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Colombini N, Abbes M, Cherpin A, Bagneres D, Devos M, Charbit M, Rossi P. Comprehensive evaluation of using computerised provider order-entry system for hospital discharge orders. Int J Med Inform 2022; 160:104703. [DOI: 10.1016/j.ijmedinf.2022.104703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 09/15/2021] [Accepted: 01/18/2022] [Indexed: 11/28/2022]
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Chuen VL, Chan ACH, Ma J, Alibhai SMH, Chau V. The frequency and quality of delirium documentation in discharge summaries. BMC Geriatr 2021; 21:307. [PMID: 33980170 PMCID: PMC8117503 DOI: 10.1186/s12877-021-02245-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 04/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The National Institute for Health and Care Excellence recommends documenting all delirium episodes in the discharge summary using the term "delirium". Previous studies demonstrate poor delirium documentation rates in discharge summaries and no studies have assessed delirium documentation quality. The aim of this study was to determine the frequency and quality of delirium documentation in discharge summaries and explore differences between medical and surgical services. METHODS This was a multi-center retrospective chart review. We included 110 patients aged ≥ 65 years identified to have delirium during their hospitalization using the Chart-based Delirium Identification Instrument (CHART-DEL). We assessed the frequency of any delirium documentation in discharge summaries, and more specifically, for the term "delirium". We evaluated the quality of delirium discharge documentation using the Joint Commission on Accreditation of Healthcare Organization's framework for quality discharge summaries. Comparisons were made between medical and surgical services. Secondary outcomes included assessing factors influencing the frequency of "delirium" being documented in the discharge summary. RESULTS We identified 110 patients with sufficient chart documentation to identify delirium and 80.9 % of patients had delirium documented in their discharge summary ("delirium" or other acceptable term). The specific term "delirium" was reported in 63.6 % of all delirious patients and more often by surgical than medical specialties (76.5 % vs. 52.5 %, p = 0.02). Documentation quality was significantly lower by surgical specialties in reporting delirium as a diagnosis (23.5 % vs. 57.6 %, p < 0.001), documenting delirium workup (23.4 % vs. 57.6 %, p = 0.001), etiology (43.3 % vs. 70.4 %, p = 0.03), treatment (36.7 % vs. 66.7 %, p = 0.02), medication changes (44.4 % vs. 100 %, p = 0.002) and follow-up (36.4 % vs. 88.2 %, p = 0.01). CONCLUSIONS The frequency of delirium documentation is higher than previously reported but remains subpar. Medical services document delirium with higher quality, but surgical specialties document the term "delirium" more frequently. The documentation of delirium in discharge summaries must improve to meet quality standards.
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Affiliation(s)
- Victoria L Chuen
- Faculty of Medicine, University of Toronto, Ontario, Toronto, Canada.,Faculty of Medicine, McMaster University, Ontario, Hamilton, Canada
| | - Adrian C H Chan
- Faculty of Medicine, University of Toronto, Ontario, Toronto, Canada.,Faculty of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Jin Ma
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Shabbir M H Alibhai
- Division of General Internal Medicine and Geriatrics, Department of Medicine, University Health Network, Toronto, Ontario, Canada.,Division of General Internal Medicine and Geriatrics, Department of Medicine, Sinai Health System, Ontario, Toronto, Canada
| | - Vicky Chau
- Division of General Internal Medicine and Geriatrics, Department of Medicine, University Health Network, Toronto, Ontario, Canada. .,Division of General Internal Medicine and Geriatrics, Department of Medicine, Sinai Health System, Ontario, Toronto, Canada.
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Weetman K, Spencer R, Dale J, Scott E, Schnurr S. What makes a "successful" or "unsuccessful" discharge letter? Hospital clinician and General Practitioner assessments of the quality of discharge letters. BMC Health Serv Res 2021; 21:349. [PMID: 33858383 PMCID: PMC8048210 DOI: 10.1186/s12913-021-06345-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 04/03/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Sharing information about hospital care with primary care in the form of a discharge summary is essential to patient safety. In the United Kingdom, although discharge summary targets on timeliness have been achieved, the quality of discharge summaries' content remains variable. METHODS Mixed methods study in West Midlands, England with three parts: 1. General Practitioners (GPs) sampling discharge summaries they assessed to be "successful" or "unsuccessful" exemplars, 2. GPs commenting on the reasons for their letter assessment, and 3. surveying the hospital clinicians who wrote the sampled letters for their views. Letters were examined using content analysis; we coded 15 features (e.g. "diagnosis", "GP plan") based on relevant guidelines and standards. Free text comments were analysed using corpus linguistics, and survey data were analysed using descriptive statistics. RESULTS Fifty-three GPs participated in selecting discharge letters; 46 clinicians responded to the hospital survey. There were statistically significant differences between "successful" and "unsuccessful" inpatient letters (n = 375) in relation to inclusion of the following elements: reason for admission (99.1% vs 86.5%); diagnosis (97.4% vs 74.5%), medication changes (61.5% vs 48.9%); reasons for medication changes (32.1% vs 18.4%); hospital plan/actions (70.5% vs 50.4%); GP plan (69.7% vs 53.2%); information to patient (38.5% vs 24.8%); tests/procedures performed (97.0% vs 74.5%), and test/examination results (96.2% vs 77.3%). Unexplained acronyms and jargon were identified in the majority of the sample (≥70% of letters). Analysis of GP comments highlighted that the overall clarity of discharge letters is important for effective and safe care transitions and that they should be relevant, concise, and comprehensible. Hospital clinicians identified several barriers to producing "successful" letters, including: juniors writing letters, time limitations, writing letters retrospectively from patient notes, and template restrictions. CONCLUSIONS The failure to uniformly implement national discharge letter guidance into practice is continuing to contribute to unsuccessful communication between hospital and general practice. While the study highlighted barriers to producing high quality discharge summaries which may be addressed through training and organisational initiatives, it also indicates a need for ongoing audit to ensure the quality of letters and so reduce patient risk at the point of hospital discharge.
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Affiliation(s)
- Katharine Weetman
- Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Coventry, England, CV4 7AL, UK.
| | - Rachel Spencer
- Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Coventry, England, CV4 7AL, UK
| | - Jeremy Dale
- Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Coventry, England, CV4 7AL, UK
| | - Emma Scott
- Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Coventry, England, CV4 7AL, UK
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Killin L, Hezam A, Anderson KK, Welk B. Advanced Medication Reconciliation: A Systematic Review of the Impact on Medication Errors and Adverse Drug Events Associated with Transitions of Care. Jt Comm J Qual Patient Saf 2021; 47:438-451. [PMID: 34103267 DOI: 10.1016/j.jcjq.2021.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 03/26/2021] [Accepted: 03/26/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The goal of this study was to conduct a systematic review on the impact of in-hospital electronic/enhanced medication reconciliation compared to basic medication reconciliation on medication errors, discrepancies, and adverse drug events (ADEs). METHODS The study team searched for peer-reviewed English-language articles in EMBASE, OVID, and Scopus databases up to October 2019. Included were randomized controlled trials (RCTs), pre-post, or interrupted time series designs with medication errors, discrepancies, or ADEs as an outcome, and medication reconciliation applied at hospital discharge. Basic medication reconciliation was defined as using a paper-based format, electronic medication reconciliation as using an electronic format, and enhanced medication reconciliation as incorporating additional interventions to reduce medication errors. RESULTS Ten studies (three RCTs, one retrospective cohort study, two interrupted time series studies, three pre-post studies, and one longitudinal study) were identified, with six and four studies comparing basic medication reconciliation to electronic and enhanced medication reconciliation, respectively. The overall risk of bias of the included studies was low (three), unclear (two), moderate (three), and serious/high (two). In general, studies demonstrated that electronic medication reconciliation reduced the odds of a medication discrepancy or ADE and may reduce the mean number of medication discrepancies. Enhanced medication reconciliation was more equivocal, with some studies showing improvement; however, risk of bias was generally significant. CONCLUSION Electronic medication reconciliation tends to reduce the risk of ADE; however, these conclusions were limited due to a lack of consistency in study settings, interventions, and outcome definitions. Future studies with more rigorous designs and standardized outcome definitions would provide clarity on this topic.
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Williams M, Jordan A, Scott J, Jones M. A systematic review examining the characteristics of users of NHS patient medicines helpline services, and the types of enquiries they make. Eur J Hosp Pharm 2020; 27:323-329. [PMID: 33097614 PMCID: PMC7856156 DOI: 10.1136/ejhpharm-2019-002001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 10/03/2019] [Accepted: 10/14/2019] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Patient medicines helpline services (PMHS) are available from some National Health Service Trusts in the UK to support patients following their discharge from hospital. The aim of this systematic review was to examine the available evidence regarding the characteristics of enquirers and enquiries to PMHS, in order to develop recommendations for service improvement. METHODS Searches were conducted using Medline, Embase, Cumulative Index of Nursing and Allied Health Literature, Scopus, and Web of Science, on 4 June 2019. Forward and backward citation searches were conducted, and grey literature was searched. Studies were included if they reported any characteristics of enquirers who use PMHS, and/or enquiries received. Study quality was assessed using the Axis tool. A narrative synthesis was conducted, and where appropriate, weighted means (WMs) were calculated. Where possible, outcomes were compared with Hospital Episode Statistics (HES) data for England, to establish whether the profile of helpline users may differ to that of hospital patients. RESULTS Nineteen studies were included (~4362 enquiries). Risk of bias from assessed studies was 71%. Enquirers were predominantly female (WM=53%; HES mean=57%), elderly (WM=69 years; HES mean=53 years) and enquired regarding themselves (WM=72%). Out of inpatient and outpatient enquirers, 50% were inpatients and 50% were outpatients (WM). Six of 15 studies reported adverse effects as the main enquiry reason. Two of four studies reported antimicrobial drugs as the main enquiry drug class. From two studies, the main clinical origin of enquiries were general surgery and cardiology. Across six studies, 27% (WM) of enquiries concerned medicines-related errors. CONCLUSIONS Our findings show that PMHS are often used by elderly patients, which is important since this group may be particularly vulnerable to experiencing medicines-related issues following hospital discharge. Over a quarter of enquiries to PMHS may concern medicines-related errors, suggesting that addressing such errors is an important function of this service. However, our study findings may be limited by a high risk of bias within included studies. Further research could provide a more detailed profile of helpline users (eg, ethnicity, average number of medicines consumed), and we encourage helpline providers to use their enquiry data to conduct local projects to improve hospital services (eg, reducing errors). PROSPERO REGISTRATION NUMBER CRD42018116276.
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Affiliation(s)
- Matt Williams
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - Abbie Jordan
- Department of Psychology, University of Bath, Bath, UK
| | - Jenny Scott
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - Matthew Jones
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
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Williams M, Jordan A, Scott J, Jones MD. Service users' experiences of contacting NHS patient medicines helpline services: a qualitative study. BMJ Open 2020; 10:e036326. [PMID: 32595161 PMCID: PMC7322281 DOI: 10.1136/bmjopen-2019-036326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Patient medicines helpline services (PMHS) are available from some National Health Service (NHS) Trusts in the UK to provide medicines information to hospital patients and carers. To date, studies of PMHS have examined the views of service users via satisfaction surveys. This study used qualitative methods to explore service users' experiences of using a PMHS, including perceived benefits and areas for improvement. DESIGN Qualitative, using semi-structured interviews. SETTING This study was conducted across seven NHS Trusts in England. PARTICIPANTS Forty users of PMHS were individually interviewed over the telephone. Interviews were audio-recorded, transcribed verbatim and analysed using Braun and Clarke's inductive reflexive thematic analysis. Ethical approval was obtained before study commencement. RESULTS Participants predominantly called a PMHS for themselves (82%; carers: 18%). Two main themes were generated. Theme 1: timeliness-PMHS provide support during the uncertain transition of care period from hospital to home, when patients and carers often feel vulnerable because support is less available. PMHS met service users' needs for timely and easily accessible support, and quick resolution of their issues. PMHS could be improved with staffing beyond typical work week hours, and by having staff available to answer calls instead of using an answerphone. Theme 2: PMHS are best-placed to help-PMHS were perceived as best-placed to answer enquiries that arose from hospital care. Service users felt reassured from speaking to pharmacy professionals, and PMHS were perceived as the optimal service in terms of knowledge and expertise regarding medicines-related questions. However, several participants were initially unaware that their PMHS existed. CONCLUSIONS PMHS are perceived to be a valuable means of accessing timely medicines-related support when patients and carers may be feeling particularly vulnerable. However, their availability and promotion could be improved. We recommend that providers of PMHS consider whether this is achievable, in order to better meet the needs of service users.
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Affiliation(s)
- Matt Williams
- Department of Pharmacy & Pharmacology, University of Bath, Bath, UK
| | - Abbie Jordan
- Psychology and Centre for Pain Research, University of Bath, Bath, UK
| | - Jennifer Scott
- Department of Pharmacy & Pharmacology, University of Bath, Bath, UK
| | - Matthew D Jones
- Department of Pharmacy & Pharmacology, University of Bath, Bath, UK
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Lloyd M. Comparison of pharmacy technicians’ and doctors’ medication transcribing errors at hospital discharge. Eur J Hosp Pharm 2020; 27:9-13. [DOI: 10.1136/ejhpharm-2018-001538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 06/15/2018] [Accepted: 06/19/2018] [Indexed: 11/03/2022] Open
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Caleres G, Modig S, Midlöv P, Chalmers J, Bondesson Å. Medication Discrepancies in Discharge Summaries and Associated Risk Factors for Elderly Patients with Many Drugs. Drugs Real World Outcomes 2019; 7:53-62. [PMID: 31834621 PMCID: PMC7060975 DOI: 10.1007/s40801-019-00176-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Background and Objective Elderly patients are at high risk for medication errors in care transitions. The discharge summary aims to counteract drug-related problems due to insufficient information transfer in care transitions, hence the accuracy of its medication information is of utmost importance. The purpose of this study was to describe the medication discrepancy rate and associated risk factors in discharge summaries for elderly patients. Methods Pharmacists collected random samples of discharge summaries from ten hospitals in southern Sweden. Medication discrepancies, organisational, and patient- and care-specific factors were noted. Patients aged ≥ 75 years with five or more drugs were further included. Descriptive and logistic regression analyses were performed. Results Discharge summaries for a total of 933 patients were included. Average age was 83.1 years, and 515 patients (55%) were women. Medication discrepancies were noted for 353 patients (38%) (mean 0.87 discrepancies per discharged patient, 95% confidence interval 0.76–0.98). Unintentional addition of a drug was the most common discrepancy type. Central nervous system drugs/analgesics were most commonly affected. Major risk factors for the presence of discrepancies were multi-dose drug dispensing (adjusted odds ratio 3.42, 95% confidence interval 2.48–4.74), an increasing number of drugs in the discharge summary (adjusted odds ratio 1.09, 95% confidence interval 1.05–1.13) and discharge from departments of surgery (adjusted odds ratio 2.96, 95% confidence interval 1.55–5.66). By contrast, an increasing number of drug changes reduced the odds of a discrepancy (adjusted odds ratio 0.93, 95% confidence interval 0.88–0.99). Conclusions Medication discrepancies were common. In addition, we identified certain circumstances in which greater vigilance may be of considerable value for increased medication safety for elderly patients in care transitions.
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Affiliation(s)
- Gabriella Caleres
- Department of Clinical Sciences in Malmö/Family Medicine, Center for Primary Health Care Research, Lund University, Box 50332, 20213, Malmö, Sweden.
| | - Sara Modig
- Department of Clinical Sciences in Malmö/Family Medicine, Center for Primary Health Care Research, Lund University, Box 50332, 20213, Malmö, Sweden.,Department of Medicines Management and Informatics in Skåne County, Kristianstad, Sweden
| | - Patrik Midlöv
- Department of Clinical Sciences in Malmö/Family Medicine, Center for Primary Health Care Research, Lund University, Box 50332, 20213, Malmö, Sweden
| | - John Chalmers
- The George Institute for Global Health, Sydney, NSW, Australia
| | - Åsa Bondesson
- Department of Clinical Sciences in Malmö/Family Medicine, Center for Primary Health Care Research, Lund University, Box 50332, 20213, Malmö, Sweden.,Department of Medicines Management and Informatics in Skåne County, Kristianstad, Sweden
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Williams M, Jordan A, Scott J, Jones MD. A systematic review examining the effectiveness of medicines information services for patients and the general public. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2019; 28:26-40. [PMID: 31512292 DOI: 10.1111/ijpp.12571] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 07/09/2019] [Accepted: 07/11/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Hospital-based patient medicines helpline services (PMHS) and medicines information services for the general public (MISGP) are available in many countries to support people with their medicines. Our aim was to examine the available evidence regarding the effectiveness of PMHS and MISGP. METHODS Searches were conducted using Medline, EMBASE, CINAHL, Scopus and Web of Science, on 11 August 2018. Forward and backward citation searches were conducted, grey literature was searched, and study quality/risk of bias was assessed. Findings were synthesised in a narrative synthesis. Where appropriate, weighted means were calculated. KEY FINDINGS Thirty-two studies were identified for inclusion (17 published articles, 15 conference abstracts). Eighteen studies were conducted within the United Kingdom. Mean quality assessment was moderate (51%), and risk of bias was high (63%). PMHS and MISGP are both typically perceived as positive (e.g. 94% and 91% of participants were satisfied with using a PMHS and MISGP, respectively). For PMHS, the advice received is reported to be usually followed (94%, and 66% for MISGP). For both services, users report several positive outcomes (e.g. problems resolved/avoided, feeling reassured and improved health). PMHS may also be effective for correcting medicines-related errors (up to 39% of calls may concern such errors) and for potentially avoiding medicines-related harm (48% of enquiries concerned situations that were judged to have the potential to harm patients). CONCLUSIONS Findings suggest that both PMHS and MISGP may be beneficial sources of medicines-related support. However, the moderate quality and high risk of bias of studies highlight that more high-quality research is needed.
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Affiliation(s)
- Matt Williams
- Department of Pharmacy & Pharmacology, University of Bath, Bath, UK
| | - Abbie Jordan
- Department of Psychology, University of Bath, Bath, UK
| | - Jenny Scott
- Department of Pharmacy & Pharmacology, University of Bath, Bath, UK
| | - Matthew D Jones
- Department of Pharmacy & Pharmacology, University of Bath, Bath, UK
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George D, Supramaniam ND, Hamid SQA, Hassali MA, Lim WY, Hss AS. Effectiveness of a pharmacist-led quality improvement program to reduce medication errors during hospital discharge. Pharm Pract (Granada) 2019; 17:1501. [PMID: 31592290 PMCID: PMC6763293 DOI: 10.18549/pharmpract.2019.3.1501] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 08/05/2019] [Indexed: 11/14/2022] Open
Abstract
Background: Patients requiring medications during discharge are at risk of discharge medication errors that potentially cause readmission due to medication-related events. Objective: The objective of this study was to develop interventions to reduce percentage of patients with one or more medication errors during discharge. Methods: A pharmacist-led quality improvement (QI) program over 6 months was conducted in medical wards at a tertiary public hospital. Percentage of patients discharge with one or more medication errors was reviewed in the pre-intervention and four main improvements were developed: increase the ratio of pharmacist to patient, prioritize discharge prescription order within office hours, complete discharge medication reconciliation by ward pharmacist, set up a Centralized Discharge Medication Pre-packing Unit. Percentage of patients with one or more medication errors in both pre- and post-intervention phase were monitored using process control chart. Results: With the implementation of the QI program, the percentage of patients with one or more medication errors during discharge that were corrected by pharmacists significantly increased from 77.6% to 95.9% (p<0.001). Percentage of patients with one or more clinically significant error was similar in both pre and post-QI with an average of 24.8%. Conclusions: Increasing ratio of pharmacist to patient to complete discharge medication reconciliation during discharge significantly recorded a reduction in the percentage of patients with one or more medication errors.
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Affiliation(s)
- Doris George
- Pharmacy Department, Raja Permaisuri Bainun Hospital; &. Discipline of Social & Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia. Penang (Malaysia).
| | | | - Siti Q Abd Hamid
- Pharmacy Department, Raja Permaisuri Bainun Hospital. Perak (Malaysia).
| | - Mohamad A Hassali
- Discipline of Social & Administrative Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia. Penang (Malaysia).
| | - Wei-Yin Lim
- Center for Clinical Epidemiology, Institute for Clinical Research, National Institutes of Health, Ministry of Health. Selangor (Malaysia).
| | - Amar-Singh Hss
- Pediatric Department, Raja Permaisuri Bainun Hospital, Ministry of Health. Perak (Malaysia).
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Redmond P, McDowell R, Grimes TC, Boland F, McDonnell R, Hughes C, Fahey T. Unintended discontinuation of medication following hospitalisation: a retrospective cohort study. BMJ Open 2019; 9:e024747. [PMID: 31167862 PMCID: PMC6561421 DOI: 10.1136/bmjopen-2018-024747] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 03/01/2019] [Accepted: 05/01/2019] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES Whether unintended discontinuation of common, evidence-based, long-term medication occurs after hospitalisation; what factors are associated with unintended discontinuation; and whether the presence of documentation of medication at hospital discharge is associated with continuity of medication in general practice. DESIGN Retrospective cohort study between 2012 and 2015. SETTING Electronic records and hospital supplied discharge notifications in 44 Irish general practices. PARTICIPANTS 20 488 patients aged 65 years or more prescribed long-term medication for chronic conditions. PRIMARY AND SECONDARY OUTCOMES Discontinuity of four evidence-based medication drug classes: antithrombotic, lipid-lowering, thyroid replacement drugs and respiratory inhalers in hospitalised versus non-hospitalised patients; patient and health system factors associated with discontinuity; impact of the presence of medication in the hospital discharge summary on continuity of medication in a patient's general practitioner (GP) prescribing record at 6 months follow-up. RESULTS In patients admitted to hospital, medication discontinuity ranged from 6%-11% in the 6 months posthospitalisation. Discontinuity of medication is significantly lower for hospitalised patients taking respiratory inhalers (adjusted OR (AOR) 0.63, 95% CI (0.49 to 0.80), p<0.001) and thyroid medications (AOR 0.62, 95% CI (0.40 to 0.96), p=0.03). There is no association between discontinuity of medication and hospitalisation for antithrombotics (AOR 0.95, 95% CI (0.81 to 1.11), p=0.49) or lipid lowering medications (AOR 0.92, 95% CI (0.78 to 1.08), p=0.29). Older patients and those who paid to see their GP were more likely to experience increased odds of discontinuity in all four medicine groups. Less than half (39% to 47.4%) of patients had medication listed on their hospital discharge summary. Presence of medication on hospital discharge summary is significantly associated with continuity of medication in the GP prescribing record for lipid lowering medications (AOR 1.64, 95% CI (1.15 to 2.36), p=0.01) and respiratory inhalers (AOR 2.97, 95% CI (1.68 to 5.25), p<0.01). CONCLUSION Discontinuity of evidence-based long-term medication is common. Increasing age and private medical care are independently associated with a higher risk of medication discontinuity. Hospitalisation is not associated with discontinuity but less than half of hospitalised patients have medication recorded on their hospital discharge summary.
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Affiliation(s)
- Patrick Redmond
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Ronald McDowell
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
- Centre for Public Health, Queen’s University, Cancer Epidemiology and Health Services Group, Belfast, UK
| | | | - Fiona Boland
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ronan McDonnell
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Carmel Hughes
- School of Pharmacy, Queens University Belfast, Belfast, UK
| | - Tom Fahey
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
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Giannini O, Rizza N, Pironi M, Parlato S, Waldispühl Suter B, Borella P, Pagnamenta A, Fishman L, Ceschi A. Prevalence, clinical relevance and predictive factors of medication discrepancies revealed by medication reconciliation at hospital admission: prospective study in a Swiss internal medicine ward. BMJ Open 2019; 9:e026259. [PMID: 31133583 PMCID: PMC6538074 DOI: 10.1136/bmjopen-2018-026259] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE Medication reconciliation (MedRec) is a relevant safety procedure in medication management at transitions of care. The aim of this study was to evaluate the impact of MedRec, including a best possible medication history (BPMH) compared with a standard medication history in patients admitted to an internal medicine ward. DESIGN Prospective interventional study. Data were analysed using descriptive statistics followed by univariate and multivariate Poisson regression models and a zero-inflated Poisson regression model. SETTING Internal medicine ward in a secondary care hospital in Southern Switzerland. PARTICIPANTS The first 100 consecutive patients admitted in an internal medicine ward. PRIMARY AND SECONDARY OUTCOME MEASURES Medication discrepancies between the medication list obtained by the physician and that obtained by a pharmacist according to a systematic approach (BPMH) were collected, quantified and assessed by an expert panel that assigned a severity score. The same procedure was applied to discrepancies regarding allergies. Predicting factors for medication discrepancies were identified. RESULTS The median of medications per patient was 8 after standard medication history and 11 after BPMH. Total admission discrepancies were 524 (5.24 discrepancies per patient) with at least 1 discrepancy per patient. For 47 patients, at least one discrepancy was classified as clinically relevant. Discrepancies were classified as significant and serious in 19% and 2% of cases, respectively. Furthermore, 67% of the discrepancies were detected during the interview conducted by the pharmacist with the patients and/or their caregivers. The number of drugs used and the autonomous management of home therapy were associated with an increased number of clinically relevant discrepancies in a multivariable Poisson regression model. CONCLUSION Even in an advanced healthcare system, a standardised MedRec process including a BPMH represents an important strategy that may contribute to avoid a notable number of clinically relevant discrepancies and potential adverse drug events.
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Affiliation(s)
- Olivier Giannini
- Department of Internal Medicine, Ospedale Regionale di Mendrisio, Ente Ospedaliero Cantonale, Mendrisio, Ticino, Switzerland
| | - Nicole Rizza
- Hospital Pharmacy Service, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Michela Pironi
- Hospital Pharmacy Service, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | - Saida Parlato
- Hospital Pharmacy Service, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
| | | | - Paola Borella
- Department of Internal Medicine, Ospedale Regionale di Mendrisio, Ente Ospedaliero Cantonale, Mendrisio, Ticino, Switzerland
| | - Alberto Pagnamenta
- Unit of Clinical Epidemiology, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Division of Pneumology, University of Geneva, Geneva, Switzerland
| | | | - Alessandro Ceschi
- Division of Clinical Pharmacology and Toxicology, Institute of Pharmacological Sciences of Southern Switzerland, Ente Ospedaliero Cantonale, Lugano, Switzerland
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, Zurich, Switzerland
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13
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Schwarz CM, Hoffmann M, Schwarz P, Kamolz LP, Brunner G, Sendlhofer G. A systematic literature review and narrative synthesis on the risks of medical discharge letters for patients' safety. BMC Health Serv Res 2019; 19:158. [PMID: 30866908 PMCID: PMC6417275 DOI: 10.1186/s12913-019-3989-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 03/06/2019] [Indexed: 11/30/2022] Open
Abstract
Background The medical discharge letter is an important communication tool between hospitals and other healthcare providers. Despite its high status, it often does not meet the desired requirements in everyday clinical practice. Occurring risks create barriers for patients and doctors. This present review summarizes risks of the medical discharge letter. Methods The research question was answered with a systematic literature research and results were summarized narratively. A literature search in the databases PubMed and Cochrane Library for Studies between January 2008 and May 2018 was performed. Two authors reviewed the full texts of potentially relevant studies to determine eligibility for inclusion. Literature on possible risks associated with the medical discharge letter was discussed. Results In total, 29 studies were included in this review. The major identified risk factors are the delayed sending of the discharge letter to doctors for further treatments, unintelligible (not patient-centered) medical discharge letters, low quality of the discharge letter, and lack of information as well as absence of training in writing medical discharge letters during medical education. Conclusions Multiple risks factors are associated with the medical discharge letter. There is a need for further research to improve the quality of the medical discharge letter to minimize risks and increase patients’ safety.
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Affiliation(s)
- Christine Maria Schwarz
- Research Unit for Safety in Health, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Magdalena Hoffmann
- Research Unit for Safety in Health, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria. .,Executive Department for Quality and Risk Management, University Hospital Graz, Auenbruggerplatz 1/3, 8036, Graz, Austria.
| | - Petra Schwarz
- Carinthia University of Applied Science, Feldkirchen, Austria
| | - Lars-Peter Kamolz
- Research Unit for Safety in Health, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Gernot Brunner
- Research Unit for Safety in Health, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria
| | - Gerald Sendlhofer
- Research Unit for Safety in Health, c/o Division of Plastic, Aesthetic and Reconstructive Surgery, Department of Surgery, Medical University of Graz, Graz, Austria.,Executive Department for Quality and Risk Management, University Hospital Graz, Auenbruggerplatz 1/3, 8036, Graz, Austria
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14
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Williams M, Jordan A, Scott J, Jones MD. Operating a patient medicines helpline: a survey study exploring current practice in England using the RE-AIM evaluation framework. BMC Health Serv Res 2018; 18:868. [PMID: 30454023 PMCID: PMC6245845 DOI: 10.1186/s12913-018-3690-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 11/05/2018] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Patient medicines helplines provide a means of accessing medicines-related support following hospital discharge. However, it is unknown how many National Health Service (NHS) Trusts currently provide a helpline, nor how they are operated. Using the RE-AIM evaluation framework (Reach, Effectiveness, Adoption, Implementation, and Maintenance), we sought to obtain key data concerning the provision and use of patient medicines helplines in NHS Trusts in England. This included the extent to which the delivery of helplines meet with national standards that are endorsed by the Royal Pharmaceutical Society (standards pertaining to helpline access, availability, and promotion). METHODS An online survey was sent to Medicines Information Pharmacists and Chief Pharmacists at all 226 acute, mental health, specialist, and community NHS Trusts in England in 2017. RESULTS Adoption: Fifty-two percent of Trusts reported providing a patient medicines helpline (acute: 67%; specialist: 41%; mental health: 29%; community: 18%). Reach: Helplines were predominantly available for discharged inpatients, outpatients, and carers (98%, 95% and 93% of Trusts, respectively), and to a lesser extent, the local public (22% of Trusts). The median number of enquiries received per week was five. IMPLEMENTATION For helpline access, 54% of Trusts reported complying with all 'satisfactory' standards, and 26% reported complying with all 'commendable' standards. For helpline availability, the percentages were 86% and 5%, respectively. For helpline promotion, these percentages were 3% and 40%. One Trust reported complying with all standards. Maintenance: The median number of years that helplines had been operating was six. Effectiveness: main perceived benefits included patients avoiding harm, and improving patients' medication adherence. CONCLUSIONS Patient medicines helplines are provided by just over half of NHS Trusts in England. However, the proportion of mental health and community Trusts that operate a helpline is less than half of that of the acute Trusts, and there are regional variations in helpline provision. Adherence to the national standards could generally be improved, although the lowest adherence was regarding helpline promotion. Recommendations to increase the use of helplines include increasing the number of promotional methods used, the number of ways to contact the service, and the number of hours that the service is available.
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Affiliation(s)
- Matt Williams
- Department of Pharmacy & Pharmacology, University of Bath, 5 West, Claverton Down, Bath, BA2 7AY UK
| | - Abbie Jordan
- Department of Psychology, University of Bath, 10 West, Claverton Down, Bath, BA2 7AY UK
| | - Jenny Scott
- Department of Pharmacy & Pharmacology, University of Bath, 5 West, Claverton Down, Bath, BA2 7AY UK
| | - Matthew D. Jones
- Department of Pharmacy & Pharmacology, University of Bath, 5 West, Claverton Down, Bath, BA2 7AY UK
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15
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Béchet C, Pichon R, Giordan A, Bonnabry P. A cross-sectional comparison between the perception of physicians and pharmacists concerning the role of the pharmacist in physician training. ANNALES PHARMACEUTIQUES FRANÇAISES 2018; 76:408-417. [DOI: 10.1016/j.pharma.2018.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 04/12/2018] [Accepted: 04/13/2018] [Indexed: 11/28/2022]
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16
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[Medication safety in Switzerland: Where are we today?]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2018; 61:1152-1158. [PMID: 30043087 DOI: 10.1007/s00103-018-2794-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Empirical research shows that medication safety is an urgent area of concern in the Swiss healthcare system. Adverse drug events and medication errors are common and risks such as polypharmacy are widespread. No comprehensive national strategy explicitly dedicated to medication safety exists in Switzerland. The federalist system of government with relative autonomy of the cantons relating to healthcare laws influences the implementation of national healthcare reforms, also to the disadvantage of medication safety. Direct dispensing of drugs by the prescribing physician is permitted in almost all German-speaking cantons. This special feature of the Swiss system implies specific challenges for medication safety. Nonetheless, there is an increasing number of national activities dealing with various aspects of medication safety, such as the "progress!" programmes within the National Quality Strategy. Within the National Research Programme "Smarter Health Care" (NRP 74) of the Swiss National Science Foundation, several research projects are currently focusing on medication safety. Clinical pharmacy activities in hospitals are relatively widespread. In the primary care sector, pharmaceutical care practice and the corresponding competencies for pharmacists are being further developed. However, a comprehensive strategy, priority-setting and effectiveness studies involving all stakeholders are required in order for the Swiss healthcare system, to meet the challenges facing medication safety in a forward-looking manner.
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17
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Dräger S. Who is responsible for a safe discharge from hospital? A prospective risk analysis in the German setting. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2018; 113:9-18. [PMID: 27480184 DOI: 10.1016/j.zefq.2016.04.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2015] [Revised: 04/11/2016] [Accepted: 04/20/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND A representative national survey on risk management in German hospitals has recently identified hospital discharge as a key area of attention. Based on the consensus in the literature about the need to address patient safety at system level, this paper does not only look at the processes of discharge designed by single hospitals, but also takes account of the broader legal and regulatory framework. METHODS Failure Mode and Effects Analysis (FMEA) was applied for risk identification and assessment. For the analysis of the current status in hospitals, three hospitals were interviewed about their discharge processes. For the system perspective, the legislative and self-administrative framework specific for the German setting was reviewed. RESULTS The FMEA allowed the identification of a number of actions for risk control in the responsibility of the hospitals and within the framework. Some risks are mainly caused by the legal framework, whereas others can only be addressed by the hospitals themselves. The continuity of drug treatment and the lack of back-up systems after discharge were identified as posing relevant risks to patient safety. CONCLUSION Rich interaction was found between the hospitals and the framework they work in impacting patient safety at hospital discharge. The contribution of the legal and regulatory framework to patient safety needs to be taken into account more actively by policy makers in the future.
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Affiliation(s)
- Sigrid Dräger
- Baden-Württembergische Krankenhausgesellschaft e.V., Stuttgart, Germany.
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18
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Colombo F, Nunnari P, Ceccarelli G, Romano AV, Barbieri P, Scaglione F. Measures of Drug Prescribing at Care Transitions in an Internal Medicine Unit. J Clin Pharmacol 2018; 58:1171-1183. [PMID: 29723431 DOI: 10.1002/jcph.1123] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Accepted: 02/23/2018] [Indexed: 11/09/2022]
Abstract
Care transitions represent a common source of drug errors and confusions. The purpose of our prospective observational study was to assess the prevalence of medication discrepancies at care transitions, along with potentially inappropriate medications and potential drug-drug interactions, in an internal medicine unit of an Italian hospital. Adverse drug reactions that occurred in the 30-day period after the discharge from the hospital were included. A related-samples McNemar test was performed for evaluating the effects of hospitalization on the above-mentioned measures of drug prescribing. Medication discrepancies were frequent both on admission (93.4% [95%CI 0.8749, 0.9713]) and at discharge (78.7% [95%CI 0.7035, 0.8558]), with a significant difference between transition times (-14.7% [95%CI -21.82%, -7.69%]; P < .001)]. A high potentially inappropriate medication use prevalence was revealed without differences between care transitions. Potential drug-drug interactions were more frequent at admission to the hospital, with a significant difference of 8.2% in the distribution of patients with potential drug-drug interactions between care transitions. None of the adverse drug reactions recorded on follow-up was related to unintentional discrepancies, and the prevalence rate of patients with potentially inappropriate medication-related adverse drug reactions ranged between 4.9% and 6.9%, and the prevalence rate of patients with drug-drug interaction-related adverse drug reactions was 4.1% of patients. This study is important to raise awareness of the potential dangers medication discrepancies, potentially inappropriate medications, and potential drug-drug interactions could have on older adults. Clinicians and clinical pharmacologists must collaborate to improve patient care and minimize drug-related clinical outcomes.
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Affiliation(s)
- Fabrizio Colombo
- Internal Medicine Department, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Pietro Nunnari
- Department of Oncology and Onco-Hematology, Postgraduate School of Clinical Pharmacology and Toxicology, University of Milan, Milan, Italy
| | - Giovanni Ceccarelli
- Quality and Clinical Risk Department, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Angelo Valerio Romano
- Department of Oncology and Onco-Hematology, Postgraduate School of Clinical Pharmacology and Toxicology, University of Milan, Milan, Italy
| | - Pietro Barbieri
- Quality and Clinical Risk Department, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Francesco Scaglione
- Department of Oncology and Onco-Hematology, Postgraduate School of Clinical Pharmacology and Toxicology, University of Milan, Milan, Italy.,Clinical Pharmacology Unit, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
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19
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Wilkin ME, Knight AT, Boyce LE. An audit of medication information in electronic discharge summaries for older patients discharged from medical wards at a regional hospital. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2018. [DOI: 10.1002/jppr.1340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Mary E. Wilkin
- Clinical Pharmacist; Pharmacy Department; Manning Hospital; Taree Australia
| | - Anne T. Knight
- Senior Lecturer in Medicine; University of Newcastle Department of Rural Health; Newcastle Australia
- General Physician; Manning Hospital; Taree Australia
| | - Laura E. Boyce
- Clinical Pharmacist; Pharmacy Department; Manning Hospital; Taree Australia
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20
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Onatade R, Sawieres S, Veck A, Smith L, Gore S, Al-Azeib S. The incidence and severity of errors in pharmacist-written discharge medication orders. Int J Clin Pharm 2017; 39:722-728. [PMID: 28573438 PMCID: PMC5541123 DOI: 10.1007/s11096-017-0468-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 04/18/2017] [Indexed: 11/17/2022]
Abstract
Background Errors in discharge prescriptions are problematic. When hospital pharmacists write discharge prescriptions improvements are seen in the quality and efficiency of discharge. There is limited information on the incidence of errors in pharmacists’ medication orders. Objective To investigate the extent and clinical significance of errors in pharmacist-written discharge medication orders. Setting 1000-bed teaching hospital in London, UK. Method Pharmacists in this London hospital routinely write discharge medication orders as part of the clinical pharmacy service. Convenient days, based on researcher availability, between October 2013 and January 2014 were selected. Pre-registration pharmacists reviewed all discharge medication orders written by pharmacists on these days and identified discrepancies between the medication history, inpatient chart, patient records and discharge summary. A senior clinical pharmacist confirmed the presence of an error. Each error was assigned a potential clinical significance rating (based on the NCCMERP scale) by a physician and an independent senior clinical pharmacist, working separately. Main outcome measure Incidence of errors in pharmacist-written discharge medication orders. Results 509 prescriptions, written by 51 pharmacists, containing 4258 discharge medication orders were assessed (8.4 orders per prescription). Ten prescriptions (2%), contained a total of ten erroneous orders (order error rate—0.2%). The pharmacist considered that one error had the potential to cause temporary harm (0.02% of all orders). The physician did not rate any of the errors with the potential to cause harm. Conclusion The incidence of errors in pharmacists’ discharge medication orders was low. The quality, safety and policy implications of pharmacists routinely writing discharge medication orders should be further explored.
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Affiliation(s)
- Raliat Onatade
- Institute of Pharmaceutical Sciences, King's College London, London, UK. .,Pharmaceutical Sciences Clinical Academic Group, King's Health Partners, London, UK. .,Pharmacy Department, Barts Health NHS Trust, London, E1 2ES, UK.
| | - Sara Sawieres
- Pharmaceutical Sciences Clinical Academic Group, King's Health Partners, London, UK.,Pharmacy Department, King's College Hospital NHS Foundation Trust, London, UK
| | - Alexandra Veck
- Pharmacy Department, Western Sussex Hospitals NHS Foundation Trust, Chichester, UK
| | - Lindsay Smith
- Pharmaceutical Sciences Clinical Academic Group, King's Health Partners, London, UK.,Pharmacy Department, King's College Hospital NHS Foundation Trust, London, UK
| | - Shivani Gore
- Pharmacy Department, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Sumiah Al-Azeib
- Pharmaceutical Sciences Clinical Academic Group, King's Health Partners, London, UK.,Pharmacy Department, King's College Hospital NHS Foundation Trust, London, UK
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21
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The Relationship Between Index Hospitalizations, Sepsis, and Death or Transition to Hospice Care During 30-Day Hospital Readmissions. Med Care 2017; 55:362-370. [PMID: 27820595 DOI: 10.1097/mlr.0000000000000669] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Hospital readmissions are common, expensive, and increasingly used as a metric for assessing quality of care. The relationship between index hospitalizations and specific outcomes among those readmitted remains largely unknown. OBJECTIVES Identify risk factors present during the index hospitalization associated with death or transition to hospice care during 30-day readmissions and examine the contribution of infection in readmissions resulting in death. RESEARCH DESIGN Retrospective cohort study. SUBJECTS A total of 17,716 30-day readmissions in an academic health system. MEASURES We used mixed-effects multivariable logistic regression models to identify risk factors associated with the primary outcome, in-hospital death, or transition to hospice during 30-day readmissions. RESULTS Of 17,716 30-day readmissions, 1144 readmissions resulted in death or transition to hospice care (6.5%). Risk factors identified included: age, burden, and type of comorbid conditions, recent hospitalizations, nonelective index admission type, outside hospital transfer, low discharge hemoglobin, low discharge sodium, high discharge red blood cell distribution width, and disposition to a setting other than home. Sepsis (OR=1.33; 95% CI, 1.02-1.72; P=0.03) and shock (OR=1.78; 95% CI, 1.22-2.58; P=0.002) during the index admission were associated with the primary outcome, and in-hospital mortality specifically. In patients who died, infection was the primary cause for readmission in 51.6% of readmissions after sepsis and 28.6% of readmissions after a nonsepsis hospitalization (P=0.009). CONCLUSIONS We identified factors, including sepsis and shock during the index hospitalization, associated with death or transition to hospice care during readmission. Infection was frequently implicated as the cause of a readmission that ended in death.
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22
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Couturier B, Carrat F, Hejblum G. A systematic review on the effect of the organisation of hospital discharge on patient health outcomes. BMJ Open 2016; 6:e012287. [PMID: 28003282 PMCID: PMC5223668 DOI: 10.1136/bmjopen-2016-012287] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE The transition from hospital to home represents a key step in the management of patients and several problems related to this transition may arise, with potential adverse effects on patient health after discharge. The purpose of our study was to explore the association between components of the hospital discharge process including subsequent continuity of care and patient outcomes in the post-discharge period. DESIGN Systematic review of observational and interventional studies. SETTING We conducted a combined search in the Medline and Web of Science databases. Additional studies were identified by screening the bibliographies of the included studies. The data collection process was conducted using a standardised predefined grid that included quality criteria. PARTICIPANTS A standard patient population returning home after hospitalisation. PRIMARY AND SECONDARY OUTCOMES Adverse health outcomes occurring after hospital discharge. RESULTS In the 20 studies fulfilling our eligibility criteria, the main discharge-process components explored were: discharge summary (n=2), discharge instructions (n=2), drug-related problems at discharge (n=4), transition from hospital to home (n=5) and continuity of care after hospital discharge (n=7). The major subsequent patient health outcomes measured were: rehospitalisations (n=18), emergency department visits (n=8) and mortality (n=5). Eight of the 18 studies exploring rehospitalisations and two of the eight studies examining emergency department visits reported at least one significant association between the discharge process and these outcomes. None of the studies investigating patient mortality reported any significant such associations between the discharge process and these outcomes. CONCLUSIONS Irrespective of the component of the discharge process explored, the outcome considered (composite or not), the sample size and the study design, no consistent statistical association between hospital discharge and patient health outcome was identified. This systematic review highlights a wide heterogeneity between studies, especially in terms of the component(s) of the hospital discharge process investigated, study designs, outcomes and follow-up durations.
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Affiliation(s)
- Bérengère Couturier
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis d’Épidémiologie et de Santé Publique (IPLESP UMRS 1136), Paris, France
- AP–HP, Hôpital St-Antoine, Unité de Santé Publique, Paris, France
| | - Fabrice Carrat
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis d’Épidémiologie et de Santé Publique (IPLESP UMRS 1136), Paris, France
- AP–HP, Hôpital St-Antoine, Unité de Santé Publique, Paris, France
| | - Gilles Hejblum
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis d’Épidémiologie et de Santé Publique (IPLESP UMRS 1136), Paris, France
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23
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Ehnbom EC, Raban MZ, Walter SR, Richardson K, Westbrook JI. Do electronic discharge summaries contain more complete medication information? A retrospective analysis of paper versus electronic discharge summaries. Health Inf Manag 2016; 43:4-12. [PMID: 27009792 DOI: 10.1177/183335831404300301] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Complete, accurate and timely hospital discharge summaries are important for continuity of care. The aim of this study was to evaluate the effectiveness of an electronic discharge summary system in improving the medication information provided compared to the information in paper discharge summaries. We conducted a retrospective audit of 199 paper and 200 electronic discharge summaries from a 350-bed teaching hospital in Sydney, Australia. The completeness of medication information, and whether medication changes during the admission were explained, were assessed. Further, the likelihood of any incomplete information having an impact on continuity of care was assessed. There were 1352 and 1771 medication orders assessed in paper and electronic discharge summaries, respectively. Of these, 90.9% and 93.4% were complete in paper and electronic discharge summaries, respectively. The dose (OR 25.24, 95%CI: 3.41-186.9) and route (OR 8.65, 95%CI: 3.46-21.59) fields of medication orders, were more likely to be complete in electronic as compared with paper discharge summaries. There was no difference for drug frequency (OR 1.09, 95%CI: 0.77-1.55). There was no significant improvement in the proportion of incomplete medication orders rated as unclear and likely to impede continuity of care in paper compared with electronic discharge summaries (7.3% vs. 6.5%). Of changes to medication regimen, only medication additions were more likely to be explained in the electronic (n=253, 37.2%) compared to paper (n=104, 14.3%) discharge summaries (OR 3.14; 95%CI: 2.20-4.18). In summary, electronic discharge summaries offer some improvements over paper discharge summaries in terms of the quality of medication information documented. However, explanations of changes to medication regimens remained low, despite this being crucial information. Future efforts should focus on including the rationale for changes to medication regimens in discharge summaries.
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Affiliation(s)
- Elin C Ehnbom
- The University of New South Wales UNSW Sydney NSW 2052 Australia
| | - Magdalena Z Raban
- Australian Institute of Health Innovation The University of New South Wales, Sydney NSW
| | - Scott R Walter
- Australian Institute of Health Innovation The University of New South Wales, Sydney NSW 2052
| | | | - Johanna I Westbrook
- Centre for Health Systems and Safety Research Australian Institute of Health Innovation The University of New South Wales, Sydney NSW 2052
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24
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Aziz C, Grimes T, Deasy E, Roche C. Compliance with the Health Information and Quality Authority of Ireland National Standard for Patient Discharge Summary Information: a retrospective study in secondary care. Eur J Hosp Pharm 2016; 23:272-277. [PMID: 31156864 PMCID: PMC6451507 DOI: 10.1136/ejhpharm-2015-000748] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 01/01/2016] [Accepted: 01/13/2016] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Unexplained changes to medication are common at hospital discharge and underscore the need to standardise patient discharge clinical documentation. In 2013, the Health Information and Quality Authority in Ireland published a Standard on the structure and content of discharge summaries. The intention was to ensure that all necessary information was complete and communicated to the next care provider. OBJECTIVES This study investigated one Hospital's compliance with the Standard, and appraised two methods of electronic discharge communication (Symphony or Tallaght Education and Audit Management System (TEAMS)). METHOD A retrospective survey of 198 randomly selected discharge summaries was conducted at the study hospital, a 600 bed academic teaching hospital located in Dublin, Ireland. RESULTS Of the 198 evaluated summaries, mean total compliance was 77%±4.2 (95% CI 76.3 to 77.5). Most (84.7%, n=173) summaries were completed using one of the systems (TEAMS). Absence of communication about alteration of preadmission medication was frequent (107 out of 130 patients (82.3%, CI 76.2 to 89.2)). Higher compliance rates were observed however, when information was interfaced or where there were dedicated fields to be completed. CONCLUSIONS Efforts to improve compliance with the National Standard for Patient Discharge Summary Information should focus on reporting changes made to medication during hospitalisation.
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Affiliation(s)
- Claudine Aziz
- Department of Pharmacy, Trinity College Dublin, Dublin, Ireland
| | - Tamasine Grimes
- Department of Pharmacy, Trinity College Dublin, Dublin, Ireland
- Pharmacy Department, Tallaght Hospital, Dublin, Ireland
| | - Evelyn Deasy
- Pharmacy Department, Tallaght Hospital, Dublin, Ireland
| | - Cicely Roche
- Department of Pharmacy, Trinity College Dublin, Dublin, Ireland
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25
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Hammad EA, Bale A, Wright DJ, Bhattacharya D. Pharmacy led medicine reconciliation at hospital: A systematic review of effects and costs. Res Social Adm Pharm 2016; 13:300-312. [PMID: 27298139 DOI: 10.1016/j.sapharm.2016.04.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2015] [Revised: 04/29/2016] [Accepted: 04/29/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Transition of patients care between settings presents an increased opportunity for errors and preventable morbidity. A number of studies outlined that pharmacy-led medicine reconciliation (MR) might facilitate safer information transfer and medication use. MR practice is not well standardized and often delivered in combination with other health care activities. The question regarding the effects and costs of pharmacy-led MR and the optimum MR practice is warranted of value. OBJECTIVES To review the evidence for the effects and costs/cost-effectiveness of complete pharmacy-led MR in hospital settings. METHODS A systematic review searching the following database was conducted up to the 13th December 2015; EMBASE & MEDLINE Ovid, CINAHL and the Cochrane library. Studies evaluating pharmacy-led MR performed fully from admission till discharges were included. Studies evaluated non-pharmacy-led MR at only one end of patient care or transfer was not included. Articles were screened and extracted independently by two investigators. Studies were divided into those in which: MR was the primary element of the intervention and labeled as "primarily MR" studies, or MR combined with non-MR care activities and labeled as "supplemented MR" studies. Quality assessment of studies was performed by independent reviewers using a pre-defined and validated tool. RESULTS The literature search identified 4065 citations, of which 13 implemented complete MR. The lack of evidence precluded addressing the effects and costs of MR. CONCLUSIONS The composite of optimum MR practice is not widely standardized and requires discussion among health professions and key organizations. Research focused on evaluating cost-effectiveness of pharmacy-led MR is lacking.
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Affiliation(s)
- Eman A Hammad
- School of Pharmacy, Department of Biopharmaceutics and Clinical Pharmacy, University of Jordan, Amman 11942, Jordan.
| | - Amanda Bale
- Pharmacy Department, Cambridge University Hospitals, Cambridge, UK
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Hammad EA, Wright DJ, Walton C, Nunney I, Bhattacharya D. Adherence to UK national guidance for discharge information: an audit in primary care. Br J Clin Pharmacol 2015; 78:1453-64. [PMID: 25041244 DOI: 10.1111/bcp.12463] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Accepted: 07/03/2014] [Indexed: 01/10/2023] Open
Abstract
AIMS Poor communication of clinical information between healthcare settings is associated with patient harm. In 2008, the UK National Prescribing Centre (NPC) issued guidance regarding the minimum information to be communicated upon hospital discharge. This study evaluates the extent of adherence to this guidance and identifies predictors of adherence. METHODS This was an audit of discharge summaries received by medical practices in one UK primary care trust of patients hospitalized for 24 h or longer. Each discharge summary was scored against the applicable NPC criteria which were organized into: 'patient, admission and discharge', 'medicine' and 'therapy change' information. RESULTS Of 3444 discharge summaries audited, 2421 (70.3%) were from two teaching hospitals and 906 (26.3%) from three district hospitals. Unplanned admissions accounted for 2168 (63.0%) of the audit sample and 74.6% (2570) of discharge summaries were electronic. Mean (95% CI) adherence to the total NPC minimum dataset was 71.7% [70.2, 73.2]. Adherence to patient, admission and discharge information was 77.3% (95% CI 77.0, 77.7), 67.2% (95% CI 66.3, 68.2) for medicine information and 48.9% (95% CI 47.5, 50.3) for therapy change information. Allergy status, co-morbidities, medication history and rationale for therapy change were the most frequent omissions. Predictors of adherence included quality of the discharge template, electronic discharge summaries and smaller numbers of prescribed medicines. CONCLUSIONS Despite clear guidance regarding the content of discharge information, omissions are frequent. Adherence to the NPC minimum dataset might be improved by using comprehensive electronic discharge templates and implementation of effective medicines reconciliation at both sides of the health interface.
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Affiliation(s)
- Eman A Hammad
- Department of Biopharmaceutics and Clinical Pharmacy, School of Pharmacy, University of Jordan, Amman, 11942, Jordan
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Cresswell A, Hart M, Suchanek O, Young T, Leaver L, Hibbs S. Mind the gap: Improving discharge communication between secondary and primary care. BMJ QUALITY IMPROVEMENT REPORTS 2015; 4:bmjquality_uu207936.w3197. [PMID: 26734391 PMCID: PMC4693041 DOI: 10.1136/bmjquality.u207936.w3197] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Revised: 07/07/2015] [Indexed: 11/12/2022]
Abstract
Foundation year doctors (FYDs) write most hospital discharge communication, although they have minimal training in this skill. Poor quality discharge summaries increase the risk of adverse events and rehospitalisation. With a multidisciplinary team approach, we developed a list of “golden rules” for good discharge communication. Against these standards, we analysed the quality of electronic inpatient discharge documentation (eIDD) sent over two months from OUH Trust. We found one third of eIDDs were missing details of the discharging doctor. In 68%, changes to medications were not documented clearly and follow-up was not completed in 40%. To improve this suboptimal state, we implemented interactive teaching sessions for FYDs, designed an e-learning module, and suggested software changes to the current electronic discharge proforma. Early re-audit one month after the first teaching sessions did not demonstrate any significant improvement. However, re-auditing after twelve months is planned. Through data collection and discussion with key stakeholders, we have identified standards for discharge communication. We developed interventions to help the trust achieve these standards, aiming to enhance patient safety in the peri-discharge period. While discharge communication is delegated to less-experienced team members, they should receive clear guidance and training.
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von Klüchtzner W, Grandt D. Influence of hospitalization on prescribing safety across the continuum of care: an exploratory study. BMC Health Serv Res 2015; 15:197. [PMID: 25962594 PMCID: PMC4494641 DOI: 10.1186/s12913-015-0844-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Accepted: 04/24/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Transitions between different levels of healthcare, such as hospital admission and discharge, pose a considerable threat to the quality and continuity of drug therapy. This study aims to further explore the current role of hospitalization in prescribing error exposure and medication-related communication as patients are transferred from and back to ambulatory care. METHODS Assisted by electronic decision support, pre-admission and discharge medication regimens of 187 adult patients in a German university hospital were comparatively screened for clinically relevant categories of potentially inadequate prescribing. Binary logistic regression analyses were conducted to identify risk factors predisposing individuals to prescribing errors as a result of hospitalization. Additionally, it was established to what extent medication changes and potentially inappropriate prescribing decisions originating from inpatient treatment were communicated in discharge letters. RESULTS 94.7% of the patients are subjected to differences between pre-admission and discharge prescriptions occurring at a rate of 461 per 100 hospitalizations. However, these modifications in drug therapy do not have a significant effect on the total number of potential prescribing errors per patient (p = 0.135) even though a large potential for improvement exists throughout the care continuum. For instance, almost a quarter of study participants with impaired kidney function lacks appropriate dose adjustment for one or more drugs before onset and at the end of inpatient treatment alike (22.5% [95% CI: 13.5%-34.0%] vs. 22.8% [95% CI: 14.1%-33.6%]). Overall, the probability of error exposure following hospitalization rises with an increasing number of prescribed drugs per patient, while individuals treated on surgical wards are four times more likely to be discharged with a prescribing-related safety hazard than their counterparts from medical departments (OR: 4.069 [95% CI: 1.126-14.703]; p = 0.032). In the study population's discharge summaries only 14.8% of medication changes and none of the potentially inappropriate prescribing decisions made during inpatient care are addressed, despite the latter occurring at a rate of 91 per 100 hospitalizations. CONCLUSIONS There is urgent need for standardized and evidence-based measures contributing to patient safety across sectorial interfaces of drug therapy. Our findings provide useful orientation for the targeted and rational design of such improvement strategies.
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Dodds LJ. Pharmacist contributions to ensuring safe and accurate transfer of written medicines-related discharge information: lessons from a collaborative audit and service evaluation involving 45 hospitals in England. Eur J Hosp Pharm 2014. [DOI: 10.1136/ejhpharm-2013-000418] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Barr R, Chin KY, Yeong K. Improving patient discharge process using electronic medication input tool and on-line guide to arranging follow-ups. BMJ QUALITY IMPROVEMENT REPORTS 2013; 2:bmjquality_u756_w711. [PMID: 26734179 PMCID: PMC4652709 DOI: 10.1136/bmjquality.u756.w711] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Indexed: 11/03/2022]
Abstract
Complete, accurate and timely discharge summaries (TTOs) enable effective communication between hospital teams and GPs. It can prevent adverse events and reduce hospital readmission rates (1). If the discharge summary does not contain important information (e.g. follow-up arrangements, accurate discharge medication list), or if follow-up arrangements are not made, then patient care and outcome can be adversely affected (2,3). An electronic Medication Input Wizard was developed to improve the quality and reduce the error rates of TTOs. The Wizard makes entering drug information faster; prompts for reasons medication changes; provides examples for Controlled Drug (CD) prescribing; and prompts to refer patients taking warfarin to anticoagulation clinic. An on-line guide was developed which explains how to arrange investigations and appointments. Retrospective studies of TTOs were carried out before and after these interventions, analysing documentation of medication and completion of intended follow-up arrangements. A baseline audit found 65% of medication changes on TTOs were not clearly documented, and only 8% with changes documented reasons. 40% of prescriptions for CDs were incorrect delaying discharge by 4.9 hours per patient. 80% of intended follow-ups actually happened. After intervention, TTOs written using the Wizard had 100% of medication changes documented, and 75% were documented with reasons. CD errors decreased to 28% (76% of errors were done without using the Wizard). Follow-up arrangements that occurred increased to 86%. A survey showed 78% of Doctors reported the Wizard was faster than typing the details in separate textboxes, and 94% believed it was beneficial. Systems should be optimised to encourage better documentation of medication details and reduce prescribing errors. Guides that explain how to make follow-up arrangements should be accessible to Doctors, to make sure follow-ups are organised correctly.
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Gilbert AV, Patel B, Morrow M, Williams D, Roberts MS, Gilbert AL. Providing community-based health practitioners with timely and accurate discharge medicines information. BMC Health Serv Res 2012; 12:453. [PMID: 23228183 PMCID: PMC3556303 DOI: 10.1186/1472-6963-12-453] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2012] [Accepted: 12/03/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Accurate and timely medication information at the point of discharge is essential for continuity of care. There are scarce data on the clinical significance if poor quality medicines information is passed to the next episode of care. This study aimed to compare the number and clinical significance of medication errors and omission in discharge medicines information, and the timeliness of delivery of this information to community-based health practitioners, between the existing Hospital Discharge Summary (HDS) and a pharmacist prepared Medicines Information Transfer Fax (MITF). METHOD The study used a sample of 80 hospital patients who were at high risk of medication misadventure, and who had a MITF completed in the study period June - October 2009 at a tertiary referral hospital. The medicines information in participating patients' MITFs was validated against their Discharge Prescriptions (DP). Medicines information in each patient's HDS was then compared with their validated MITF. An expert clinical panel reviewed identified medication errors and omissions to determine their clinical significance. The time between patient discharge and the dispatching of the MITF and the HDS to each patient's community-based practitioners was calculated from hospital records. RESULTS DPs for 77 of the 80 patients were available for comparison with their MITFs. Medicines information in 71 (92%) of the MITFs matched that of the DP. Comparison of the HDS against the MITF revealed that no HDS was prepared for 16 (21%) patients. Of the remaining 61 patients; 33 (54%), had required medications omitted and 38 (62%) had medication errors in their HDS. The Clinical Panel rated the significance of errors or omissions for 70 patients (16 with no HDS prepared and 54 who's HDS was inconsistent with the validated MITF). In 17 patients the error or omission was rated as insignificant to minor; 23 minor to moderate; 24 moderate to major and 6 major to catastrophic. 28 (35%) patients had their HDS dispatched to their community-based practitioners within 48 hours post discharge compared to 80 (100%) of MITFs. CONCLUSION The MITF is an effective approach for the timely delivery of accurate discharge medicines information to community-based practitioners responsible for the patient's ongoing care.
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Affiliation(s)
- Alice V Gilbert
- Pharmacy Department, Royal Darwin Hospital, Rocklands Drive, Darwin 0810, Australia
| | - Bhavini Patel
- Pharmacy Department, Royal Darwin Hospital, Rocklands Drive, Darwin 0810, Australia
| | - Melanie Morrow
- Pharmacy Department, Royal Darwin Hospital, Rocklands Drive, Darwin 0810, Australia
| | - Desmond Williams
- School of Pharmacy and Medical Science, University of South Australia, North Terrace, Adelaide, Australia
| | - Michael S Roberts
- School of Medicine, Queensland University, Sir Fred Schonell Drive, Queensland, 4072, Australia
| | - Andrew L Gilbert
- School of Pharmacy and Medical Science, University of South Australia, North Terrace, Adelaide, Australia
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Ziaeian B, Araujo KLB, Van Ness PH, Horwitz LI. Medication reconciliation accuracy and patient understanding of intended medication changes on hospital discharge. J Gen Intern Med 2012; 27:1513-20. [PMID: 22798200 PMCID: PMC3475816 DOI: 10.1007/s11606-012-2168-4] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Revised: 06/19/2012] [Accepted: 06/25/2012] [Indexed: 11/24/2022]
Abstract
BACKGROUND Adverse drug events after hospital discharge are common and often serious. These events may result from provider errors or patient misunderstanding. OBJECTIVE To determine the prevalence of medication reconciliation errors and patient misunderstanding of discharge medications. DESIGN Prospective cohort study SUBJECTS Patients over 64 years of age admitted with heart failure, acute coronary syndrome or pneumonia and discharged to home. MAIN MEASURES We assessed medication reconciliation accuracy by comparing admission to discharge medication lists and reviewing charts to resolve discrepancies. Medication reconciliation changes that did not appear intentional were classified as suspected provider errors. We assessed patient understanding of intended medication changes through post-discharge interviews. Understanding was scored as full, partial or absent. We tested the association of relevance of the medication to the primary diagnosis with medication accuracy and with patient understanding, accounting for patient demographics, medical team and primary diagnosis. KEY RESULTS A total of 377 patients were enrolled in the study. A total of 565/2534 (22.3 %) of admission medications were redosed or stopped at discharge. Of these, 137 (24.2 %) were classified as suspected provider errors. Excluding suspected errors, patients had no understanding of 142/205 (69.3 %) of redosed medications, 182/223 (81.6 %) of stopped medications, and 493 (62.0 %) of new medications. Altogether, 307 patients (81.4 %) either experienced a provider error, or had no understanding of at least one intended medication change. Providers were significantly more likely to make an error on a medication unrelated to the primary diagnosis than on a medication related to the primary diagnosis (odds ratio (OR) 4.56, 95 % confidence interval (CI) 2.65, 7.85, p<0.001). Patients were also significantly more likely to misunderstand medication changes unrelated to the primary diagnosis (OR 2.45, 95 % CI 1.68, 3.55), p<0.001). CONCLUSIONS Medication reconciliation and patient understanding are inadequate in older patients post-discharge. Errors and misunderstandings are particularly common in medications unrelated to the primary diagnosis. Efforts to improve medication reconciliation and patient understanding should not be disease-specific, but should be focused on the whole patient.
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Affiliation(s)
- Boback Ziaeian
- Hospitalist Medicine, Yale-New Haven Hospital, New Haven, CT, USA
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Legault K, Ostro J, Khalid Z, Wasi P, You JJ. Quality of discharge summaries prepared by first year internal medicine residents. BMC MEDICAL EDUCATION 2012; 12:77. [PMID: 22894637 PMCID: PMC3532338 DOI: 10.1186/1472-6920-12-77] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 08/13/2012] [Indexed: 06/01/2023]
Abstract
BACKGROUND Patients are particularly susceptible to medical error during transitions from inpatient to outpatient care. We evaluated discharge summaries produced by incoming postgraduate year 1 (PGY-1) internal medicine residents for their completeness, accuracy, and relevance to family physicians. METHODS Consecutive discharge summaries prepared by PGY-1 residents for patients discharged from internal medicine wards were retrospectively evaluated by two independent reviewers for presence and accuracy of essential domains described by the Joint Commission for Hospital Accreditation. Family physicians rated the relevance of a separate sample of discharge summaries on domains that family physicians deemed important in previous studies. RESULTS Ninety discharge summaries were assessed for completeness and accuracy. Most items were completely reported with a given item missing in 5% of summaries or fewer, with the exception of the reason for medication changes, which was missing in 15.9% of summaries. Discharge medication lists, medication changes, and the reason for medication changes--when present--were inaccurate in 35.7%, 29.5%, and 37.7% of summaries, respectively. Twenty-one family physicians reviewed 68 discharge summaries. Communication of follow-up plans for further investigations was the most frequently identified area for improvement with 27.7% of summaries rated as insufficient. CONCLUSIONS This study found that medication details were frequently omitted or inaccurate, and that family physicians identified lack of clarity about follow-up plans regarding further investigations and visits to other consultants as the areas requiring the most improvement. Our findings will aid in the development of educational interventions for residents.
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Affiliation(s)
- Kimberly Legault
- Department of Medicine, McMaster University, 25 Charlton Ave. East, Suite 708, Hamilton, ON L8P 3B2, Canada
| | - Jacqueline Ostro
- Department of Medicine, Internal Medicine Residency Office, McMaster University, HSC-3W10A-C, 1200 Main St. West, Hamilton, ON L8N 3Z5, Canada
| | - Zahira Khalid
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Parveen Wasi
- Departments of Medicine, and of Oncology, Juravinski Hospital and Cancer Centre, McMaster University, B3:169D, 711 Concession St, Hamilton, ON L8V 1C3, Canada
| | - John J You
- Departments of Medicine, and of Clinical Epidemiology & Biostatistics, McMaster University, 1200 Main Street West, HSC-3V51B, Hamilton, ON L8N 3Z5, Canada
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Cain CH, Neuwirth E, Bellows J, Zuber C, Green J. Patient experiences of transitioning from hospital to home: an ethnographic quality improvement project. J Hosp Med 2012; 7:382-7. [PMID: 22378714 DOI: 10.1002/jhm.1918] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2011] [Revised: 12/02/2011] [Accepted: 01/08/2012] [Indexed: 11/07/2022]
Abstract
BACKGROUND Little is known about patient perspectives of the transition from hospital to home. OBJECTIVE To develop a richly detailed, patient-centered view of patient and caregiver needs in the hospital-to-home transition. DESIGN An ethnographic approach including participant observation and in-depth, semi-structured video recorded interviews. SETTING Kaiser Permanente's Southern California, Colorado, and Hawaii regions. PATIENTS Twenty-four adult inpatients hospitalized for a range of acute and chronic conditions and characterized by variety in diagnoses, illness severity, planned or unplanned hospitalization, age, and ability to self manage. RESULTS During the hospital-to-home transition, patients and caregivers expressed or demonstrated experiences in 6 domains: 1) translating knowledge into safe, health-promoting actions at home; 2) inclusion of caregivers at every step of the transition process; 3) having readily available problem-solving resources; 4) feeling connected to and trusting providers; 5) transitioning from illness-defined experience to "normal" life; and 6) anticipating needs after discharge and making arrangements to meet them. The work of transitioning occurs for patients and caregivers in the hours and days after they return home and is fraught with challenges. CONCLUSIONS Reducing readmissions will remain challenging without a broadened understanding of the types of support and coaching patients need after discharge. We are piloting strategies such as risk stratification and tailoring of care, a specialized phone number for recently discharged patients, standardized same-day discharge summaries to primary care providers, medication reconciliation, follow-up phone calls, and scheduling appointments before discharge.
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Affiliation(s)
- Carol H Cain
- The Permanente Federation, Oakland, California 94612, USA.
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Accuracy of medication documentation in hospital discharge summaries: A retrospective analysis of medication transcription errors in manual and electronic discharge summaries. Int J Med Inform 2010; 79:58-64. [DOI: 10.1016/j.ijmedinf.2009.09.002] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2009] [Revised: 09/08/2009] [Accepted: 09/10/2009] [Indexed: 11/21/2022]
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