A Time and Motion Study of Pharmacists and Pharmacy Technicians Obtaining Admission Medication Histories

Medication reconciliationis it possible to speed up without compromising quality? A before-after study in the emergency department

OBJECTIVE

The aim of this study was to investigate whether it was possible to decrease the time used for medication reconciliation (MR) in the emergency department without compromising quality. A more efficient method will enable more patients to receive MR as early as possible after admission to hospital.

METHODS

Potential key factors for improvement of the standard method of MR by clinical pharmacists were identified through an observational period. A revised method was developed, focusing on decreasing time spent on the patient interview by use of a condensed checklist and probing questions based on information from a prescription database. Non-inferior quality (proportion of patients with at least one identified medication discrepancy and number of identified medication discrepancies per patient) of the revised method was evaluated using a before-after study design with 200 individuals in each group. Non-inferiority limit was set at 10%. The Mann-Whitney U test was used for statistical evaluation of the difference in time use per patient in the MR process between the before and after group.

RESULTS

Mean age of the included patients was 78 years in both groups. The time used for MR in the after group was 34% shorter (37 min vs 56 min, p<0.0001) compared with the before group. The revised method was shown to be non-inferior compared with the original method with respect to the proportion of patients with at least one identified discrepancy (81%, 95% CI 76% to 86% vs 79%, 95% CI 73% to 84%). Also, non-inferiority was shown for the number of identified discrepancies per patient, where the average number of discrepancies per patient was 1.9 (95% CI 1.7 to 2.1) in both groups.

CONCLUSION

This study showed that it was possible to speed up the MR process without compromising its effectiveness in identifying medication discrepancies.

Exploring pharmacists' perspectives on preparing discharge medicine lists: A qualitative study

Background

Hospital pharmacists play an important role in the discharge process, including conducting medicine reconciliation, counselling patients or carers, and generating discharge medicine lists. These contribute to medicine handover at transition of care from hospital discharge. However, pharmacists face numerous barriers to providing comprehensive discharge services.

Aim

To gain a deeper understanding of the hospital pharmacists discharge processes.

Method

Qualitative study design was used to explore pharmacists' experiences and opinions regarding (1) the use of technology and software to prepare patient discharges, (2) involvement of pharmacy assistants in discharge processes, and (3) challenges and facilitators in preparing patient discharges. An independent researcher conducted semi-structured interviews with 15 pharmacists between 29 October and 22 December 2021 (mean interview 21 min). Interview transcriptions were analysed using thematic analysis.

Results

Interviews revealed four overarching themes: patient safety, staff involved in discharge processes, discharge handover procedures and electronic health software. Barriers to completing discharges included staff workloads, poor medical record software integration and lack of advanced discharge notice. Good communication between pharmacists and other clinicians, including the presence of a discharge nurse on the inpatient unit, made discharges more efficient, and most pharmacists favoured utilisation of pharmacy assistants in preparing discharge medicine lists.

Conclusion

Poor integration between medical software systems negatively impacts pharmacists' ability to complete discharge medicine lists. Pharmacists require advance notice of upcoming discharges to effectively prioritise high workloads, while increased utilisation of trained pharmacy assistants may facilitate discharge workflows.

Exploring the time required by pharmacists to prepare discharge medicine lists: a time-and-motion study

BACKGROUND  : Discharge medicine lists provide patients, carers and primary care providers a summary of new, changed or ceased medicines when patients discharge from hospital. Hospital pharmacists play an important role in preparing these lists although this process is time consuming. AIM  : To measure the time required by hospital pharmacists to complete the various tasks involved in discharge medicine handover. METHOD  : Time-and-motion study design was used to (1) determine the time involved for pharmacists to produce discharge medicine lists, (2) explore how pharmacists utilise various software programs to prepare lists, and (3) compare the time involved in discharge medicine handover processes considering confounding factors. An independent observer shadowed 16 pharmacists between 22 February and 12 March 2021 and recorded tasks involved in 50 discharge medicine handovers. Relevant information about each discharge was also collected. RESULTS  : Pharmacists observed represented a range of practice experiences and inpatient units. Mean time to complete discharges was 26.2 min (SD 13.6), with over half of this time used to check documentation and prepare discharge medicine lists. A mean of 4.0 min was spent on manually retyping and reconciling medicine lists in different software systems. Medical inpatient unit discharges took 4.6 min longer to prepare compared to surgical ones. None of the 50 discharges involved support from pharmacy assistants; all 50 discharges had changed or ceased medicines. CONCLUSION : There is a need to streamline current discharge processes through optimisation of electronic health software systems and better delegation of technical tasks to trained pharmacy assistants.

Exploring multi-stakeholder perceptions of practice-related facilitators to optimising the quality of integration of regulated pharmacy technicians in community pharmacy in Ontario: a qualitative study

OBJECTIVES

The objective of this study was to investigate multi-stakeholder perceptions of practice-related facilitators to optimising the quality of Regulated Pharmacy Technician (RPT) integration into the community workforce in Ontario. Facilitators to incorporating technicians into the workflow and supporting their optimal scope of practice were explored.

METHODS

A qualitative exploratory study comprising a series of one-to-one interviews using a piloted, semi-structured interview guide was conducted with four community pharmacy stakeholder groups; pharmacists, RPTs, pharmacy assistants and pharmacy owners. Interviews were conducted until saturation of themes. Verbatim transcripts were coded inductively using the software, NVivo v12 (QSR International) and general inductive analysis identified key findings.

KEY FINDINGS

Twenty-seven interviews were conducted consisting of seven pharmacists, seven RPTs, eight assistants and five pharmacy owners working within community pharmacy and/or academia or hospital. All participants from every stakeholder group acknowledged that the promise of regulation of pharmacy technicians was unfulfilled in practice. Three major themes of practical significance were derived: (i) A viable business plan that incorporates RPT remuneration and ensures sustainability is a facilitator to fuller integration of RPTs, (ii) Planning the pharmacy workflow to support RPTs' and pharmacists' evolving scopes is a facilitator to RPT integration and (iii) Schedule planning to incorporate RPTs and appropriate staffing ratios in relation to prescription volume and pharmacy services allows for optimal utilisation of RPT skills and facilitates their integration.

CONCLUSIONS

Achieving integration of RPTs into the business of a community pharmacy has educational, workplace and regulatory implications, requiring the effective engagement of all stakeholders in pharmacy.

Detecting direct oral anticoagulants in trauma patients using liquid chromatography-mass spectrometry: A novel approach to medication reconciliation

BACKGROUND

Accurate medication reconciliation in trauma patients is essential but difficult. Currently, there is no established clinical method of detecting direct oral anticoagulants (DOACs) in trauma patients. We hypothesized that a liquid chromatography-mass spectrometry (LCMS)-based assay can be used to accurately detect DOACs in trauma patients upon hospital arrival.

METHODS

Plasma samples were collected from 356 patients who provided informed consent including 10 healthy controls, 19 known positive or negative controls, and 327 trauma patients older than 65 years who were evaluated at our large, urban level 1 trauma center. The assay methodology was developed in healthy and known controls to detect apixaban, rivaroxaban, and dabigatran using LCMS and then applied to 327 samples from trauma patients. Standard medication reconciliation processes in the electronic medical record documenting DOAC usage were compared with LCMS results to determine overall accuracy, sensitivity, specificity, and positive and negative predictive values (PPV, NPV) of the assay.

RESULTS

Of 356 patients, 39 (10.96%) were on DOACs: 21 were on apixaban, 14 on rivaroxaban, and 4 on dabigatran. The overall accuracy of the assay for detecting any DOAC was 98.60%, with a sensitivity of 94.87% and specificity of 99.05% (PPV, 92.50%; NPV, 99.37%). The assay detected apixaban with a sensitivity of 90.48% and specificity of 99.10% (PPV, 86.36%; NPV 99.40%). There were three false-positive results and two false-negative LCMS results for apixaban. Dabigatran and rivaroxaban were detected with 100% sensitivity and specificity.

CONCLUSION

This LCMS-based assay was highly accurate in detecting DOACs in trauma patients. Further studies need to confirm the clinical efficacy of this LCMS assay and its value for medication reconciliation in trauma patients.

LEVEL OF EVIDENCE

Diagnostic Test, level III.

Medication reconciliation: time to save? A cross-sectional study from one acute hospital

PURPOSE

Medication errors during transitional care are an important patient safety issue. Medication reconciliation is an established intervention to reduce such errors. Current evidence has not demonstrated an associated reduction in healthcare costs, however, with complexity and resource intensity being identified as issues. The aims of this study were to examine an existing process of medication reconciliation in terms of time taken, to identify factors associated with additional time, and to determine if additional time is associated with detecting errors of clinical significance.

METHODS

A cross-sectional study was conducted. Issues arising during medication reconciliation incurring a time burden additional to the usual process were logged and quantified by pharmacists. Regression analyses investigated associations between patient characteristics and clinically significant errors and additional time. Cost for additional time in terms of hospital pharmacist salary was calculated.

RESULTS

Eighty-nine patients were included. Having a personal record of medication at admission (OR 3.30, 95% CI: (1.05 to 10.42), p = 0.004) was a significant predictor of additional time. No significant associations were found between the occurrence of clinically significant error and additional time (p > 0.05). The most common reason for additional time was clarifying issues pertaining to primary care medication information. Projected annual 5-year costs for the mean additional time of 3.75 min were €1.8-1.9 million.

CONCLUSIONS

Spending additional time on medication reconciliation is associated with economic burden and may not yield benefit in terms of capturing clinically significant errors. There is a need to improve communication of medication information between primary and secondary care.

Medications and patient safety in the trauma setting: a systematic review

Background

Medication errors account for the most common adverse events and a significant cause of mortality in the USA. The Joint Commission has required medication reconciliation since 2006. We aimed to survey the literature and determine the challenges and effectiveness of medication reconciliation in the trauma patient population.

Materials and methods

We conducted a systematic review of the literature to determine the effectiveness of medication reconciliation in trauma patients. English language articles were retrieved from PubMed/Medline, CINAHL, and Cochrane Review databases with search terms "trauma OR injury, AND medication reconciliation OR med rec OR med rek, AND effectiveness OR errors OR intervention OR improvements."

Results

The search resulted in 82 articles. After screening for relevance and duplicates, the 43 remaining were further reviewed, and only four articles, which presented results on medication reconciliation in 3041 trauma patients, were included. Two were retrospective and two were prospective. Two showed only 4% accuracy at time of admission with 48% of medication reconciliations having at least one medication discrepancy. There were major differences across the studies prohibiting comparative statistical analysis.

Conclusions

Trauma medication reconciliation is important because of the potential for adverse outcomes given the emergent nature of the illness. The few articles published at this time on medication reconciliation in trauma suggest poor accuracy. Numerous strategies have been implemented in general medicine to improve its accuracy, but these have not yet been studied in trauma. This topic is an important but unrecognized area of research in this field.

[Involvement of hospital pharmacy technician for expanding medication reconciliation process in France: Actors' willingness and opinions]

OBJECTIVES

Medication reconciliation is widely promoted by international health authorities. Its expansion requires human resources, which are limited and unequally distributed among health care facilities. Recent international studies support the involvement of pharmacy technician in the medication reconciliation process but his role remains unstructured in France. We aimed to assess pharmacy technicians' opinions and willingness to be involved in the medication reconciliation process expansion and to identify the levers and barriers of the project.

METHODS

A field study was conducted among health facilities of our territory hospital group. Semi-structured interviews were carried out with different pharmacy technicians. Data were analyzed using a qualitative thematic analysis approach.

RESULTS

Overall, 12 pharmacy technicians from 5 hospitals were interviewed and almost all assumed their rightful place in the medication reconciliation process (n=11), with a view to revaluating tasks. For all pharmacy technicians, the main barriers to participate in medication reconciliation were the lack of time and training. The spread of a "patient culture", the supervision by pharmacists, the desire to be part of the care team in the ward and additional training requests were major levers of change.

CONCLUSIONS

Pharmacy technicians' role in expanding medication reconciliation process is legitimate and must be standardized in France. The deployment of the project requires to be formalized within a territory and should consider and develop local organisations.

Improving admission medication reconciliation with pharmacists or pharmacy technicians in the emergency department: a randomised controlled trial

BACKGROUND

Admission medication history (AMH) errors frequently cause medication order errors and patient harm.

OBJECTIVE

To quantify AMH error reduction achieved when pharmacy staff obtain AMHs before admission medication orders (AMO) are placed.

METHODS

This was a three-arm randomised controlled trial of 306 inpatients. In one intervention arm, pharmacists, and in the second intervention arm, pharmacy technicians, obtained initial AMHs prior to admission. They obtained and reconciled medication information from multiple sources. All arms, including the control arm, received usual AMH care, which included variation in several common processes. The primary outcome was severity-weighted mean AMH error score. To detect AMH errors, all patients received reference standard AMHs, which were compared with intervention and control group AMHs. AMH errors and resultant AMO errors were independently identified and rated by ≥2 investigators as significant, serious or life threatening. Each error was assigned 1, 4 or 9 points, respectively, to calculate severity-weighted AMH and AMO error scores for each patient.

RESULTS

Patient characteristics were similar across arms (mean±SD age 72±16 years, number of medications 15±7). Analysis was limited to 278 patients (91%) with reference standard AMHs. Mean±SD AMH errors per patient in the usual care, pharmacist and technician arms were 8.0±5.6, 1.4±1.9 and 1.5±2.1, respectively (p<0.0001). Mean±SD severity-weighted AMH error scores were 23.0±16.1, 4.1±6.8 and 4.1±7.0 per patient, respectively (p<0.0001). These AMH errors led to a mean±SD of 3.2±2.9, 0.6±1.1 and 0.6±1.1 AMO errors per patient, and mean severity-weighted AMO error scores of 6.9±7.2, 1.5±2.9 and 1.2±2.5 per patient, respectively (both p<0.0001).

CONCLUSIONS

Pharmacists and technicians reduced AMH errors and resultant AMO errors by over 80%. Future research should examine other sites and patient-centred outcomes.

TRIAL REGISTRATION NUMBER

NCT02026453.