuming, make it challenging to perform medication reconciliation for all outpatients. Therefore, we aimed to get insight into the proportion of outpatient visits in which information obtained with medication reconciliation led to additional drug-related actions.

Methods

In October and November 2018, we performed a cross-sectional observational study at the rheumatology outpatient clinic. Based on a standardized data collection form, outpatient visits were observed by a pharmacy technician trained to observe and report all drug-related actions made by the rheumatologist. Afterwards, the nine observed rheumatologists and an expert panel, consisting of two rheumatologists and two pharmacists, were individually asked which drug information reported on the drug list composed by medication reconciliation was required to perform the drug-related actions. The four members of the expert panel discussed until consensus was reached about their assessment of the required information. Subsequently, a researcher determined if the required information was available in digital sources: electronic medical record (electronic prescribing system plus physician’s medical notes) or Dutch Nationwide Medication Record System.

Results

Of the 114 selected patients, 83 (73%) patients were included. If both digital drug sources were available, patient’s input during medication reconciliation resulted in additional information to perform drug-related actions according to the rheumatologist in 0% of the visits and according to the expert panel in 14%. If there was only access to the electronic medical record, the proportions were 8 and 29%, respectively. Patient’s input was especially required for starting a new drug and discussing drug-related problems.

Conclusions

If rheumatologists only had access to the electronic medical record, in 1 out of 3 visits the patient provided additional information during medication reconciliation which was required to perform a drug-related action. When rheumatologists had access to two digital sources, patient’s additional input during medication reconciliation was at most 14%. As the added value of patient’s input was highest when rheumatologists prescribe a new drug and/or discuss a drug-related problem, it may be considered that rheumatologists only perform medication reconciliation during the visit when performing one of these actions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08391-7.

Recevoir un soutien aux capacités d’autosoins lors de la transition posthospitalisation en résidence pour aînés en perte d’autonomie : un besoin non comblé

INTRODUCTION

Elderly people who receive appropriate transitional care after hospitalization experience fewer complications.

CONTEXT

However, in Quebec, transitional care for the elderly is limited to case management and targets elderly people who are in need of resources. This often excludes those who remain in homes for the elderly.

OBJECTIVES

The objective of this study was to identify the unmet needs of elderly people during the posthospitalization transition to intermediate care facilities in Quebec, as well as the strategies they use on a daily basis to cope with these needs.

METHODS

A descriptive qualitative study was conducted as part of an intervention research process. Eleven elderly participants and health professionals were recruited (n=11).

RESULTS

The results presented suggest a need to support patients' capacity for self-care, unmet during the post-hospitalization transition to intermediate care facilities.

DISCUSSION

Supporting the self-care abilities of elderly people can help ensure their safety when living in homes for the elderly.

CONCLUSION

Supporting the capacity for self-care is an important component of transitional care after hospitalization, including for elderly people with disabilities.

Risk factors for clinically relevant deviations in patients' medication lists reported by patients in personal health records: a prospective cohort study in a hospital setting

Background Personal health records have the potential to identify medication discrepancies. Although they facilitate patient empowerment and broad implementation of medication reconciliation, more medication discrepancies are identified through medication reconciliation performed by healthcare professionals. Aim We aimed to identify the factors associated with the occurrence of a clinically relevant deviation in a patient’s medication list based on a personal health record (used by patients) compared to medication reconciliation performed by a healthcare professional. Method Three- to 14 days prior to a planned admission to the Cardiology-, Internal Medicine- or Neurology Departments, at Amphia Hospital, Breda, the Netherlands, patients were invited to update their medication file in their personal health records. At admission, medication reconciliation was performed by a pharmacy technician. Deviations were determined as differences between these medication lists. Associations between patient-, setting-, and medication-related factors, and the occurrence of a clinically relevant deviation (National Coordinating Council for Medication Error Reporting and Prevention class \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\ge$$\end{document}≥ E) were analysed. Results Of the 488 patients approached, 155 patients were included. Twenty-four clinically relevant deviations were observed. Younger patients (adjusted odds ratio (aOR) 0.94; 95%CI:0.91–0.98), patients who used individual multi-dose packaging (aOR 14.87; 95%CI:2.02–110), and patients who used \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$\ge$$\end{document}≥ 8 different medications, were at highest risk for the occurrence of a clinically relevant deviation (sensitivity 0.71; specificity 0.62; area under the curve 0.64 95%CI:0.52–0.76). Conclusion Medication reconciliation is the preferred method to identify medication discrepancies for patients with individual multi-dose packaging, and patients who used eight or more different medications.

Implementing a Heart Failure Transition Program to Reduce 30-Day Readmissions

BACKGROUND

Thirty-day readmissions for heart failure (HF) patients are often considered avoidable and linked to inadequate treatment and poor coordination of services and discharge plans.

PROBLEM

Lack of coordinated transitional care services and high 30-day readmissions prompted the interdisciplinary team to develop an HF Transition Program (HFTP).

METHODS

This quality improvement initiative used monthly trend data before and after HFTP implementation.

INTERVENTIONS

The American Heart Association Guidelines for HF Transitions served as a framework for developing the HFTP.

RESULTS

Over an 11-month period, 466 patients were enrolled into the HFTP, resulting in 18.2% (n = 82/450) 30-day cumulative readmission rate that is lower than the 21.9% national average. Sixteen patients did not code for HF after discharge. Heart Failure Transition Program calls to patients and families within the first week home were consistently high at 92.3% (430/466).

CONCLUSIONS

These data show that care coordination and transitional care are important strategies to decrease 30-day HF readmissions.

From Hospital to Home: A Resident-Driven Quality Improvement Project to Overcome Discharge Prescription Barriers

BACKGROUND AND OBJECTIVES

Inability to obtain timely medications is a patient safety concern that can lead to delayed or incomplete treatment of illness. While there are many patient and system factors contributing to postdischarge medication nonadherence, availability and insurance-related barriers are preventable.

PURPOSE

To implement a systematic process ensuring review of discharge prescriptions to ensure availability and resolve insurance barriers before patient discharge.

METHODS

A prospective single-arm quality improvement intervention study to identify and address insurance-related prescription barriers using nonclinical staff. Intervention was pilot tested with sequential spread across general medicine resident teams. The primary outcome was successful obtainment of postdischarge prescriptions confirmed by phone calls to patients or their pharmacies.

RESULTS

From April to August 2015, 59 of 161 patients included in the improvement process (36.6%) had one or more insurance or availability-related barriers with their prescriptions, totaling 89 issues. Forty-three of the 59 patients (72.9%) responded to postdischarge phone calls, 39 of whom (39/43, 90.7%) successfully filled their prescriptions on the first pharmacy visit.

CONCLUSIONS

In our study, we preemptively identified that over a third of patients discharged would have encountered barriers filling their prescriptions. This interdisciplinary quality improvement project using nonclinical team members removed barriers for over 90% of our patients to ensure continuation of medical therapy without disruption and a safer postdischarge plan.

Emergency department visits of older adults within 30 days of discharge: analysis from the pharmacotherapy perspective

OBJECTIVE

To analyze, from the pharmacotherapy perspective, the factors associated to visits of older adults to the emergency department within 30 days after discharge.

METHODS

A cross-sectional study carried out in a general public hospital with older adults. Emergency department visit was defined as the stay of the older adult in this service for up to 24 hours. The complexity of drug therapy was determined using the Medication Regimen Complexity Index. Potentially inappropriate drugs for use in older adults were classified according to the American Geriatric Society/Beers criteria of 2015. The outcome investigated was the frequency of visits to the emergency department within 30 days of discharge. Multivariate logistic regression was performed to identify the factors associated with the emergency department visit.

RESULTS

A total of 255 elderly in the study, and 67 (26.3%) visited emergency department within 30 days of discharge. Polypharmacy and potentially inappropriate medications for older adults did not present a statistically significant association. The diagnosis of heart failure and Medication Regimen Complexity Index >16.5 were positively associated with emergency department visits (OR=2.3; 95%CI: 1.04-4.94; p=0.048; and OR=2.1; 95%CI: 1.11-4.02; p=0.011), respectively. Furthermore, the diagnosis of diabetes mellitus and chronic kidney disease were protection factors for the outcome (OR=0.4; 95%CI: 0.20-0.73; p=0.004; and OR=0.3; 95%CI: 0.13-0.86; p=0.023).

CONCLUSION

The diagnosis of heart failure and Medication Regimen Complexity Index >16.5 were positively associated with the occurrence of an emergency department visit within 30 days of discharge.

Frequency of undocumented medication discrepancies in discharge letters after hospitalization of older patients: a clinical record review study

Transitions of care may result in medication errors, when information about a patient’s medications is not communicated sufficiently. In this clinical record review study, we aimed to evaluate the frequency of undocumented medication discrepancies at discharge from hospital and evaluate which patient characteristics could be associated with undocumented medication discrepancies. Preadmission medication lists were compared against the medication list in the discharge letters, taking into account medication changes documented in the patient record throughout the inpatient stay and in the discharge summary. Out of 200 patients, 174 (87%) were affected by at least one undocumented medication discrepancy, mostly for regular medication. Of the 1972 medications used, 744 (38%) medications were changed without documentation in the patient record, the majority being over-the-counter supplements and herbal medications. Polypharmacy at admission and discharge was associated with increased undocumented medication discrepancies. This study indicates a lack of medication reconciliation during inpatient stay. Correct and complete medication lists at admission and discharge may resolve many of these discrepancies, supporting patient safety at transitions of care.