Criteria for the selection of paediatric patients susceptible to reconciliation error

OBJECTIVES

Many medication errors occur during care transitions, which are critical points for patient safety. There is strong evidence in favour of medication reconciliation as a strategy to avoid errors in adults, though few studies have been made in the paediatric setting. Likewise, no recommendations have been established for the selection and/or prioritisation of paediatric patients amenable to reconciliation.

METHODS

A retrospective study was conducted involving patients subjected to reconciliation by a pharmacist on admission to hospital and who experienced at least one reconciliation error between January and November 2018. Univariable and multivariable analyses were performed to identify possible factors associated with reconciliation error, using a logistic regression model to determine the odds ratio (OR) with the corresponding 95% confidence interval (95% CI).

RESULTS

The group of patients with at least one reconciliation error included 334 patients, compared with the group of patients without reconciliation errors, which included 1426 patients. It was determined that schoolchildren and adolescent patients had a risk of presenting a reconciliation error on hospital admission that was more than double for younger patients (OR 2.32, 95% CI 1.26 to 4.25, and OR 2.68, 95% CI 1.44 to 4.99, respectively). This risk was multiplied by five if we compared polymedicated patients versus non-polymedicated patients (OR 4.48, 95% CI 3.35 to 5.99). Patients with a neurological or onco-haematological underlying disease had a 12 and 10 times higher risk of presenting a reconciliation error compared with patients with other types of underlying diseases (OR 11.97, 95% CI 7.57 to 18.92, and OR 9.96, 95% CI 6.09 to 16.28, respectively). Finally, patients with narrow therapeutic index medicines in their usual treatment had an almost three times greater risk of presenting a reconciliation error when admitted to the hospital, although this last factor was not determined as an independent risk factor as for the others (OR 2.98, 95% CI 2.22 to 3.99).

CONCLUSIONS

The paediatric population is characterised by a number of risk factors for reconciliation error. Knowledge of these factors can allow the prioritisation of medication reconciliation in a concrete group of patients. In order to generalise the results obtained in this study, they must be confirmed in other paediatric care settings involving larger samples and different types of patients.

Impact of pharmacist involvement on medication safety in interprofessional transfer of care activity

AIM

Any transition of patient care is a high-risk time for communication error. This paper explores whether the presence of a pharmacist as part of an interprofessional group provides additional benefit and safety in transitions of care.

METHOD

Six pharmacy interns and newly qualified pharmacists joined participants from seven other health professional training programmes to take part in an interprofessional education activity. Participants were assigned to 24 mixed-professional groups. Each group was required to craft a discharge summary for the same simulated patient. Groups without a pharmacist were given additional written documentation, including medication reconciliation, discharge prescription and discharge recommendations. The 24 discharge summaries were assessed for any medication-related information, both positive and negative. Groups with a pharmacist (6) were compared with groups who did not have a pharmacist (18) for completeness and accuracy of medication management.

RESULTS

An in-person pharmacist provided more thorough, comprehensive, accessible and accurate information for the community team (p=0.003). Although there was no difference in the absolute number of medication errors between the groups (p=0.057), the groups with a pharmacist showed a significant reduction in the severity of the errors (p=0.009). This result happened despite the groups without a pharmacist being provided with all the required medication information for safe transition of care.

CONCLUSION

These findings support the case for greater involvement from a pharmacist in a patient's healthcare team, particularly for any transition of care. Healthcare teams that include a pharmacist are more likely to exceed minimum safety expectations and make less severe errors.

Incidence and Variables Associated With Inconsistencies in Opioid Prescribing at Hospital Discharge and Its Associated Adverse Drug Outcomes

OBJECTIVES

Opioid-related medication errors (MEs) can have a significant impact on patient health and contribute to opioid misuse. The objective of this study was to estimate the incidence of and variables associated with the receipt of an opioid prescription and opioid-related MEs (omissions, duplications, or dose changes) at hospital discharge. We also determined rates of adverse drug events and risks of emergency department visits, readmissions, or death 30 days and 90 days post discharge associated with MEs.

METHODS

A cohort of hospitalized patients discharged from the McGill University Health Centre between 2014 and 2016 was assembled. The impact of opioid-related MEs was assessed in a propensity score-adjusted logistic regression models. Multivariable logistic regression was used to determine characteristics associated with MEs and discharge opioid prescription.

RESULTS

A total of 1530 (43.9%) of 3486 patients were prescribed opioids, of which 13.4% (n = 205) of patients had at least 1 opioid-related ME. Rates of MEs were higher in handwritten prescriptions compared to the electronic reconciliation discharge prescription group (20.6% vs 1.2%). Computer-based prescriptions were associated with a 69% lower risk of opioid-related MEs (adjusted odds ratio: 0.31, 95% confidence interval: 0.14-0.65) as well as 63% lower risk of receiving an opioid prescription. Opioid-related MEs were associated with a 2.3 times increased risk of healthcare utilization in the 30 days postdischarge period (adjusted odds ratio: 2.32, 95% confidence interval: 1.24-4.32).

CONCLUSIONS

Opioid-related MEs are common in handwritten discharge prescriptions. Our findings highlight the need for computer-based prescribing platforms and careful review of medications during critical periods of care such as hospital transitions.

Framework for Pharmacy Services Quality Improvement-A Bridge to Cross the Quality Chasm

OBJECTIVE

To review the literature on the subject of quality improvement principles and methods applied to pharmacy services and to describe a framework for current and future efforts in pharmacy services quality improvement and effective drug therapy management.

BACKGROUND

The Academy of Managed Care Pharmacy produced the Catalog of Pharmacy Quality Indicators in 1997, followed by the Summary of National Pharmacy Quality Measures in February 1999. In April 2002, AMCP introduced Pharmacy's Framework for Drug Therapy Management in the 21st Century. The Framework documents include a self-assessment tool that details more than 250 specific "components" that describe tasks, behaviors, skills, functions, duties, and responsibilities that contribute to meeting customer expectations for effective drug therapy management.

FINDINGS

There are many opportunities for quality improvement in clinical, service, and cost outcomes related to drug therapy management. These may include patient safety; incidence of medical errors; adverse drug events; patient adherence to therapy; attainment of target goals of blood pressure, glucose, and lipid levels; risk reduction for adverse cardiac events and osteoporotic-related fractures; patient satisfaction; risk of hospitalization or mortality; and cost of care. Health care practitioners can measure improvements in health care quality in several ways including (a) a better patient outcome at the same cost, (b) the same patient outcome at lower cost, (c) a better patient outcome at lower cost, or (d) a significantly better patient outcome at moderately higher cost. Measurement makes effective management possible. A framework of component factors (e.g., tasks) is necessary to facilitate changes in the key processes and critical factors that will help individual practitioners and health care systems meet customer expectations in regard to drug therapy, thus improving these outcomes.

CONCLUSIONS

Quality improvement in health care services in the United States will be made in incremental changes that rely on a structure-process-outcome model. The structure is provided by evidence created from controlled randomized trials and other studies of care and system outcomes that are based on the scientific method. The process portion is created by the application of evidence in the form of clinical practice guidelines, clinical practice models, and self-assessment tools such as Pharmacy's Framework for Drug Therapy Management. Incremental changes in structure and process will result in the desirable outcome of meeting customer needs for more effective drug therapy and disease management.

DISCLOSURES

Authors Richard N. Fry and Steven G. Avey are employed by the Foundation for Managed Care Pharmacy, a nonprofit charitable trust that serves as the educational and philanthropic arm of the Academy of Managed Care Pharmacy; author Frederic R. Curtiss performed the majority of work associated with this manuscript prior to becoming editor-in-chief of the Journal of Managed Care Pharmacy. This manuscript underwent blinded peer review and was subject to the same standards as every article published in JMCP.

Evaluation of a method for drug-related problems identification and classification in hospital setting: applicability and reliability

Background Prescription evaluation by pharmacists has potential to improve pharmacotherapy management. It requires the use of robust methods to identify drug-related problems (DRP), which are important issues in pharmacotherapy. Objective To evaluate the applicability and reliability of Grupo de Investigação em Cuidados Farmacêuticos (GIGUF) method for prescription analysis, identification and classification of drug-related problems in inpatients prescriptions. Setting Department of Medical Clinic of a tertiary and teaching Brazilian hospital. Method An observational and retrospective study of identification and classification of drug-related problems. GIGUF method was used to evaluate prescriptions of hematological patients hospitalized between August and October 2015. The problems were categorized using GICUF-method classification. Three pharmacists performed inter-rater agreement analysis of the method using Kappa. Differences in prevalence of DRP was calculated by age, sex, pharmacotherapy complexity, length of stay and number of drugs. Main outcome measure (a) frequency and characteristics and (b) inter-rater agreement in identification and classification of the drug-related problems. Results A total of 211 problems were identified and 'inadequate dosing' was the most common problem. There was an association between the occurence of a drug-reklated problem and complexity of pharmacotherapy (p = 0.001) and number of drugs used (p = 0.010). The overall inter-rater agreement was moderate (k = 0.44 IC 95% 0.34-0.55) and the problem 'not suitable drug' (k = 0.55 IC 95% 0.44-0.66) had greater inter-rater agreement. Conclusion The method "Evaluation Drug Use Process" was useful for prescription analysis since it made the identification and classification of DRPs possible. The method demonstrated a moderate inter-rater agreement, and can contribute to pharmacotherapy management by hospital pharmacists.

Medication histories documentation at the community pharmacy setting: A study from Jordan

Objectives

The main objective of this study was to evaluate community pharmacists’ awareness and perception about medication reconciliation service and to assess the completeness of collecting patients’ medication histories in the community pharmacy setting.

Methods

A cross-sectional study was conducted between February to March 2018 in Amman-Jordan. During the study period, 150 community pharmacists were invited to participate in the study. Each pharmacist completed a validated structured questionnaire evaluating their awareness, current practice, perceived attitude and perceived barriers towards the implementation of medication reconciliation and the collection of medication histories at the community pharmacy setting.

Results

A total of 121 pharmacists agreed to participate and filled the questionnaire. Our results showed that only 13.2% of the pharmacists were able to define “medication reconciliation” correctly, and around 31% have a misconception that the medication reconciliation process should be performed only at the inpatient setting.

Only 19.8% (n = 24) of the participating pharmacists stated that they ask all patients for a complete current medication list of medications when they arrive at the pharmacy site. Medication histories for most patients were lacking information about the dosage, route, frequency, and time of the last refill for each medication listed. “Patients lack of awareness about all the medications they are receiving” was the main barrier discouraging community pharmacists from collecting medication histories and participating in reconciliation service.

Conclusion

Community pharmacists in Jordan showed a low awareness about the medication reconciliation concept and demonstrated a modest role in obtaining medication histories in community pharmacies. But still, they showed a positive attitude towards their role in implementing the different steps of medication reconciliation. This suggests that educational workshops to increase pharmacists’ awareness about their role and responsibilities in collecting a complete and accurate medication history are warrented.

Pharmacy students' medication history taking competency: Simulation and feedback learning intervention

INTRODUCTION

Obtaining accurate patient medication histories and performing medication reconciliation are core pharmacy practice skills that optimize patient safety at transitions of care. Competency-based learning and assessment of medication reconciliation skills are essential methods in undergraduate pharmacy education. The aim of this study was to investigate the impact of an in-classroom simulation- and feedback-driven training activity on pharmacy students' medication reconciliation skills, self-perceived confidence, and overall student satisfaction.

METHODS

Over a three-day learning activity in 2016, pharmacy students from a private university in Jordan were assessed by roleplay on their ability to conduct a simulated patient medication interview, obtain the Best Possible Medication History, reconcile the history against a hospital medication chart, identify discrepancies, and document findings. Students received immediate feedback and observed peers undergo the assessment process. Pre- and post-simulation questionnaires and supplementary focus groups enabled collection of quantitative and qualitative data pertaining to student self-perceived confidence, perceptions, experiences, and usefulness of the course.

RESULTS

Assessment-based competency scores demonstrated significant improvement in student performance during the activity. Self-perceived confidence scores significantly improved after the medication reconciliation training intervention. Focus group content analysis yielded positive responses such as students valuing receiving feedback on performance and recommendations for future training.

CONCLUSIONS

Simulation with feedback was a useful tool to teach pharmacy students medication reconciliation in Jordan. Subsequent to the study, medication reconciliation and interactive teaching methods were added to curriculum to supplement traditional teaching modalities.

An On-Treatment Analysis of the MARQUIS Study: Interventions to Improve Inpatient Medication Reconciliation

It is unclear which medication reconciliation interventions are most effective at reducing inpatient medication discrepancies. Five United States hospitals' interdisciplinary quality improvement (QI) teams were virtually mentored by QI-trained physicians. Sites implemented one to seven evidence-based interventions in 791 patients during the 25-month implementation period. Three interventions were associated with significant decreases in potentially harmful discrepancy rates: (1) defining clinical roles and responsibilities, (2) training, and (3) hiring staff to perform discharge medication reconciliation. Two interventions were associated with significant increases in potentially harmful discrepancy rates: training staff to take medication histories and implementing a new electronic health record (EHR). Hospitals should focus first on hiring and training pharmacy staff to assist with medication reconciliation at discharge and delineating roles and responsibilities of clinical staff. We caution hospitals implementing a large vendor EHR, as medication discrepancies may increase. Finally, the effect of medication history training on discrepancies needs further study.

Assessing the knowledge, perception and practices of physicians and pharmacists towards medication reconciliation in Kuwait governmental hospitals: a cross-sectional study

OBJECTIVES

To assess the knowledge, perception and practices towards medication reconciliation (MedRec) and its related institutional policies among physicians and pharmacists in governmental hospitals in Kuwait and identifying potential obstacles that prevent the successful implementation of MedRec.

DESIGN

A descriptive, cross-sectional study.

SETTING

Six governmental hospitals across Kuwait in January-May 2017.

PARTICIPANTS

351 physicians and 214 pharmacists.

BRIEF INTERVENTION

A self-administered questionnaire distributed to the participants.

MAIN OUTCOME MEASURES

Knowledge, perception, attitudes and practices of hospital physicians and pharmacists towards MedRec, and major barriers to implementing a MedRec process in their institution/department.

RESULTS

Of the 739 questionnaires distributed, 565 were completed (351 physicians and 214 pharmacists), giving a response rate of 76.5%. Results showed that most participants were familiar with the term MedRec (n=419; 75.2%) with significantly more pharmacists compared with physicians (n=171; 81.8% vs n=248; 71.3%; p=0.005). Most participants (n=432; 80.0%) reported perceiving MedRec as a valuable process for patient safety. However, significantly more physicians compared with pharmacists were aware of a MedRec policy in their institution (n=195; 55.9% vs n=78; 37.9%; p<0.001) and routinely asked patients about their current list of medication on arrival (n=339; 96.6% vs n=129; 61.1%; p<0.001) and provided an updated list on discharge (n=281; 80.1% vs n=107; 52.0%; p<0.001). These results are supported by the findings that participants perceived physicians as providers, mainly responsible for various steps of MedRec.

CONCLUSIONS

Overall, this study showed low awareness among physicians and pharmacists of hospital policy despite MedRec being perceived as valuable. Physicians were the providers most responsible and involved in MedRec, who may be driven by the policy putting them at core of the process. The current findings could pave the way for the expansion of the existing MedRec policies and processes in Kuwait to include pharmacists and improve patient safety.

[Preparing for the licence to prescribe in medical school - a questionnaire study on medical students professional confidence in the art of prescribing]

A prerequisite for rational use of medicines is adequate prescribing skills; drug treatment is a complex task requiring diagnostic competence combined with pharmacologic knowledge and patient communication skills. Acquiring professional confidence in the art of prescribing is essential during medical training. The results of this questionnaire study, conducted in four medical schools in Sweden after the course in internal medicine (252 respondents; response rate: 74%; median age: 24 years, 61% female), show that 45% and 62% were confident in performing medication reviews and writing medication summary reports, respectively, i.e. the basics of prescribing. The confidence increased by the number of reviews and reports performed, i.e. the extent of practice (correlation coefficients: 0.41 and 0.38, respectively, both p<0.0001), as did the extent of the students' reflection on important aspects of drug treatment such as adherence, adverse reactions, renal function, dosing, and drug interactions. In multivariate regression analyses, major predictors for confidence in performing medication reviews were extent of practice and extent of clinical supervision. The results suggest that these factors are keys to acquiring professional confidence in the art of prescribing.

The Daniel K. Inouye College of Pharmacy Scripts: Improving the Accuracy of Patient Medication Lists: Performing Medication Reconciliation by Phone Prior to Appointments

The purpose of this project was to utilize pharmacists and pharmacy students to perform comprehensive medication reconciliation by telephone prior to a patient's office visit with their primary care physician, to address any medication issues. The project's aims were to decrease polypharmacy, improve the accuracy of medication reconciliation, and to allow more time for the physician to meet with the patient. Patients were called prior to appointment and a thorough medication reconciliation was conducted including verification of current prescription medications, over-the-counter medications, and herbal supplements. A total of 21 patients were enrolled in the study, and in 36% of patients, the number of medications decreased after the intervention. However, overall, the average number of medications used by patients increased from an average of 8.9 to 9.5 medications (P = .39). All patients included in the study had at least one medication change in the electronic medical record system. Most of the changes were to add medications that were not on the medication list or to remove medications on the list that the patient was no longer taking. This study demonstrated improved accuracy with pharmacist/pharmacy student involvement in the medication reconciliation process.

Validity of a nationwide medication record system in the Netherlands

Background In the Netherlands, a nationwide Medication Record System based on pharmacy dispensing data is used to obtain information about patients' actual medication use. However, it is not clear to what extent the information of the Nationwide Medication Record System corresponds to the medication information obtained with the Best Possible Medication History. Objective To examine the validity of medication dispensing records collected from the Nationwide Medication Record System by comparing them to the Best Possible Medication History. Method An observational study was performed. Patients from several hospital departments were included at admission. To obtain the Best Possible Medication History, pharmacy technicians performed medication reconciliation at admission, using dispensing records from the Nationwide Medication Record System and information from the patient himself. Primary outcome is percentage of patients with no discrepancies between the Nationwide Medication Record System and the Best Possible Medication History. Descriptive analysis was used. Results Eighty-two patients were approached and 66 (80%) were included, with in total 478 medicines in the Best Possible Medication History. Seventeen percent of the patients had no discrepancies and 33% (n = 156) of the medication records contained a discrepancy between the Nationwide Medication Record System and the Best Possible Medication History. Most common type of discrepancy was omission (44%). Conclusion Even with a Nationwide Medication Record System medication reconciliation with the patient remains essential to obtain complete information about patient's actual medication use.

Increasing the use of home medication lists in an outpatient neurorehabilitation clinic

Medication reconciliation in ambulatory care settings helps prevent adverse drug events. Patient involvement in the process is crucial, as clinicians must verify the reported medication history with other sources such as home medication lists or brown-bagged home medications provided by patients. However, only 47.8% of brain injury and stroke adult outpatients at Toronto Rehabilitation Institute, an academic rehabilitation hospital, bring their medications/medication lists to clinic visits. In turn, missing medication information impacts the clinic by causing delays in treatment and interrupted clinic flow. This project aimed to increase the percentage of patients who bring their medications/medication lists to 80% and decrease the impact on clinic visits caused by missing medication information to 10%. This was a controlled before-after study, with the outpatient rehabilitation assessment (OPRA) clinic as the intervention and the spasticity clinic as the control. The model for improvement was used as the project framework. Process mapping, Ishikawa diagrams, driver diagrams and patient surveys generated the change ideas. Verbal reminders during confirmation phone calls, written reminders and medication list templates were implemented. Data were collected on a biweekly basis and analysed using statistical control charts. After six Plan-Do-Study-Act cycles conducted over 49 weeks, both project aims were achieved. The percentage of OPRA clinic patients who brought medications/medication lists was 81.8% and the impact on clinic visits caused by missing medication information was 9.1% of clinic visits. Special cause variation was detected on the statistical control charts. Conversely, there was no special cause variation for the spasticity clinic (the control) for either aim. Lessons learnt include the importance of prolonged data collection when implementing interventions with long lag time, and that verbal reminders may not be effective for patients with cognitive impairments. Future efforts may focus on implementing the bundle of project interventions for the spasticity clinic.

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.

Implications of involving pharmacy technicians in obtaining a best possible medication history from the perspectives of pharmaceutical, medical and nursing staff: a qualitative study

OBJECTIVES

In recent years, the involvement of pharmacy technicians in medication reconciliation has increasingly been investigated. The aim of this study was to assess the implications on professional roles and collaboration when a best possible medication history (BPMH) at admission is obtained by pharmacy technicians.

DESIGN

Qualitative study with semistructured interviews. Data were analysed using a qualitative content analysis approach.

SETTING

Internal medicine units in two mid-sized Swiss hospitals.

PARTICIPANTS

21 staff members working at the two sites (6 pharmacy technicians, 2 pharmacists, 6 nurses, 5 physician residents and 2 senior physicians).

RESULTS

Pharmacy technicians generally appreciated their new tasks in obtaining a BPMH. However, they also experienced challenges associated with their new role. Interviewees reported unease with direct patient interaction and challenges with integrating the new BPMH tasks into their regular daily duties. We found that pharmacists played a key role in the BPMH process, since they act as coaches for pharmacy technicians, transmit information to the physicians and reconcile preadmission medication lists with admission orders. Physicians stated that they benefitted from the delegation of administrative tasks to pharmacy technicians. Regarding the interprofessional collaboration, we found that pharmacy technicians in the study acted on a preliminary administrative level and did not become part of the larger treatment team. There was no direct interaction between pharmacy technicians and physicians, but rather, the supervising pharmacists acted as intermediaries.

CONCLUSION

The tasks assumed by pharmacy technicians need to be clearly defined and fully integrated into existing processes. Engaging pharmacy technicians may generate new patient safety risks and inefficiencies due to process fragmentation. Communication and information flow at the interfaces between professional groups therefore need to be well organised. More research is needed to understand if and under which circumstances such a model can be efficient and contribute to improving medication safety.

Confidence in skills applied to patient care among PharmD students in telehealth medication management programs versus other settings

INTRODUCTION

Exposure to medication therapy management (MTM) courses has demonstrated to increase student pharmacist's confidence in the application of patient care skills. The purpose of this study was to evaluate the effects of student pharmacists' work experience in a telehealth MTM program, versus hospital or community settings, on their confidence in skills applied in patient care.

METHODS

This was a cross-sectional multicenter survey. Confidence in patient care among student pharmacists was assessed between those who worked in a telehealth MTM program versus other settings. The data was evaluated using Chi-Square, Fisher exact, unpaired-t, Kruskal-Wallis, and Mann-Whitney U tests.

RESULTS

282 surveys were completed. First-year student pharmacists who worked in the telehealth MTM programs, versus other settings, were more confident in the provision of a comprehensive medication review (CMR) (p < .001), interviewing patients (p < .001), identifying medication errors (p < .001), and making therapeutic recommendations to patients (p = .04) and prescribers (p = .04). Second and third-year student pharmacists who worked in telehealth MTM programs, versus other settings, were more confident in the provision of a CMR (p ≤ .005). Fourth-year student pharmacists who worked in the telehealth MTM programs, versus other settings, were more confident in the provision of a CMR (p = .003), interviewing patients (p = .02), and identifying medication errors (p = .04).

CONCLUSION

Student pharmacists' participation in a telehealth MTM program may markedly increase their confidence in skills applied in patient care. MTM work experience should be offered to student pharmacists during their PharmD programs to enhance their confidence in the provision of patient care.

Systematic review and meta-analysis of the effectiveness of pharmacist-led medication reconciliation in the community after hospital discharge

BACKGROUND

Pharmacists' completion of medication reconciliation in the community after hospital discharge is intended to reduce harm due to prescribed or omitted medication and increase healthcare efficiency, but the effectiveness of this approach is not clear. We systematically review the literature to evaluate intervention effectiveness in terms of discrepancy identification and resolution, clinical relevance of resolved discrepancies and healthcare utilisation, including readmission rates, emergency department attendance and primary care workload.

METHODS

This is a systematic literature review and meta-analysis of extracted data. Medline, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, Allied and Complementary Medicine Database (AMED),Education Resources Information Center (ERIC), Scopus, NHS Evidence and the Cochrane databases were searched using a combination of medical subject heading terms and free-text search terms. Controlled studies evaluating pharmacist-led medication reconciliation in the community after hospital discharge were included. Study quality was appraised using the Critical Appraisal Skills Programme. Evidence was assessed through meta-analysis of readmission rates. Discrepancy identification rates, emergency department attendance and primary care workload were assessed narratively.

RESULTS

Fourteen studies were included, comprising five randomised controlled trials, six cohort studies and three pre-post intervention studies. Twelve studies had a moderate or high risk of bias. Increased identification and resolution of discrepancies was demonstrated in the four studies where this was evaluated. Reduction in clinically relevant discrepancies was reported in two studies. Meta-analysis did not demonstrate a significant reduction in readmission rate. There was no consistent evidence of reduction in emergency department attendance or primary care workload.

CONCLUSIONS

Pharmacists can identify and resolve discrepancies when completing medication reconciliation after hospital discharge, but patient outcome or care workload improvements were not consistently seen. Future research should examine the clinical relevance of discrepancies and potential benefits on reducing healthcare team workload.

Medication errors at hospital admission and discharge in Type 1 and 2 diabetes

AIMS

To assess the prevalence and characteristics of medication errors at hospital admission and discharge in people with Type 1 and Type 2 diabetes, and identify potential risk factors for these errors.

METHODS

This prospective observational study included all people with Type 1 (n = 163) and Type 2 diabetes (n = 508) admitted to the Diabetology-Department of the University Hospital of Montpellier, France, between 2013 and 2015. Pharmacists conducted medication reconciliation within 24 h of admission and at hospital discharge. Medication history collected from different sources (patient/family interviews, prescriptions/medical records, contact with community pharmacies/general practitioners/nurses) was compared with admission and discharge prescriptions to detect unintentional discrepancies in medication indicating involuntary medication changes. Medication errors were defined as unintentional medication discrepancies corrected by physicians. Risk factors for medication errors and serious errors (i.e. errors that may cause harm) were assessed using logistic regression.

RESULTS

A total of 322 medication errors were identified and were mainly omissions. Prevalence of medication errors in Type 1 and Type 2 diabetes was 21.5% and 22.2% respectively at admission, and 9.0% and 12.2% at discharge. After adjusting for age and number of treatments, people with Type 1 diabetes had nearly a twofold higher odds of having medication errors (odds ratio (OR) 1.72, 95% confidence interval (CI) 1.02-2.94) and serious errors (OR 2.17, 95% CI 1.02-4.76) at admission compared with those with Type 2 diabetes.

CONCLUSIONS

Medication reconciliation identified medication errors in one third of individuals. Clinical pharmacists should focus on poly-medicated individuals, but also on other high-risk people, for example, those with Type 1 diabetes.

[Lack of time is the greatest impeding factor to carrying out clinical medication reviews]

Clinical medication reviews can be useful in improving pharmacotherapy for elderly. This study aimed to investigate the view and knowledge of clinical medication reviews among primary care physicians in order to identify perceived barriers and facilitating factors. Data were collected via a questionnaire given to primary care physicians in southern Sweden. Eight out of ten of the respondents were familiar with the concept of clinical medication review, and four out of ten of these, used the method on a regular basis. Lack of time was identified as the greatest impeding factor. Although necessary for a medication review, medication reconciliation was often lacking. Regardless of the theoretical knowledge of medications which are potentially inappropriate for elderly, the respondents still perceived difficulties in decisions made for the individual patient. Further education about medication reviews should be offered to primary care physicians, irrespective of time in the profession.

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

Pharmacists' admission medication histories (AMHs) are known to reduce adverse drug events (ADEs). Pharmacist-supervised pharmacy technicians (PSPTs) have also been used in this role. Nonetheless, few studies estimate the costs of utilizing PSPTs to obtain AMHs. We used time and motion methodology to study the time and cost required for pharmacists and PSPTs to obtain AMHs for patients at high risk for ADEs. Pharmacists and PSPTs required 58.5 (95% confidence interval [CI], 46.9-70.1) and 79.4 (95% CI, 59.1-99.8) minutes per patient, respectively (P = 0.14). PSPT-obtained AMHs also required 26.0 (95% CI, 14.9-37.1) minutes of pharmacist supervision per patient. Based on 2015 US Bureau of Labor Statistics wage data, we estimated the cost of having pharmacists and PSPTs obtain AMHs to be $55.91 (95% CI, 44.9-67.0) and $45.00 (95% CI, 29.7-60.4), respectively, which included pharmacist supervisory cost, per patient (P = 0.32). Thus, we found no statistically significant difference in time or cost between the two provider types. Journal of Hospital Medicine 2017;12:180-183.

Process mapping evaluation of medication reconciliation in academic teaching hospitals: a critical step in quality improvement

BACKGROUND

Medication reconciliation (MedRec) has been a mandated or recommended activity in Canada, the USA and the UK for nearly 10 years. Accreditation bodies in North America will soon require MedRec for every admission, transfer and discharge of every patient. Studies of MedRec have revealed unintentional discrepancies in prescriptions but no clear evidence that clinically important outcomes are improved, leading to widely variable practices. Our objective was to apply process mapping methodology to MedRec to clarify current processes and resource usage, identify potential efficiencies and gaps in care, and make recommendations for improvement in the light of current literature evidence of effectiveness.

METHODS

Process engineers observed and recorded all MedRec activities at 3 academic teaching hospitals, from initial emergency department triage to patient discharge, for general internal medicine patients. Process maps were validated with frontline staff, then with the study team, managers and patient safety leads to summarise current problems and discuss solutions.

RESULTS

Across all of the 3 hospitals, 5 general problem themes were identified: lack of use of all available medication sources, duplication of effort creating inefficiency, lack of timeliness of completion of the Best Possible Medication History, lack of standardisation of the MedRec process, and suboptimal communication of MedRec issues between physicians, pharmacists and nurses.

DISCUSSION

MedRec as practised in this environment requires improvements in quality, timeliness, consistency and dissemination. Further research exploring efficient use of resources, in terms of personnel and costs, is required.

A call for a statewide medication reconciliation program

In the outpatient setting, it is exceedingly difficult to know what medications our patients have been prescribed and are taking. Each encounter with a specialist, hospital, or pharmacy can generate a change to a patient's list of medications, and in most systems, this information is not communicated back to the primary care practice's electronic health record-the exception being opiate prescriptions. Prescription drug monitoring programs in 48 states list every opiate prescription, the name of the prescriber, and the date and location the prescription was picked up. We propose that policy makers act to expand these programs to all medications, thus improving the likelihood that any provider prescribing a new medication would know what medicines their patient is already taking.

Applying quality improvement methods to address gaps in medicines reconciliation at transfers of care from an acute UK hospital

OBJECTIVES

Reliable reconciliation of medicines at admission and discharge from hospital is key to reducing unintentional prescribing discrepancies at transitions of healthcare. We introduced a team approach to the reconciliation process at an acute hospital with the aim of improving the provision of information and documentation of reliable medication lists to enable clear, timely communications on discharge.

SETTING

An acute 400-bedded teaching hospital in London, UK.

PARTICIPANTS

The effects of change were measured in a simple random sample of 10 adult patients a week on the acute admissions unit over 18 months.

INTERVENTIONS

Quality improvement methods were used throughout. Interventions included education and training of staff involved at ward level and in the pharmacy department, introduction of medication documentation templates for electronic prescribing and for communicating information on medicines in discharge summaries co-designed with patient representatives.

RESULTS

Statistical process control analysis showed reliable documentation (complete, verified and intentional changes clarified) of current medication on 49.2% of patients' discharge summaries. This appears to have improved (to 85.2%) according to a poststudy audit the year after the project end. Pharmacist involvement in discharge reconciliation increased significantly, and improvements in the numbers of medicines prescribed in error, or omitted from the discharge prescription, are demonstrated. Variation in weekly measures is seen throughout but particularly at periods of changeover of new doctors and introduction of new systems.

CONCLUSIONS

New processes led to a sustained increase in reconciled medications and, thereby, an improvement in the number of patients discharged from hospital with unintentional discrepancies (errors or omissions) on their discharge prescription. The initiatives were pharmacist-led but involved close working and shared understanding about roles and responsibilities between doctors, nurses, therapists, patients and their carers.

Pharmacy led medicine reconciliation at hospital: A systematic review of effects and costs

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.

Impact of a transition-of-care pharmacist during hospital discharge

OBJECTIVE

To assess the impact of a transition-of-care pharmacist during hospital discharge.

SETTING

An academic medical center in southern Arizona.

PRACTICE DESCRIPTION

One pharmacist coordinated patient discharges in two inpatient units from August 2012 through July 2013. The pharmacist attended interdisciplinary discharge coordination meetings, ensured appropriate discharge orders, facilitated the filling of medications, and educated patients on discharge medications.

PRACTICE INNOVATION

The implementation of a transition-of-care pharmacist to provide discharge medication reconciliation and education.

MAIN OUTCOME MEASURES

Readmission rates and medication interventions made by the pharmacist at discharge.

RESULTS

The pharmacist was involved in the education of 1,011 patients and performed 452 interventions. There were more readmissions per month in the control year versus the year of pharmacist involvement (median 27.5 vs. 25, P = 0.0369). Interventions made by the pharmacist to improve discharge management included starting an omitted medication (23.5%), preventing multiple discharge problems (16.4%), avoiding duplication of therapy (15.7%), correcting insurance issues related to medication coverage (12.2%), changing an improper medication dose or quantity (11.3%), changing an inappropriate prescription for a medication (5.1%), preventing a drug interaction (3.3%), and resolving other problems (12.6%). The most common medication classes involved were antimicrobial agents (9.1%), anticoagulants (8%), antihyperglycemic agents (3.8%), other drug classes (24%), and multiple drug classes (35%).

CONCLUSION

A transition-of-care pharmacist is in a unique position to educate patients on hospital discharge, to intercept a substantial number of medication errors, and to resolve insurance issues that may lead to adherence problems. These improvements in care may result in reduced hospital readmission rates.

Home medication management review in outpatients with chronic diseases in Jordan: a randomized control trial

BACKGROUND

Medication Management Review (MMR) is a patient-focused, structured and collaborative health care service provided in the community setting to optimize patient understanding and quality use of medicines.

OBJECTIVE

To conduct a randomized control trial of the MMR program in Jordan, by a pharmacist identifying treatment related problems (TRPs) through home visits, assessing type and frequency of TRPs, and eventual effect of resolving TRPs identified by the pharmacist and accepted by the physician on the health status of participating patients.

SETTING

Outpatient clinic at the Jordan University Hospital, Amman, Jordan.

METHOD

Consecutive patients from outpatient clinics who were eligible for the study were recruited and randomly distributed into two groups (control and intervention). All patients were visited at home by the pharmacist who delivered only for intervention group counseling regarding self-reported adherence, frequency of monitoring and education regarding pharmacological and non-pharmacological therapy. After identifying TRPs, the pharmacist sent a letter to the physician with certain recommendations for patients in the intervention group only. Physician ticked the approved recommendations and returned the report to the pharmacist, allowing the pharmacist to convey the approved changes to the patients. Patients were referred back to their physicians for confirmation of any changes in treatment. Both groups were reassessed after 2-3 months during their regular follow-up visits to their physicians.

MAIN OUTCOME MEASURE

To assess the impact of home medication review on the number of TRPs and self-reported adherence in outpatients with chronic diseases via hospital-based clinics in Jordan.

RESULTS

A total of 158 TRPs were identified in 112 patients; mean TRP number was 1.63 per patient. As a result of the pharmacist intervention, there was a significant decrease in number of TRPs in the intervention group, the change in the mean was (1.23 (±1.19), P < 0.001) versus the control group (0.29 (±1.24), P = 0.114). After 3 months, a reduction in non-adherence was observed in the intervention (-0.81 (±1.48), P < 0.001) in contrast to no change in self-reported adherence in the control (0.22 (± 1.12), P = 0.168) group.

CONCLUSION

Overall, home-based medication review for patients with chronic conditions decreased the total number of TRPs and improved patient self-reported adherence.

A Health Informatics Approach to Understanding the Discharge Process

This study characterises the inpatient discharge process for medical patients. Inpatient discharge represents a highly complex, distinct process at the point of transition to community care. It is poorly understood. Data were collected to assess the discharge patterns of 3386 patients admitted to a tertiary referral centre over a 9 day period. Individual patient parameters were extracted from an Electronic Patient Record and analysed for a random stratified sample of (n=150) with 12 months follow-up. Medical discharges represent 37% of non-elective discharges. 36% fewer medical discharges occurred at weekends (p&lt;0.01), patients discharged at weekends were less complex. 63% of discharges had follow up plans. GP follow up was planned for 61% of single admissions compared to 32% of patients who subsequently were readmitted. Health informatics approaches are critical to improving understanding, quality and efficiency of the discharge process.

Medication safety curriculum: enhancing skills and changing behaviors

BACKGROUND

Adverse drug reactions are a leading cause of death in the United States. Safe and effective management of complex medication regimens is a skill for which recent medical school graduates may be unprepared when they transition to residency. We wished to assess the impact of a medication safety curriculum on student competency when evaluating medication therapeutic appropriateness as well as evaluate students' ability to transfer curricular material to management of patients in clinical settings.

METHODS

To prepare 3rd and 4th year medical students to critically evaluate medication safety and appropriateness, we developed a medication reconciliation/optimization curriculum and embedded it within a Patient-Centered Medical Home longitudinal elective. This curriculum is comprised of a medication reconciliation workshop, in-class and individual case-based assignments, and authentic patient encounters in which medication management skills are practiced and refined. Pre- and post-course competency and skills with medication reconciliation/optimization are evaluated by assessing student ability to identify and resolve medication-related problems (MRPs) in case-based assignments using paired difference tests. A group of students who had wished to enroll in the elective but whose schedule did not permit it, served as a comparison group.

RESULTS

Students completing the curriculum (n = 45) identified 75 % more MRPs in case assignments compared to baseline. No changes from baseline were apparent in the comparison group. Enrolled students were able to transfer their skills to the care of authentic patients; these students identified an average of 2.5 MRPs per patient from a panel of individuals that had recently transitioned from hospital to home. Moreover, patient questionnaires (before and several months following the medication encounters with assigned students) indicated that patients felt more knowledgeable about several medication parameters as a result of the student-led medication encounter. Patients also indicated that students helped them overcome barriers to medication adherence (e.g. cost, transportation, side effects).

CONCLUSIONS

Novice learners may have difficulty transitioning from knowledge of basic pharmacology facts to application of that information in clinical practice. Our curriculum appears to bridge that gap in ways that may positively impact patient care.

Medication reconciliation at admission and discharge: an analysis of prevalence and associated risk factors

INTRODUCTION

Medication errors are frequent at care transition points and can have serious repercussions. Study objectives were to examine the frequency/type of reconciliation errors at hospital admission and discharge and to report on the drugs involved, associated risk factors and potential to cause harm in a healthcare setting with comprehensive digital health records.

MATERIAL AND METHODS

A prospective observational 2-year study was conducted in the Internal Medicine Department of a regional hospital. The best possible medication history was obtained from different sources by clinical pharmacists and compared with prescriptions at admission and discharge. The frequency and type of reconciliation errors were studied at admission and discharge, evaluating risk factors for their occurrence and their potential to cause harm.

RESULTS

The study included 814 patients (mean age: 80.2 years). At least one reconciliation error was detected in 525 (64.5%) patients at admission, with a mean of 2.2 ± 1.3 errors per patient and in 235 (32.4%) patients at discharge. Drug omission was the most frequent reconciliation error (73.6% at admission and 71.4% at discharge); 39% of errors at admission and 51% at discharge had potential to cause moderate or severe harm. The risk of error at admission was higher with more pre-admission drugs (p < 0.001) and, among patients with reconciliation errors, the number of errors was significantly higher in those receiving more drugs pre-admission or with more comorbidities. The risk at discharge was higher in patients with more drugs prescribed at discharge (p = 0.04) and in those with a longer hospital stay (p = 0.03).

CONCLUSIONS

Medication reconciliation procedures are required to minimise medication discrepancies and enhance patient safety. Integration of patient health records across care levels is necessary but not sufficient to prevent errors.

Safe Medication Reconciliation: An Intervention to Improve Residents' Medication Reconciliation Skills

BACKGROUND

Medication errors during hospitalization are a major patient safety concern. Medication reconciliation is an effective tool to reduce medication errors, yet internal medicine residents rarely receive formal education on the process.

OBJECTIVE

We assessed if an educational intervention on quality improvement principles and effective medication reconciliation for internal medicine residents will lead to fewer medication discrepancies and more accurate discharge medication lists.

METHODS

From July 2012 to May 2013, internal medicine residents from 3 academic institutions who were rotating at the Washington DC VA Medical Center received twice-monthly interactive educational sessions on medication reconciliation, using both institutional summary metrics and data from their own discharges. Sessions were led by a faculty member or chief resident. Accuracy of discharge instructions for residents in the intervention group was compared to the accuracy of discharge data from June 2012 for a group of residents who did not receive the intervention. We used χ(2) analysis to assess for differences.

RESULTS

The number of duplicate medications (23% versus 12%, P = .01); extraneous medications (14% versus 6%, P = .014); medications sorted by disease or indication (25% versus 77%, P < .001); and the number of discrepancies in discharge summaries (34% versus 11%, P < .001) statistically improved. No difference in the number of omissions was found between the 2 groups (17% versus 15%, P = .62).

CONCLUSIONS

An educational intervention targeting internal medicine residents can be implemented with reasonable staff and time costs, and is effective in reducing the number of medication discrepancies at discharge.

Discharge Time Out: An Innovative Nurse-Driven Protocol for Medication Reconciliation

An innovative method for discharge medication reconciliation was developed by nurses to ensure safe transition of care and improved patient outcomes. The discharge time-out process has empowered nurses to take a more active role in discharging their patients, and has fostered a more collaborative relationship between nurses and physicians.

Evaluation of the influence of a pharmacist-led patient-centered medication therapy management and reconciliation service in collaboration with emergency department physicians

BACKGROUND

The implementation of the Patient Protection and Affordable Care Act is anticipated to increase the frequency of emergency department (ED) visits. Therefore, there is a critical need to improve the quality of care transitions among ED patients from ED to outpatient services. 

OBJECTIVE

To evaluate the effect of systematic implementation of a pharmacist-led patient-centered approach to medication therapy management and reconciliation service (MRS) in the ED on patient utilization of available health care services.

METHODS

A single institution prospective randomized cohort study with 90-day postvisit observation randomized patients into 2 groups: (1) medication therapy management reconciliation service following a patient-centered approach (MRS) or (2) usual care provided by the institution (non-MRS). To align patient enrollment with availability of other primary care services, subjects were enrolled during weekday daytime hours. Data for the 90 days before and after the index ED visit were matched in all analyses. Generalized estimating equations evaluated any primary care (PC), urgent care (UC), and ED visits during the 90 days post-index ED visit, adjusted by age and sex and weighted by survival time. Generalized linear models evaluated the average number of ED visits during that period, adjusted by age and sex and weighted by survival time. Data were analyzed for all adult patients (ADLTS), aged ≥ 18 years, and the subpopulation taking 1 or more prescribed daily medication at the time of the index ED visit (ADLTS1+)-the patients expected to receive greatest benefit from an MRS program.

RESULTS

ADLTS MRS patients were 1.9 more likely than non-MRS patients to visit their PC providers (mean difference 0.15, P  less than  0.001). Similarly, ADLTS1+ MRS patients were 1.5 times more likely to visit their PC providers (mean difference 0.10, P = 0.026). Although ADLT MRS patients were less likely to visit the UC, this was not significant. However, ADLTS1+ MRS patients were significantly less likely than non-MRS patients (OR = 0.5, 95% CI = 0.3-0.9) to visit the UC. No significant difference was seen in ED visits.

CONCLUSIONS

The implementation of a patient-centered approach to medication therapy management and reconciliation improved the odds of patients visiting their PC providers, a positive first step in transitioning patients toward an appropriate use of PC services.

Medication reconciliation for patients undergoing spinal surgery

PURPOSE

In recent years, a marked increase of spinal operations prompted a debate on quality issues. Besides obvious factors, such as the surgical technique, medication safety has been identified as one of the major risk factors for patients undergoing anesthesia and surgery. While the issue has already been addressed by hospital pharmacist and anesthesiologists, the prescription of correct medication remains within the surgeons' responsibility. We, therefore, investigated medication-related errors in spinal instrumentation patients and applied current medication reconciliation strategies.

METHODS

We performed a data survey on all patients undergoing spinal instrumentation in 2011. Risk factors for medication safety were identified and prioritized. Specific counter-measures were introduced in 2012 and evaluated in 2013.

RESULTS

147 patients were included in the 2011 and 162 in the 2013 survey. As top five risk factors we identified the preoperative stopping of medication, recording the medication history, prescription process of postoperative analgetics and anticoagulants and the medication list at discharge. Specific counter-measures included standardization of preparations, doses and the prescription process and improving access to this information (online and via a smartphone application). In elective patients, recording the medication histories was delegated to a hospital pharmacist and informative flyers and posters were used to integrate the patients themselves into the process. Counter-measures directed against the first four risk factors resulted in a significant reduction of medication errors. The last risk factor was targeted by instructing the responsible staff only, which proved to be a rather ineffective measure.

CONCLUSIONS

Medication safety could be significantly improved by implementation of counter-measures specific to the identified risk factors.

Impact of a comprehensive pharmacist medication-therapy management service

OBJECTIVE

This proof of concept study aimed to determine whether a pharmacist-managed medication therapy management (MTM) program in a private endocrinologist physician's practice reduced healthcare services utilization and related costs 6 months after patients' discharge from an institution with a transition of care service.

METHODS

Patients were included in the study if they were English-speaking, ages >18 years, had type 1 or 2 diabetes, and had a recent transition of care experience (inpatient hospital stay or emergency department/urgent care/paramedic or other acute care visit). The study had a non-randomized design where intervention patients, enrolled July 1, 2012-September 30, 2013, were administered MTM at four visits over 6 months and were compared to historical control patients with available electronic medical records from August 8, 2008 to March 15, 2012. The primary study end-point was the rate of 30-day hospital readmissions, as related to the reason for the index admission. Secondary end-points included the cumulative rate of all-cause hospitalizations, emergency department, paramedic and urgent care visits at 30, 60, 90, and 180 days post-discharge as well as imputed total costs, including prescription medication costs, at 180 days. Propensity score weights were constructed to balance covariate characteristics between the intervention and control groups. Weighted multivariate negative binomial and generalized linear regressions were used to model cumulative utilization rates and log-transformed costs, respectively.

RESULTS

The intervention (n = 28) and control (n = 73) groups had 0% hospital readmissions at 30 days post-discharge. In propensity score weighted multivariate analyses, cumulative utilization rate was not different between the two groups (IRR = 1.61, p = 0.72 at 180 days) while costs in the intervention group were lower but not statistically different (cost ratio = 0.65, p = 0.13 at 180 days).

CONCLUSIONS

Further studies should investigate whether the integration of pharmacists in transition of care models could reduce readmission and healthcare utilization rates post-discharge.

Medication reconciliation in patients hospitalized in a cardiology unit

OBJECTIVES

To compare drugs prescribed on hospital admission with the list of drugs taken prior to admission for adult patients admitted to a cardiology unit and to identify the role of a pharmacist in identifying and resolving medication discrepancies.

METHOD

This study was conducted in a 300 bed university hospital in Brazil. Clinical pharmacists taking medication histories and reconciling medications prescribed on admission with a list of drugs used prior to admission. Discrepancies were classified as justified (e.g., based on the pharmacotherapeutic guidelines of the hospital studied) or unintentional. Treatments were reviewed within 48 hours following hospitalization. Unintentional discrepancies were further classified according to the categorization of medication error severity. Pharmacists verbally contacted the prescriber to recommend actions to resolve the discrepancies.

RESULTS

A total of 181 discrepancies were found in 50 patients (86%). Of these discrepancies, 149 (82.3%) were justified changes to the patient's home medication regimen; however, 32 (17.7%) discrepancies found in 24 patients were unintentional. Pharmacists made 31 interventions and 23 (74.2%) were accepted. Among unintentional discrepancies, the most common was a different medication dose on admission (42%). Of the unintentional discrepancies 13 (40.6%) were classified as error without harm, 11 (34.4%) were classified as error without harm but which could affect the patient and require monitoring, 3 (9.4%) as errors could have resulted in harm and 5 (15.6%) were classified as circumstances or events that have the capacity to cause harm.

CONCLUSION

The results revealed a high number of unintentional discrepancies and the pharmacist can play an important role by intervening and correcting medication errors at a hospital cardiology unit.

Accuracy of general practitioner medication histories for patients presenting to the emergency department

BACKGROUND

Clinical handover and obtaining best possible medication histories (BPMH) at transition points in care are key patient safety pri-orities. This study aimed to determine the accuracy of medication histories documented on general practitioner (GP) referral letters for patients referred to emergency departments.

METHODS

This was a multicentre prospective observational study in eight emergency departments. Patients taking ≥1 regular medication, referred to the emergency department with a GP letter and seen by a pharmacist were included. GP medication regimens were compared with BPMH documented by the emergency department pharmacist.

RESULTS

Of the GP letters (total 414), 361 (87%) had one or more discrepancies in the patients' regular medications and 62% had one or more regular medication discrepancies of moderate-high significance. Omission of medication was more prevalent in hand-written letters (P DISCUSSION: GP referral letters should not be used in isolation to determine the medication regimen taken before an emergency department presentation. Interventions are indicated to improve awareness and accuracy of medication documentation.

Medication errors: an overview for clinicians

Medication error is an important cause of patient morbidity and mortality, yet it can be a confusing and underappreciated concept. This article provides a review for practicing physicians that focuses on medication error (1) terminology and definitions, (2) incidence, (3) risk factors, (4) avoidance strategies, and (5) disclosure and legal consequences. A medication error is any error that occurs at any point in the medication use process. It has been estimated by the Institute of Medicine that medication errors cause 1 of 131 outpatient and 1 of 854 inpatient deaths. Medication factors (eg, similar sounding names, low therapeutic index), patient factors (eg, poor renal or hepatic function, impaired cognition, polypharmacy), and health care professional factors (eg, use of abbreviations in prescriptions and other communications, cognitive biases) can precipitate medication errors. Consequences faced by physicians after medication errors can include loss of patient trust, civil actions, criminal charges, and medical board discipline. Methods to prevent medication errors from occurring (eg, use of information technology, better drug labeling, and medication reconciliation) have been used with varying success. When an error is discovered, patients expect disclosure that is timely, given in person, and accompanied with an apology and communication of efforts to prevent future errors. Learning more about medication errors may enhance health care professionals' ability to provide safe care to their patients.

[Different models are used to obtain medication history and medication review in Danish hospitals]

The objective of the article is to characterize the models used by pharmacists to obtain medication history and medication review in Danish hospitals. The models are characterized based on the sources used to create an overview of the patient's medication as well as the time spent per patient. Currently pharmacists perform medication review at 16 departments. The sources frequently used are the patient journal (81%) and clinical data (81%). The patient contributes to the medication review in 25%.

[Uncertain evidence for effect of medication reviews of the prescriptions for elderly patients]

Elderly patients are often prescribed several drugs, which might increase the risk of drug-related harms and the risk of not using the drugs as prescribed, both of which can result in increased costs. The literature supports the conclusions in a newly published Cocranereview on four randomized controlled trials (RCT) showing that it is uncertain whether medication reviews reduce mortality or hospital readmissions, but medication reviews seem to reduce emergency department contacts. However, further RCT are needed before implementing medication reviews.

Making pharmacists part of the multidisciplinary team

Having pharmacists on the multidisciplinary team can help ensure that patients progress well in the hospital and that they follow their medication plan at home and avoid emergency department visits or readmissions. Pharmacists can review medication lists and correct problems as well as ensuring that patients receive the right doses and selections of medication for their ages, weights, and conditions. They can help case managers and social workers deal with complex prescription benefits plans and help with preauthorizations and other issues that can potentially delay filling prescriptions. Pharmacists can use their knowledge of medication to recognize when a patient may not be able to afford a medication and to suggest less expensive alternatives to the physician.

Inappropriate prescribing in older fallers presenting to an Irish emergency department

BACKGROUND

certain medications increase falls risk in older people.

OBJECTIVE

to assess if prescribing modification occurs in older falls presenting to an emergency department (ED).

DESIGN

before-and-after design: presentation to ED with a fall as the index event.

SUBJECTS

over 70's who presented to ED with a fall over a 4-year period.

METHODS

dispensed medication in the 12 months pre- and post-fall was identified using a primary care reimbursement services pharmacy claims database. Screening Tool of Older Person's PIP (STOPP) and Beers prescribing criteria were applied to identify potentially inappropriate prescribing (PIP). Polypharmacy was defined as four or more regular medicines. Psychotropic medication was identified using the WHO Anatomical Therapeutic Chemical classification system. Changes in prescribing were compared using McNemar's test (significance P < 0.05).

RESULTS

One thousand sixteen patients were eligible for analysis; 53.1% had at least one STOPP criteria pre-fall with no change post-fall (53.7%, P = 0.64). Beers criteria were identified in 44.0% pre-fall, with no change post-fall (41.5%, P = 0.125). The most significant individual indicators to change were neuroleptics, which decreased from 17.5 to 14.7% (P = 0.02) and long-acting benzodiazepines decreased from 10.7 to 8.6% (P = 0.005). Polypharmacy was observed in 63% and was strongly predictive of PIP, OR 4.0 (95% CI 3.0, 5.32). A high prevalence of psychotropic medication was identified pre-fall: anxiolytics (15.7%), antidepressants (26%), hypnosedatives (30%). New initiation of anxiolytics and hypnosedatives occurred in 9-15%, respectively, post-fall.

CONCLUSION

a significant prevalence of PIP was observed in older fallers presenting to the ED. No substantial improvements in PIP occurred in the 12 months post-fall, suggesting the need for focused intervention studies to be undertaken in this area.