Drug history taking and the identification of drug related problems in an accident and emergency department

Medication Allergy and Adverse Drug Reaction Documentation Discrepancies in an Urban, Academic Emergency Department

INTRODUCTION

Medication histories, including knowledge of allergies and adverse drug reactions (ADRs), are a nationally recognized quality measure. Medication histories in the emergency department (ED) are often inaccurate or incomplete. Our objective was to determine the prevalence and nature of medication allergy and ADR discrepancies in an urban ED.

METHODS

This was a prospective observational descriptive study, enrolling a convenience sample of adults over 7 months at a single academic urban ED. Trained personnel recorded patient demographics and number of daily medications. Patients listed any prior drug allergies or non-allergic ADRs. Following the ED encounter, the patients' self-reported allergies and ADRs were compared to the electronic medical record (EMR) to identify and describe discrepancies.

RESULTS

A sample of 1014 patients, predominantly black (81%), female (60%), and in the 18- to 59-year-old range (69%), was recruited. Most patients were taking at least one daily medication (74%). Three hundred fifteen patients reported at least one allergy (31%), and 252 (25%) at least one ADR. Four hundred sixteen patients (41%) had a discrepancy between their self-report of allergy or ADR and the EMR. Omissions were the most frequent discrepancy. Full descriptions of allergies or ADR were present in 18.4% of charts. Fifty-seven patients (5.6%) were administered a medication which could have interacted with a documented allergy or ADR; none of the allergy EMR records were updated to reflected this.

CONCLUSIONS

In this cross-sectional ED study, drug allergies and ADRs were both highly prevalent. There were significant discrepancies in documentation of allergies and ADRs between patient self-report and the EMR.

Investigating the Relative Significance of Drug-Related Problem Categories

The aim of the review was to investigate whether an assessment of clinical significance can be related to specific drug-related problems (DRPs) and hence may assist in prioritizing individual categories of DRP categorization systems. The literature search using Google Scholar was performed for the period 1990 to 2013 and comprised primary research studies of clinical pharmacy interventions including DRP and clinical significance assessments. Two reviewers assessed the titles, abstracts, and full-text papers individually, and inclusion was determined by consensus. A total of 27 unique publications were included in the review. They had been conducted in 14 different countries and reported a large range of DRPs (71-5948). Five existing DRP categorisation systems were frequently used, and two methods employed to assess clinical significance were frequently reported. The present review could not establish a consistent relation between the DRP categories and the level of clinical significance. However, the categories "ADR" and possibly "Drug interaction" were often associated with an assessed high clinical significance, albeit they were infrequently identified in the studies. Hence, clinical significance assessments do not seem to be useful in prioritizing individual DRPs in the DRP categorization systems. Consequently, it may be necessary to reconsider our current approach for evaluating DRPs.

Management of children's acute diarrhea by community pharmacies in five towns of Ethiopia: simulated client case study

BACKGROUND

Acute diarrhea is the major cause of child morbidity and mortality in low-income nations. It is the second most common cause of death among children <5 years of age globally. The indispensable role of community pharmacists is clearly observed in the prevention and treatment of diarrhea. However, there is a paucity of data on how community pharmacies manage acute childhood diarrhea cases in Ethiopia. This study aimed to evaluate the experience of community pharmacies in the management of acute diarrhea in northern Ethiopia.

METHODS

A simulated case-based cross-sectional study was conducted in community pharmacies from five towns of northern Ethiopia between April 2015 and September 2015. Convenience sampling technique was used to select sample towns. A structured questionnaire was organized to collect the information. Descriptive statistics, chi-squared test, one-way analysis of variance, and binary logistic regression were performed to describe, infer, and test for association between the variables. SPSS for Windows Version 21 was used to enter and analyze the data. A 95% confidence interval and P-value of 0.05 were set to test the level of significance.

RESULTS

Approximately 113 community pharmacies were visited to collect the required data from five towns. Majority (78, 69%) of them were located away from hospitals and health care areas. Nine components of history taking were presented for dispensers. Regarding the patient history, "age" was frequently taken, (90.3%), whereas "chief complaint" was the least to be taken (23%), for patients presenting with diarrhea. Approximately 96 (85.0%) cases were provided with one or more medications. The remaining 17 (15%) cases did not receive any medication. A total of six pharmacologic groups of medications were given to alleviate acute diarrheal symptoms. Majority (66, 29.6%) of the medications were oral rehydration salts with zinc. The mean number of medications was 1.99 per visit. Components of advice, such as dose, frequency, duration, drug action, and adverse drug reactions, were found to vary among the five towns at a statistically significant level.

CONCLUSION

Community pharmacies provided inadequate treatment for acute childhood diarrhea. Inappropriate history taking and incorrect drug and food instructions have been frequently encountered during acute diarrhea management. Practitioners working in northern Ethiopia should receive proper training on the management of acute childhood diarrhea.

Medical History of Elderly Patients in the Emergency Setting: Not an Easy Point-of-Care Diagnostic Marker

Background. Medical histories are a crucially important diagnostic tool. Elderly patients represent a large and increasing group of emergency patients. Due to cognitive deficits, taking a reliable medical history in this patient group can be difficult. We sought to evaluate the medical history-taking in emergency patients above 75 years of age with respect to duration and completeness. Methods. Anonymous data of consecutive patients were recorded. Times for the defined basic medical history-taking were documented, as were the availability of other sources and times to assess these. Results. Data of 104 patients were included in the analysis. In a quarter of patients (25%, n = 26) no complete basic medical history could be obtained. In the group of patients where complete data could be gathered, only 16 patients were able to provide all necessary information on their own. Including other sources like relatives or GPs prolonged the time until complete medical history from 7.3 minutes (patient only) to 26.4 (+relatives) and 56.3 (+GP) minutes. Conclusions. Medical histories are important diagnostic tools in the emergency setting and are prolonged in the elderly, especially if additional documentation and third parties need to be involved. New technologies like emergency medical cards might help to improve the availability of important patient data but implementation of these technologies is costly and faces data protection issues.

Which Medication Is the Patient Taking at Admission to the Emergency Ward? Still Unclear Despite the Swedish Prescribed Drug Register

INTRODUCTION

Correct information on patients' medication is crucial for diagnosis and treatment in the Emergency Department. The aim of this study was to investigate the concordance between the admission chart and two other records of the patient's medication.

METHODS

This cohort study includes data on 168 patients over 18 years admitted to the Emergency Ward between September 1 and 30, 2008. The record kept by the general practitioner and the patient record of dispensed drugs in the Swedish Prescribed Drug Register were compared to the admission chart record.

RESULTS

Drug record discrepancies of potential clinical significance between the admission chart record and the Swedish Prescribed Drug Register or general practitioner record were present in 79 and 82 percent, respectively. For 63 percent of the studied patients the admission chart record did not include all drugs registered in the Swedish Prescribed Drug Register. For 62 percent the admission chart record did not include all drugs registered in the general practitioner record. In addition, for 32 percent of the patients the admission chart record included drugs not registered in the Swedish Prescribed Drug Register and for 52 percent the admission chart record included drugs not found in the general practitioner record. The most discordant drug classes were cardiovascular and CNS-active drugs. Clinically significant drug record discrepancies were more frequent in older patients with multiple medication and caregivers.

CONCLUSION

The apparent absence of an accurate record of the patient's drugs at admission to the Emergency Ward constitutes a potential patient safety hazard. The available sources in Sweden, containing information on the drugs a particular patient is taking, do not seem to be up to date. These results highlight the importance of an accurate list of currently used drugs that follows the patient and can be accessed upon acute admission to the hospital.

Educating medical trainees on medication reconciliation: a systematic review

BACKGROUND

Effective medication reconciliation is critical in reducing the risk of preventable adverse drug events. Medical trainees are often responsible for medication reconciliation on admission, transfer and discharge of the most vulnerable patients; therefore, it is important that trainees are educated on this aspect of quality care.

METHODS

We conducted a systematic review using MEDLINE and EMBASE databases to identify education initiatives targeted at improving trainee skill and knowledge in carrying out medication reconciliation. Studies published in English or French between July 1980 and July 2013, where the primary focus of the article was the role of medical trainees in conducting medication reconciliation, and where trainee-specific data was reported, were included. Included articles must have reported trainee-specific data. Given the anticipated heterogeneity and array of outcomes, we were unable to employ a specific tool in assessing the risk of bias across studies.

RESULTS

Seven studies met pre-specified eligibility criteria, indicating the lack of published education initiatives targeted towards improving trainee knowledge and experience. Four described an education intervention targeted towards students completing internal medicine clerkship, while the remaining 3 were implemented among residents. Although no two interventions were the same, 5 out of 7 included an experiential component.

CONCLUSIONS

Varying success was achieved with medication reconciliation education interventions. While some noted improved competence and/or confidence amongst trainees, namely undergraduate medical students, others noted little effect resulting from the intervention.

Custom and practice: a multi-center study of medicines reconciliation following admission in four acute hospitals in the UK

BACKGROUND

Many studies have highlighted the problems associated with different aspects of medicines reconciliation (MR). These have been followed by numerous recommendations of good practice shown in published studies to decrease error; however, there is little to suggest that practice has significantly changed. The study reported here was conducted to review local medicines reconciliation practice and compare it to data within previously published evidence.

OBJECTIVES

To determine current medicines reconciliation practice in four acute hospitals (A-D) in one region of the United Kingdom and compare it to published best practices.

METHOD

Quantitative data on key indicators were collected prospectively from medical wards in the four hospitals using a proforma compiled from existing literature and previous, validated audits. Data were collected on: i) time between admission and MR being undertaken; ii) time to conduct MR; iii) number and type of sources used to ascertain current medication; and iv) number, type and potential severity of unintended discrepancies. The potential severity of the discrepancies was retrospectively dually rated in 10% of the sample using a professional panel.

RESULTS

Of the 250 charts reviewed (54 Hospital A, 61 Hospital B, 69 Hospital C, 66 Hospital D), 37.6% (92/245) of patients experienced at least one discrepancy on their drug chart, with the majority of these being omissions (237/413, 57.1%). A total of 413 discrepancies were discovered, an overall mean of 1.69 (413/245) discrepancies per patient. The number of sources used to reconcile medicines varied with 36.8% (91/247) only using one source of information and the patient being used as a source in less than half of all medicines reconciliations (45.7%, 113/247). In three out of the four hospitals the discrepancies were most frequently categorized as potentially requiring increased monitoring or intervention.

CONCLUSION

This study shows higher rates of unintended discrepancies per patient than those in previous studies, with omission being the most frequently occurring type of discrepancy. None of the four centers adhered to current UK guidance on medicines reconciliation. All four centers demonstrated a strong reliance on General Practitioner (GP)-based sources. A minority of discrepancies had the potential to cause injury to patients and to increase utilization of health care resources. There is a need to review current practice and procedures at transitions in care to improve the accuracy of medication history-taking at admission by doctors and to encourage pharmacy staff to use an increased number of sources to validate the medication history. Although early research indicates that safety can be improved through patient involvement, this study found that patients were not involved in the majority of reconciliation encounters.

Design of a medication reconciliation application: facilitating clinician-focused decision making with data from multiple sources

BACKGROUND

Medication reconciliation is an essential, but resource-intensive process without a "gold standard" to measure medication adherence. Medication reconciliation applications that focus on facilitating clinicians' decision-making are needed. Since no single available source of medication information is adequate, combining data sources may improve usefulness and outcomes.

OBJECTIVES

We aimed to design a medication reconciliation application that could incorporate multiple data sources and convey information about patients' adherence to prescribed medications. We discuss design decisions integral to developing medication reconciliation applications for the electronic health record. The discussion is relevant for health IT developers, clinical providers, administrators, policy makers, and patients. Three hypotheses drove our design of this application: 1) Medication information comes from a variety of sources, each having benefits and limitations; 2) improvements in patient safety can result from reducing the cognitive burden and time required to identify medication changes; 3) a well-designed user interface can facilitate clinicians' understanding and clinical decision making.

METHODS

Relying on evidence about interface design and medication reconciliation, an application for the electronic health record at an academic medical center in the U.S. was designed. Multiple decisions that considered the availability, value, and display of the medication data are explored: Information from different sources; interval changes in medications; the sorting of information; and the user interface.

RESULTS

THE PROTOTYPE MEDICATION RECONCILIATION APPLICATION DESIGN REFLECTS THE VISUAL ORGANIZATION, CATEGORIZATION, MODALITY OF INTERACTIONS, AND PRESENTATION OF MEDICATION INFORMATION FROM THREE DATA SOURCES: patient, electronic health record, and pharmacy.

CONCLUSIONS

A new medication reconciliation user interface displays information from multiple sources, indicates discrepancies among sources, displays information about adherence, and sorts the medication list in a useful display for clinical decision making. Gathering, verifying, and updating medication data are resource-intensive processes. The outcomes of integrating, interpreting, and presenting medication information from multiple sources remain to be studied.

Using novel Canadian resources to improve medication reconciliation at discharge: study protocol for a randomized controlled trial

Background

Adverse drug events are responsible for up to 7% of all admissions to acute care hospitals. At least 58% of these are preventable, resulting from incomplete drug information, prescribing or dispensing errors, and overuse or underuse of medications. Effective implementation of medication reconciliation is considered essential to reduce preventable adverse drug events occurring at transitions between community and hospital care. An electronically enabled discharge reconciliation process represents an innovative approach to this problem.

Methods/Design

Participants will be recruited in Quebec and are eligible for inclusion if they are using prescription medication at admission, covered by the Quebec drug insurance plan, admitted from the community, 18 years or older, admitted to a general or intensive care medical or surgical unit, and discharged alive. A sample size of 3,714 will be required to detect a 5% reduction in adverse drug events. The intervention will comprise electronic retrieval of the community drug list, combined with an electronic discharge reconciliation module and an electronic discharge communication module. The primary outcomes will be adverse drug events occurring 30 days post-discharge, identified by a combination of patient self-report and chart abstraction. All emergency room visits and hospital readmission during this period will be measured as secondary outcomes. A cluster randomization approach will be used to allocate 16 medical and 10 surgical units to electronic discharge reconciliation and communication versus usual care. An intention-to-treat approach will be used to analyse data. Logistic regression will be undertaken within a generalized estimating equation framework to account for clustering within units.

Discussion

The goal of this prospective trial is to determine if electronically enabled discharge reconciliation will reduce the risk of adverse drug events, emergency room visits and readmissions 30 days post-discharge compared with usual care. We expect that this intervention will improve adherence to medication reconciliation at discharge, the accuracy of the community-based drug history and effective communication of hospital-based treatment changes to community care providers. The results may support policy-directed investments in computerizing and training of hospital staff, generate key requirements for future hospital accreditation standards, and highlight functional requirements for software vendors.

Trial registration

NCT01179867

A Cost-Effectiveness Evaluation of Hospital Discharge Counseling by Pharmacists

Objectives: This study estimated the cost-effectiveness of pharmacist discharge counseling on medication-related morbidity in both the high-risk elderly and general US population. Methods: A cost-effectiveness decision analytic model was developed using a health care system perspective based on published clinical trials. Costs included direct medical costs, and the effectiveness unit was patients discharged without suffering a subsequent adverse drug event. A systematic review of published studies was conducted to estimate variable probabilities in the cost-effectiveness model. To test the robustness of the results, a second-order probabilistic sensitivity analysis (Monte Carlo simulation) was used to run 10 000 cases through the model sampling across all distributions simultaneously. Results: Pharmacist counseling at hospital discharge provided a small, but statistically significant, clinical improvement at a similar overall cost. Pharmacist counseling was cost saving in approximately 48% of scenarios and in the remaining scenarios had a low willingness-to-pay threshold for all scenarios being cost-effective. In addition, discharge counseling was more cost-effective in the high-risk elderly population compared to the general population. Conclusion: This cost-effectiveness analysis suggests that discharge counseling by pharmacists is quite cost-effective and estimated to be cost saving in over 48% of cases. High-risk elderly patients appear to especially benefit from these pharmacist services.

Pharmacists' participation in the documentation of medication history in a developing setting: An exploratory assessment with new criteria

Objective

To assess the impact of pharmacists’ participation on the frequency and depth of medication history information documented in a developing setting like Nigeria

Method

The study consisted of two phases. The first phase was a baseline cross-sectional assessment of the frequency and depth of medication history information documented by physicians in case notes of systematic samples of 900 patients that were stratified over 9 Medical outpatients Units at a premier teaching hospital in south western Nigeria. The second phase was an exploratory study involving 10 pharmacists who conducted cross-sectional medication history interview for 324 randomly selected patients.

Results

49.2% of patients, whose medication history were documented at the baseline, by physicians, were males; while 50.3% of patient interviewed by pharmacists were male. Mean age (SD) of males and females whose medication histories were documented by physicians and pharmacists were 43.2 (SD=18.6), 43.1 (SD=17.9) years and 51.5 (SD=17.6), 52.1 (SD=17.4) years respectively. The frequency of medication history information documented by pharmacists was significantly higher for twelve of the thirteen medication history components (P < 0.0001). These include prescription medicines; over the counter medicines; source of medicines; adverse drug reactions; allergy to drugs, allergy to foods, allergy to chemicals; patient adherence; alcohol use; cigarette smoking; dietary restrictions and herbal medicine use. The depth of medication history information acquired and documented by pharmacist was significantly better for all the thirteen medication history components (P<0.0001).

Conclusion

Pharmacists’ participation resulted in significant increase in frequency and depth of medication history information documented in a developing setting like Nigeria. The new medication history evaluation criteria proved useful in assessing the impact of pharmacists’ participation.

Medication histories: does anyone know what medicines a patient should be taking?

Objective

To determine and evaluate the accuracy of physician-acquired medication histories for patients admitted to the surgical and medical admission units in a large teaching hospital in the UK.

Method

The pharmacist obtained a medication history, including allergy status, by interviewing the patient. This was compared with the physician's history as documented in the medical notes and with a third source, for example general practitioner (GP) records, and then with what was prescribed on the inpatient prescription chart.

Key findings

In total, 126 medical patients and 51 surgical patients were reviewed. 102 (17%) medicines were prescribed on the inpatient chart but not documented in the medical notes; 179 (16.7%) medicines were documented in the notes but not prescribed on the prescription chart, with no explanation by the doctor; 75 (9.8%) medicines were documented in the notes by doctor with no dose; 227 (41%) medicines from pharmacist interview were not prescribed on the chart; 189 (34.1%) medicines were identified from pharmacist interview but not recorded in the notes; 113 (28.9%) medicines from pharmacist interview had a dose that was different in the notes; 45 (12.8%) medicines from pharmacist interview had a dose that was different on the chart; and 103 (21.1%) medicines from pharmacist interview had a dose different from that in the third source. A total of 51 medicines were identified from the pharmacist interviews that were not on the records of the GP or nursing home, and these accounted for approximately 5% of all medicines recorded.

Conclusion

This study supports the findings of previous studies that there are substantial numbers of discrepancies between documented sources of patients' medicines and what patients report they are taking. Furthermore our findings add to existing knowledge by highlighting the need for clearer and more complete documentation of medication histories in the patient's medical notes. The inaccuracies observed with GPs' records and in comparison with hospital records suggest that currently there is no ‘gold standard’ medication history available, other than a list of drugs taken from a patient who is perceived to be ‘reliable’.

An evaluation of the contribution of the medical admissions pharmacist at a London teaching hospital

Objective

To evaluate the contribution of the medical admissions pharmacist (MAP) at a London teaching hospital.

Method

A descriptive study using quantitative methods to compare the activities of former non-designated pharmacists with that of the currently employed MAP in relation to interventions made regarding the drug therapy of patients in one medical admissions ward in a London hospital. The outcome measures were numbers of pharmacist interventions made and their clinical significance. A multi-disciplinary panel assessed clinical significance using an adapted form of a previously validated method.

Key findings

Overall, significantly more interventions were made per day after appointment of the MAP (P= 0.003). In particular, interventions relating to drug administration/route, choice, dose, medication history and need for drug therapy significantly increased. Interventions made by the MAP were found to be of greater clinical significance when compared with those made by the non-designated pharmacists (P= 0.005). In a separate assessment of medication history accuracy, 12% of the patients' regular medicines were unintentionally omitted and 6% of prescriptions unintentionally changed. All unintentional omissions and discrepancies identified resulted in an intervention by the MAP. The majority of these interventions were found to be of moderate clinical significance.

Conclusions

The MAP made more interventions than the previous non-designated ward pharmacists and, overall, the interventions were of greater clinical significance. The research demonstrates the potential contribution of an MAP on post-admission ward rounds to ensure the safe and appropriate prescribing of medicines on the medical admissions ward. Confirming medication histories was shown to be important in ensuring appropriate prescribing of patients' regular medicines on admission to hospital.

Reducing medication errors and improving systems reliability using an electronic medication reconciliation system

BACKGROUND

Medication reconciliation (MedRecon) has been a Joint Commission National Patient Safety Goal since 2006. However, there is scant literature on the evaluation of electronic MedRecon systems in reducing medication errors and on improving reliability of the MedRecon process.

METHODS

An electronic MedRecon system was designed and implemented in an acute inpatient care facility. Two analyses were performed: (1) one based on a 2-week pilot evaluation of the system based on 120 MedRecon events, and (2) a more comprehensive 17-month evaluation of the system, based on 19,356 MedRecon events.

RESULTS

The unintended discrepancy rate between a patient's home medications and admission medication orders was reduced from 20% during the pilot phase to 1.4%. The omission of a home medication was the most common type of discrepancy. Nighttime admission (8 P.M.-8 A.M.), total home medications > four, patient age > 65 years, and resident physician performing the medication reconciliation were found to have a significant positive correlation (p < .05) with the discrepancy rate. Using computerized alerts improved compliance with the MedRecon process from 34% to 98%-100%.

DISCUSSION

Using a multidisciplinary process based on an electronic system substantially reduced medication errors on admission, suggesting that an electronic MedRecon system can be an important tool in improving patient safety. The use of an interactive reminder alert in the MedRecon system improved systems reliability by ensuring physician compliance with MedRecon performance. Although computerized physician order entry (CPOE) decision support tools are an important component of medication error prevention strategies, they alone are not sufficient to prevent errors of prescribing.

Frequency of incomplete medication histories obtained at triage

PURPOSE

The frequency of incomplete medication histories obtained at triage in an emergency department (ED) is described.

METHODS

The survey of medication histories collected during ED triage was conducted during a 20-week period. Data collection occurred on weekdays during the dayshift for 15 hours per week for a total of 300 hours. Patients who bypassed triage or were unconscious, unable to communicate, uncooperative, or violent were excluded. Ten student pharmacists were trained on study procedures and collected data using a data collection tool which included patient's chief complaints, medications and dosages, and whether medications were identified at triage. Patients' medication-related ED visits were classified as being caused by adverse effects, medication errors, poor adherence, intentional overdose, or therapeutic failure.

RESULTS

During the 300 hours of data collection, 2063 patients were admitted to the ED. Of these, 1465 (71%) were interviewed and evaluated for complete medication histories. Among 1172 (80%) patients identified as taking medications, the history obtained at triage failed to identify at least one medication in 707 (48%) patients. In cases where medications were not identified, a mixture of prescription (73%) and nonprescription (27%) medications were missed with a median of 2 drugs (range, 1-20 drugs). Drugs missed at triage were related to the patient's chief complaint in 27% of the cases.

CONCLUSION

Medication histories collected at triage in the ED of an urban medical center were often incomplete, especially among patients taking multiple medications. Efforts should be taken to improve methods for obtaining more complete medication histories during triage and collecting supplemental medication histories to ensure appropriate emergency care.

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

BACKGROUND

One of the Joint Commission on Accreditation of Healthcare Organization's National Patient Safety Goals is for hospitals to accurately and completely reconcile patients' medications. Unfortunately, medication histories in charts might bc inaccurate and incomplete. In a thorough medication history, each medication should match a particular reported medical condition. The use of medications without a clear reported indication is of particular concern and has been associated with inappropriate use and polypharmacy.

OBJECTIVES

The purposes of this study were to evaluate the occurrence of discrepancies between home medications listed in hospital admission notes and patients' reported medical conditions and to describe the types of medications most often identified as not having a corresponding indication.

METHODS

In this retrospective observational study, data were included from adult patients (> or =18 years of age) who were receiving > or =3 home medications on admission to medical wards at a university hospital during a 6-month period. Each home medication listed in the admission note, together with any preadmission paperwork, was matched with an indication listed in the note. Medications were deemed unspecified if an indicated disease state or condition for the medication was not reported.

RESULTS

Data from 121 patients were included. The majority (91.7%) of the patients were admitted to an internal medicine service. Eighty-four patients (69.4%) had > or =1 unspecified medication listed in the admission note. Patients with > or =1 unspecified home medication reported taking a significantly higher number of home medications (10.2 [4.5] vs 7.5 [3.5] in those without unspecified medications; P = 0.007). Thirty-two patients (26.4%) were receiving proton pump inhibitors or histamine type 2 antagonists without a reported indication. Seventeen patients (14.0%) were receiving selective serotonin reuptake inhibitors without a reported indication.

CONCLUSIONS

Nearly 70% of patients admitted to a medical ward had > or =1 unspecified medication listed in the admission note. Based on these results, health care professionals must bc careful to obtain and document complete medication histories with matching indications.

Design and implementation of an application and associated services to support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network

Confusion about patients' medication regimens during the hospital admission and discharge process accounts for many preventable and serious medication errors. Many organizations have begun to redesign their clinical processes to address this patient safety concern. Partners HealthCare, an integrated delivery network in Boston, Massachusetts, has answered this interdisciplinary challenge by leveraging its multiple outpatient electronic medical records (EMR) and inpatient computerized provider order entry (CPOE) systems to facilitate the process of medication reconciliation. This manuscript describes the design of a novel application and the associated services that aggregate medication data from EMR and CPOE systems so that clinicians can efficiently generate an accurate pre-admission medication list. Information collected with the use of this application subsequently supports the writing of admission and discharge orders by physicians, performance of admission assessment by nurses, and reconciliation of inpatient orders by pharmacists. Results from early pilot testing suggest that this new medication reconciliation process is well accepted by clinicians and has significant potential to prevent medication errors during transitions of care.

Medication errors in mental healthcare: a systematic review

BACKGROUND

It has been estimated that medication error harms 1-2% of patients admitted to general hospitals. There has been no previous systematic review of the incidence, cause or type of medication error in mental healthcare services.

METHODS

A systematic literature search for studies that examined the incidence or cause of medication error in one or more stage(s) of the medication-management process in the setting of a community or hospital-based mental healthcare service was undertaken. The results in the context of the design of the study and the denominator used were examined.

RESULTS

All studies examined medication management processes, as opposed to outcomes. The reported rate of error was highest in studies that retrospectively examined drug charts, intermediate in those that relied on reporting by pharmacists to identify error and lowest in those that relied on organisational incident reporting systems. Only a few of the errors identified by the studies caused actual harm, mostly because they were detected and remedial action was taken before the patient received the drug. The focus of the research was on inpatients and prescriptions dispensed by mental health pharmacists.

CONCLUSION

Research about medication error in mental healthcare is limited. In particular, very little is known about the incidence of error in non-hospital settings or about the harm caused by it. Evidence is available from other sources that a substantial number of adverse drug events are caused by psychotropic drugs. Some of these are preventable and might probably, therefore, be due to medication error. On the basis of this and features of the organisation of mental healthcare that might predispose to medication error, priorities for future research are suggested.

Pharmacologic issues in geriatric emergency medicine

The challenge for the practitioner is to balance incomplete evidence about efficacy of medications in frail older people against the problems related to adverse drug reactions without denying people potentially valuable pharmacotherapeutic interventions. Prescribers need to be diligent in reviewing medications periodically as well as when new medications are being considered. Review of updated explicit criteria is essential to understand and prescribe appropriately in this special population.

Interview of patients by pharmacists contributes significantly to the identification of drug-related problems (DRPs)

PURPOSE

To investigate whether pharmacist interviews of hospitalised patients about their medication would result in identification of more drug-related problems (DRPs) than those found by usual care procedures and further to characterise the DRPs revealed at the interviews.

METHODS

Patients from five internal medicine and two rheumatology departments in four hospitals in Norway were prospectively included in the study. Clinical pharmacists assessed DRPs by reviewing medical records and by participating in multidisciplinary team discussions. Drugs used, medical history, laboratory data and clinical/pharmacological risk factors were recorded (usual care procedure). A proportion of patients were randomly selected for interview with pharmacists. A quality team assessed the clinical significance of the DRPs.

RESULTS

Seven hundred and twenty seven patients were included. Significantly more DRPs were found in the interview group (96 patients), an average of 4.4 DRPs per patient as compared to 2.4 DRPs in the non-interview group (631 patients) (p < 0.01). Of a total of 431 DRPs recorded in the interview group, 168 DRPs (39.9%) were disclosed through interviews. 'Need for additional drug', 'medical chart error', 'patient adherence' and 'need for patient education' were significantly more often recorded in this group. The quality team assessed 63% of the DRPs revealed in the interviews to be of major clinical significance.

CONCLUSION

Significantly more DRPs were identified among the patients who were interviewed compared to those patients having only usual care examination. A high proportion of the DRPs identified in the interviews were of major clinical significance. The clinical pharmacists, with their way of interviewing, seem to fill a gap, ensuring that significant DRPs do not escape detection.

Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review

BACKGROUND

Over a quarter of hospital prescribing errors are attributable to incomplete medication histories being obtained at the time of admission. We undertook a systematic review of studies describing the frequency, type and clinical importance of medication history errors at hospital admission.

METHODS

We searched MEDLINE, EMBASE and CINAHL for articles published from 1966 through April 2005 and bibliographies of papers subsequently retrieved from the search. We reviewed all published studies with quantitative results that compared prescription medication histories obtained by physicians at the time of hospital admission with comprehensive medication histories. Three reviewers independently abstracted data on methodologic features and results.

RESULTS

We identified 22 studies involving a total of 3755 patients (range 33-1053, median 104). Errors in prescription medication histories occurred in up to 67% of cases: 10%- 61% had at least 1 omission error (deletion of a drug used before admission), and 13%- 22% had at least 1 commission error (addition of a drug not used before admission); 60%- 67% had at least 1 omission or commission error. Only 5 studies (n = 545 patients) explicitly distinguished between unintentional discrepancies and intentional therapeutic changes through discussions with ordering physicians. These studies found that 27%- 54% of patients had at least 1 medication history error and that 19%- 75% of the discrepancies were unintentional. In 6 of the studies (n = 588 patients), the investigators estimated that 11%-59% of the medication history errors were clinically important.

INTERPRETATION

Medication history errors at the time of hospital admission are common and potentially clinically important. Improved physician training, accessible community pharmacy databases and closer teamwork between patients, physicians and pharmacists could reduce the frequency of these errors.

Prevalence of over-the-counter drug-related overdoses at Accident and Emergency departments in Northern Ireland--a retrospective evaluation

BACKGROUND AND OBJECTIVES

One major concern associated with misuse/abuse of over-the-counter (OTC) products is the potential for over-dosage. The aim of this research study was to evaluate, over a 3-month period, OTC medicine-related overdoses (those involving OTC drugs only and OTC drugs in combination with other drugs) that led to patients presenting at the Accident and Emergency (A & E) departments in four Belfast hospitals.

METHODS

A data collection sheet was designed to capture the information required from the A & E records in each hospital. A retrospective week-by-week data collection, reviewing A & E records, took place over a 3-month period (starting on 1 December 2002). All data related to cases presenting at the A & E departments because of drug overdoses (either accidental or deliberate according to Read Clinical Classification) were included in the study. Data were coded and entered into a custom designed SPSS database for analysis, using Chi square and Fisher exact tests.

RESULTS

OTC drug-related overdoses comprised 40.1% of all overdoses, of which 24.0% were OTC-only overdoses. Those who overdosed on OTC drugs (solely or combined with other drugs) were mainly female (62.3%) and in the age category 31-50 years (44.9%; P <0.05). The majority (n=215) of OTC-related overdoses were intentional, whereas only 28 were accidental. Of those who attended the A & E departments and had an overdose history, one-third overdosed on OTC-related products and two-thirds overdosed on OTC drugs only.

CONCLUSIONS

OTC drugs accounted for a significant proportion of overdose presentations at the A & E departments in Northern Ireland. Higher awareness of the potential of OTC product use in overdose cases (intentional or accidental) is recommended for both the public and health care professionals.

Over-the-counter medicine use prior to and during hospitalization

BACKGROUND

In the UK, medicines are being reclassified from prescription-only drugs to allow supply without prescription. This allows faster and easier access to medicines to treat minor ailments and allows patients to take greater responsibility for their health. However, over-the-counter (OTC) drugs may pose risks to patients; thus, it is important to understand patients' OTC medicine use.

OBJECTIVE

To assess use of OTC drugs prior to and during hospital stay of inpatients of all ages and specialties.

METHODS

Data were collected for 186 randomly selected patients. Patients were interviewed about OTC medicine use. Clinical notes and drug charts were examined for documentation of OTC medicine use.

RESULTS

A total of 268 OTC medicines were used by 119 (64.0%) patients, and 117 (43.7%) were taken at least daily. Only 13 (4.9%) OTC drugs were recorded in the drug history taken at admission. Twenty-six (9.7%) OTC agents were still taken during hospitalization, but only 8 (31%) were recorded on drug charts. Patients bought 183 (68.3%) items from pharmacies, 28 (10.4%) in health food shops, and 57 (21.7%) elsewhere including supermarkets, homeopaths, or mail order. Patients had little knowledge of potential adverse effects or contraindications.

CONCLUSIONS

Many patients use OTC medication prior to and during hospital stay, but documentation in hospital notes is poor. Healthcare professionals must pay closer attention to patients' use of OTC drugs.

The use of over-the-counter drugs among surgical and medical patients

INTRODUCTION

An increasing number of drugs are sold directly to the consumers without a prescription from pharmacies and from non-pharmacies such as supermarkets and gas stations.

AIM OF STUDY

To analyse the consumption of over-the-counter drugs (OTCs) among patients recently discharged from two hospital departments. Furthermore, to describe where the drugs had been bought and to which extent OTCs used prior to admission were recorded in the hospital files.

METHOD

Patients were visited within 1 week after discharge and interviewed about OTC use. Home inventories were inspected. Hospital files and discharge letters were examined.

RESULTS

In totally, 83 surgical and 117 medical patients were included (n=200). Whereas the home inventories of 187 patients comprised 587 OTCs, 13 patients (7%) stored no OTCs. Of the patients, 134 (67%) used OTCs daily and 132 patients (66%) used OTCs on demand; 79 patients (40%) stored a total of 157 OTCs not currently used. Analgesics were used by 138 patients (78%). Acetaminophen was the OTC used most frequently. Of the 240 OTCs used daily, 238 (99%) had been purchased from pharmacies and 169 (70%) had been prescribed. Of the 430 OTCs used daily or on demand, 348 (81%) had been recommended verbally or prescribed by health care professionals. Among the 206 OTCs used daily prior to admission, 162 (79%) were recorded in hospital files, whereas only 41 (24%) of 173 OTCs used on demand were recorded.

CONCLUSION

Two of three surgical and medical patients use OTCs daily. Most OTCs are used with the consent of health care professionals and are purchased from pharmacies. Pre-admission OTC use is incompletely recorded in the hospital files. If information was systematically collected from pharmacies and general practitioners, the number of recall biases concerning OTC use in the medication histories may be reduced.

Use and abuse of over-the-counter analgesic agents

Pain and discomfort in everyday life are often treated with over-the-counter (OTC) analgesic medications. These drugs are remarkably safe, but serious side effects can occur. Up to 70% of the population in Western countries uses analgesics regularly, primarily for headaches, other specific pains and febrile illness. It is not known whether the patterns of use are consistent with good pain management practices. OTC analgesics are also widely used to treat dysphoric mood states and sleep disturbances, and high levels of OTC analgesic medication use are associated with psychiatric illness, particularly depressive symptoms, and the use of alcohol, nicotine and caffeine. More than 4 g per day of acetylsalicylic acid (ASA) or acetaminophen over long periods is considered abuse. People using excessive amounts of OTC analgesics may need more effective treatments for chronic pain, depression or dysthymia. The possibility that these drugs have subtle reinforcing properties needs to be investigated. Certainly phenacetin, which was taken off the market in the 1970s, had intoxicating effects. A better understanding of patterns of use is needed to determine the extent of problem use of OTC analgesics, and whether health could be improved by educating people about the appropriate use of these drugs.