Pharmacy-based medication reconciliation program utilizing pharmacists and technicians: a process improvement initiative

The medication discrepancy detection service: A cost-effective multidisciplinary clinical approach

OBJECTIVE

To estimate the effectiveness of a Medication Discrepancy Detection Service (MDDS), a collaborative service between the community pharmacy and Primary Care.

DESIGN

Non-controlled before-and-after study.

SETTING

Bidasoa Integrated Healthcare Organisation, Gipuzkoa, Spain.

PARTICIPANTS

The service was provided by a multidisciplinary group of community pharmacists (CPs), general practitioners (GPs), and primary care pharmacists, to patients with discrepancies between their active medical charts and medicines that they were actually taking.

OUTCOMES

The primary outcomes were the number of medicines, the type of discrepancy, and GPs' decisions. Secondary outcomes were time spent by CPs, emergency department (ED) visits, hospital admissions, and costs.

RESULTS

The MDDS was provided to 143 patients, and GPs resolved discrepancies for 126 patients. CPs identified 259 discrepancies, among which the main one was patients not taking medicines listed on their active medical charts (66.7%, n=152). The main GPs' decision was to withdraw the treatment (54.8%, n=125), which meant that the number of medicines per patient was reduced by 0.92 (9.12±3.82 vs. 8.20±3.81; p<.0001). The number of ED visits and hospital admissions per patient were reduced by 0.10 (0.61±.13 vs 0.52±0.91; p=.405 and 0.17 (0.33±0.66 vs. 0.16±0.42; p=.007), respectively. The cost per patient was reduced by €444.9 (€1003.3±2165.3 vs. €558.4±1273.0; p=.018).

CONCLUSION

The MDDS resulted in a reduction in the number of medicines per patients and number of hospital admissions, and the service was associated with affordable, cost-effective ratios.

The impact of community-pharmacist-led medication reconciliation process: Pharmacist-patient-centered medication reconciliation

Background and Purpose:

Patients and their healthcare providers’ are in need to access a correct and complete list of all patients’ active bills for safe and effective clinical care. Currently, Healthcare Information Systems are not providing a proper access to the patients’ medications lists. Thus, this study aimed to evaluate the impact of community pharmacist-led medication reconciliation process in community pharmacies in the UAE through applying a pharmacist–patient-centered medication reconciliation (PPCMR).

Materials and Methods:

This was an interventional study of medication reconciliation process in 25 pharmacies in the UAE during July 1, 2019 till September 1, 2019. The participant pharmacists were surveyed and interviewed to gather more information about the barriers and enablers of the process before and after the implementation of PPCMR.

Results:

After the implementation of PPCMR, medication reconciliation service was available in 84% of the pharmacies compared to 40% before the PPCMR (Z = –2.84, P = 0.005). The main workforce barriers to implement this service were reduced to 27% compared to 47% before the PPCMR. The operational barriers for the service were decreased from 56% to 28%. The facilitators in delivering the service in community pharmacies were improved from 29% to 63%. The active collaboration between the pharmacists and physicians was enhanced from 28% to 72% (Z = –3.2, P = 0.001) in the participated pharmacies. There is a statistically significant difference toward the impact of the PPCMR on the whole medication reconciliation service χ²(df = 3) = 200, P < 0.001.

Conclusion:

Community pharmacists are not always accessible or well placed to provide a medication reconciliation service. The implementation of PPCMR in each community pharmacy will raise the expectations regarding the appropriateness of medication management and use.

Pharmacists and medication reconciliation: a review of recent literature

Background: Adverse drug event (ADE) errors are common and costly in health care systems across the world. Medication reconciliation is a means to decrease these medication-related injuries and increase quality of care. Research has shown that medication reconciliation accuracy and efficiency improved when pharmacists are directly involved in the process. Objective: We review studies examining how pharmacists impact the medication reconciliation process and we discuss pharmacists' future roles during the medication reconciliation process and then barriers pharmacy staff may face during this critical process. Methods: A comprehensive literature search from MEDLINE and manual searching of bibliographies was performed for the time period January 2012 through November 2018. Conclusion: Although the issue of rising costs and injury due to medication errors in our health care system are not solvable via medication reconciliation alone, it is the first and perhaps most critical piece of the medication management puzzle. As such, numerous organizations have called for pharmacists to expand their roles in the medication reconciliation process due to their expertise in medication management.

Impact of a pharmacy technician-centered medication reconciliation program on medication discrepancies and implementation of recommendations

Objectives:

To evaluate the impact of a pharmacy-technician centered medication reconciliation (PTMR) program by identifying and quantifying medication discrepancies and outcomes of pharmacist medication reconciliation recommendations.

Methods:

A retrospective chart review was performed on two-hundred patients admitted to the internal medicine teaching services at Cooper University Hospital in Camden, NJ. Patients were selected using a stratified systematic sample approach and were included if they received a pharmacy technician medication history and a pharmacist medication reconciliation at any point during their hospital admission. Pharmacist identified medication discrepancies were analyzed using descriptive statistics, bivariate analyses. Potential risk factors were identified using multivariate analyses, such as logistic regression and CART. The priority level of significance was set at 0.05.

Results:

Three-hundred and sixty-five medication discrepancies were identified out of the 200 included patients. The four most common discrepancies were omission (64.7%), non-formulary omission (16.2%), dose discrepancy (10.1%), and frequency discrepancy (4.1%). Twenty-two percent of pharmacist recommendations were implemented by the prescriber within 72 hours.

Conclusion:

A PTMR program with dedicated pharmacy technicians and pharmacists identifies many medication discrepancies at admission and provides opportunities for pharmacist reconciliation recommendations.

Trained student pharmacists' telephonic collection of patient medication information: Evaluation of a structured interview tool

OBJECTIVE

To determine the feasibility and fidelity of student pharmacists collecting patient medication list information using a structured interview tool and the accuracy of documenting the information. The medication lists were used by a community pharmacist to provide a targeted medication therapy management (MTM) intervention.

DESIGN

Descriptive analysis of patient medication lists collected with telephone interviews.

PARTICIPANTS

Ten trained student pharmacists collected the medication lists.

INTERVENTION

Trained student pharmacists conducted audio-recorded telephone interviews with 80 English-speaking, community-dwelling older adults using a structured interview tool to collect and document medication lists.

MAIN OUTCOME MEASURES

Feasibility was measured using the number of completed interviews, the time student pharmacists took to collect the information, and pharmacist feedback. Fidelity to the interview tool was measured by assessing student pharmacists' adherence to asking all scripted questions and probes. Accuracy was measured by comparing the audio-recorded interviews to the medication list information documented in an electronic medical record.

RESULTS

On average, it took student pharmacists 26.7 minutes to collect the medication lists. The community pharmacist said the medication lists were complete and that having the medication lists saved time and allowed him to focus on assessment, recommendations, and education during the targeted MTM session. Fidelity was high, with an overall proportion of asked scripted probes of 83.75% (95% confidence interval [CI], 80.62-86.88%). Accuracy was also high for both prescription (95.1%; 95% CI, 94.3-95.8%) and nonprescription (90.5%; 95% CI, 89.4-91.4%) medications.

CONCLUSION

Trained student pharmacists were able to use an interview tool to collect and document medication lists with a high degree of fidelity and accuracy. This study suggests that student pharmacists or trained technicians may be able to collect patient medication lists to facilitate MTM sessions in the community pharmacy setting. Evaluating the sustainability of using student pharmacists or trained technicians to collect medication lists is needed.

A global picture of pharmacy technician and other pharmacy support workforce cadres

INTRODUCTION

Understanding how pharmacy technicians and other pharmacy support workforce cadres assist pharmacists in the healthcare system will facilitate developing health systems with the ability to achieve universal health coverage as it is defined in different country contexts. The aim of this paper is to provide an overview of the present global variety in the technician and other pharmacy support workforce cadres considering; their scope, roles, supervision, education and legal framework.

MATERIAL AND METHODS

A structured online survey instrument was administered globally using the Survey Monkey platform, designed to address the following topic areas: roles, responsibilities, supervision, education and legislation. The survey was circulated to International Pharmaceutical Federation (FIP) member organisations and a variety of global list serves where pharmaceutical services are discussed.

RESULTS

193 entries from 67 countries and territories were included in the final analysis revealing a vast global variety with respect to the pharmacy support workforce.

ROLES AND COMPETENCY

From no pharmacy technicians or other pharmacy support workforce cadres in Japan, through a variety of cadre interactions with pharmacists, to the autonomous practice of pharmacy support workforce cadres in Malawi.

RESPONSIBILITIES

From strictly supervised practice with a focus on supply, through autonomous practice for a variety of responsibilities, to independent practice.

SUPERVISION

From complete supervision for all tasks, through geographical varied supervision, to independent practice.

EDUCATION

From on the job training, through certificate level vocational courses, to 3-4 year diploma programs.

LEGISLATION, REGULATION AND LIABILITY

From well-regulated and registered, through part regulation with weak implementation, to completely non-regulated contexts.

CONCLUSION

This paper documents wide differences in supervision requirements, education systems and supportive legislation for pharmacy support workforce cadres globally. A more detailed understanding of specific country practice settings is required if the use of pharmacy support workforce cadres is to be optimized.

Expanded Roles for Pharmacy Technicians in the Medication Reconciliation Process: A Qualitative Review

Background: Collection of a complete and accurate medication history is an essential component of the medication reconciliation process. The role of pharmacy technicians in supporting medication reconciliation has been the subject of recent interest. Purpose: The purpose of this article is to review the existing literature on pharmacy technician involvement in the medication reconciliation process and to summarize outcomes on the quality and accuracy of pharmacy technician-collected medication histories. Method: A literature review was conducted using MEDLINE and Academic Search Premier (1948 - April 2015). Results: Sixteen papers were identified, with 12 containing a formal evaluation of outcomes. Three were purely descriptive, and 9 compared the pharmacy technician's performance to pharmacists, nurses, physicians, and/or interdisciplinary teams. Studies used a variety of endpoints, but they demonstrated similar or improved outcomes by engaging pharmacy technicians. Evidence demonstrates that trained pharmacy technicians are able to gather medication histories with similar completeness and accuracy to other health care professionals. Conclusion: The use of pharmacy technicians may be a viable strategy for developing and expanding medication reconciliation processes with appropriate supervision. Future efforts should focus on evaluating the impact of expanded roles for pharmacy technicians in the health care system; assessing the need for standardization of pharmacy technician education, training, and certification; and obtaining clarification from state pharmacy boards regarding these expanded roles.

Utilization of Pharmacy Technicians to Increase the Accuracy of Patient Medication Histories Obtained in the Emergency Department

PURPOSE

The purpose of this study is to determine the accuracy of a pharmacy technician-collected medication history pilot program in the emergency department. This was completed by reviewing all elements of the technician activity by direct observation and by verifying the technician-collected medication list through a second phone call by a pharmacist to the outpatient pharmacy.

METHODS

This was a retrospective, single-center study conducted from March to April 2015. Four certified pharmacy technicians were trained by a postgraduate year 1 (PGY1) pharmacy practice resident on how to collect, verify, and accurately enter medication histories into the electronic medical record. Accuracy of pharmacy technician-collected medication histories was verified by a pharmacist through observation of their patient interviews, review of technician-completed medication history forms, and by contacting the patient's outpatient pharmacy.

RESULTS

The pharmacy technician-completed medication histories resulted in an absolute risk reduction of errors of 50% and a relative risk reduction of errors of 77% (p < .001) in comparison to medication histories collected by non-pharmacy personnel.

CONCLUSION

With high accuracy rates, pharmacy technicians proved to be a valuable asset to the medication history process and can enhance patient safety during care transitions. The results of this study further support the Pharmacy Practice Model Initiative vision to advance the pharmacy technician role to improve the process of medication history taking and reconciliation within the health care system.

Pharmacy impact on medication reconciliation in the medical intensive care unit

Objective:

Pharmacy-driven medication history (MH) programs have been shown to reduce the number of serious or potentially life-threatening (S/PLT) medication discrepancies (MDs) in many settings, but not Intensive Care Units (ICUs).

Methods:

MHs were repeated over a 6-week period. Demographics, number, and nature of MDs were documented. Discrepancy severity was graded using a previously published method. Primary outcome was the proportion of MHs containing >1 S/PLT MDs.

Findings:

Sixty-three MHs were repeated. Pharmacy MHs were less likely to contain ≥1 S/PLT MDs (0% vs. 50%, P < 0.001).

Conclusion:

Pharmacy MHs contained fewer S/PLT MDs in this small sample. S/PLT MDs on admission and home medication lists were common in patients admitted to the medical ICU. Pharmacy-driven medication reconciliation (MR) reduced the number and frequency of these discrepancies. Further research is required to improve current MR procedures.

Impact of pharmacy-led medication reconciliation on medication errors during transition in the hospital setting

Objective:

To assess if the pharmacy department should be more involved in the medication reconciliation process to assist in the reduction of medication errors that occur during transition of care points in the hospital setting.

Methods:

This was an observational prospective cohort study at a 531-bed hospital in Pensacola, FL from June 1, 2014 to August 31, 2014. Patients were included in the study if they had health insurance and were taking five or more medications. Patients with congestive heart failure were excluded from the study. Student pharmacists collected and evaluated medication histories obtained from patients’ community pharmacies, and directed patient interviews. Primary care providers were only contacted on an as needed basis. The information collected was presented to the clinical pharmacist, where interventions were made utilizing clinical judgment.

Results:

During the three month study, 1045 home medications were reviewed by student pharmacist. Of these, 290 discrepancies were discovered (27.8%; p=0.02). The most common medication discrepancy found was dose optimization (45.5%). The remaining discrepancies included: added therapy (27.6%), other (15.2%), and discontinued therapy (11.7%). Pharmacists made 143 interventions based on clinical judgment (49.3%; p=0.04).

Conclusion:

Involvement of pharmacy personnel during the medication reconciliation process can be an essential component in reducing medical errors. With the addition of the pharmacy department during the admission process, accuracy, cost savings, and patient safety across all phases and transition points of care were achieved.

Medication Reconciliation Practices in Canadian Emergency Departments: A National Survey

BACKGROUND

As of 2015, Accreditation Canada's Qmentum program expects emergency departments (EDs) to initiate medication reconciliation for 2 groups of patients: (1) those with a decision to admit and (2) those without a decision to admit who meet the criteria of a risk-based, health care organization-defined selection process. Pharmacist-led best possible medication histories (BPMHs) obtained in the ED are considered more complete and accurate than BPMHs obtained by other ED providers, with pharmacy technicians obtaining BPMHs as effectively as do pharmacists. A current assessment of the role of pharmacy in BPMH processes in Canadian EDs is lacking.

OBJECTIVES

To identify and describe BPMH and medication reconciliation practices in Canadian EDs, including those performed by members of the ED pharmacy team.

METHODS

All Canadian hospitals with an ED and at least 50 acute care beds were contacted to identify the presence of dedicated ED pharmacy services (defined as at least a 0.5 full-time equivalent position). Different electronic surveys were then distributed to ED pharmacy team members (where available) and ED managers (all hospitals).

RESULTS

Survey responses were obtained from 60 (63%) of 95 ED pharmacy teams and 128 (53%) of 243 ED managers. Only 38 (30%) of the 128 ED managers believed that their current BPMH processes were adequate to obtain a BPMH for all admissions. Fifty-nine (98%) of the ED pharmacy personnel reported obtaining BPMHs (most commonly 6-10 per day), with priority given to admitted patients. Only 14 (23%) of the 60 ED pharmacy teams reported that their EDs had adequate staffing to comply with Accreditation Canada's requirements for obtaining BPMHs. This result is supported by the 104 (81%) out of 128 ED managers who reported that additional ED staffing would be needed to comply with the requirements. Numerous ED managers identified the need to expand ED pharmacy services and improve information technology support.

CONCLUSIONS

BPMH processes in Canadian EDs were variable and inadequately supported. Survey responses suggested that additional staff and significant improvements in structured processes would be required to meet Accreditation Canada standards.

Medication reconciliation improvement in a private psychiatric inpatient hospital

Introduction: How to improve medication reconciliation has been an ongoing discussion in hospitals across the nation. This study was designed to identify areas for potential improvement in the medication reconciliation process for an 80-bed, inpatient psychiatric hospital. A previous evaluation conducted at the site indicated that 45% of medication reconciliations were correct. Subsequently, a new process was developed to improve this area of patient care. This process included an update to existing medication-reconciliation forms, staff education, and the standardization of all protocols involved. The investigators examined the updated process to identify gaps in patient care during the admission medication-reconciliation process.

Methods: The primary outcome of the study was an assessment of the accuracy of the updated medication-reconciliation protocols. Data, including medication, dosage, route, and frequency, were collected from randomly selected patients (13 years and older) admitted during the 2-month study period. These data were collected at least 24 hours after admission. Patients were interviewed and their home pharmacy was contacted to determine whether the information collected during the initial medication-reconciliation process was correct.

Results: The investigator identified 44 patients during the collection period and compared the results to the previous study, before the enhancements in the medication-reconciliation process. The accuracy of medication reconciliation in this analysis was 80%, compared with 45% from the previous study (P = 0.0011).

Discussion: Personnel training and protocol updates led to a statistically significant increase in the accuracy of the hospitals medication-reconciliation process. Ongoing staff education and assessment of the improved protocol may further increase accuracy in the medication-reconciliation process at this hospital.

Inpatient prescribing and monitoring of fentanyl transdermal systems: adherence to safety regulations

BACKGROUND

National safety guidelines were developed to minimize the occurrence of serious adverse drug events (ADEs) associated with the use of the fentanyl transdermal system (FTS), however, reports of use in opioid-naïve patients for treatment of acute pain and associated ADEs continue to occur.

OBJECTIVE

To evaluate the prescribing patterns of the FTS for adherence to recent US regulatory recommendations and identify the impact of health information technology (HIT) on adherence rates.

METHODS

A retrospective pre- and postintervention analysis was performed in hospitalized adult patients receiving FTS. Electronic medication order instructions and text questions were incorporated into FTS electronic medication orders. The primary outcome measure was adherence of FTS medication orders to regulatory guidelines defined as (a) a new order in an opioid-tolerant patient for use in moderate to severe chronic pain or (b) continuation of the documented home dose in use for at least 7 days. Safety measures included respiratory rate and documented ADEs.

RESULTS

Adherence rates were significantly increased in the postintervention cohort as compared to the preintervention cohort (48.7% vs 85.0%; P < .0001). Incidence of ADEs was significantly lower post intervention (34.7% vs 23.3%; P = .043), including a lower incidence of respiratory depression (16.7% vs 8.3%; P = .043). Documentation was increased in the postintervention cohort (76% vs 100%). However, supporting documentation confirmed responses in only 59.2% of records reviewed.

CONCLUSIONS

Incorporation of HIT via electronic order text questions increased overall adherence rates to regulatory recommendations, increased documentation, and decreased the rate of associated ADEs.