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National electronic Library for Medicines
Medicines Management Overview
December 2011
MEDICINES RECONCILIATION
Annotated bibliography of publications in 2010-2011
Summary
Contents
Summary
1
Introduction
by Linda Dodds
2
Synopsis
3
This report lists publications on medicines reconciliation
which appeared in 2010 and 2011. Most refer to a hospital
environment, but there is also some mention of primary
care.
The bibliography is based on searches of the National
Electronic Library for Medicines (NeLM), Medline and
Google Scholar, without restrictions of language, and lists
retrieved papers in alphabetical order by author, with a
summary and a link to the original publication in each case.
Some key publications
before 2010
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2010 and 2011
Publications
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Produced for the
National electronic
Library for Medicines
by:
Tom Burnham,
Information Specialist,
London and South East
Medicines Information
Service, Guy’s Hospital,
London SE1 9RT
Tel: 020 7188 5026
[email protected]
A synopsis attempts to provide a general overview of the
Wmain themes which emerge, including the important role of
e pharmacists in the medicines reconciliation process.
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Introduction
By Linda Dodds, Director, Medicines Use and Safety Division, East and South East
England Specialist Pharmacy Services
Incomplete or inaccurate communication at the time of admission has been shown
to lead to prescribing errors in up to 67% of all admissions. Studies which have
included multidisciplinary review of unintentional discrepancies between the preadmission and admission medication lists have concluded that between 30-50% of
intercepted errors have the potential to translate into adverse events which impact
on patient outcomes, leading to increased monitoring and length of inpatient stay
or worse. Uncorrected errors on admission to hospital not only impact on the
inpatient stay, but may be continued after discharge and adversely affect long term
care, resulting in further patient harm, increased contact with healthcare providers
and even death. For these reasons, accurate medicines reconciliation at admission
to hospital has been endorsed as a key patient safety initiative in many health
economies, with England and Wales producing a joint NICE/NPSA Safety solution in
2007.
As well as improving patient safety, accurate medicines reconciliation also
contributes to the QIPP programme, by reducing length of stay, and the risk of
readmission
The challenges of providing medicines reconciliation to all patients shortly after
their admission are however well recognised, and most organisations are still
working to optimise delivery of a pharmacy led service within the limited staff
resource available. Recent published literature on medicines reconciliation can not
only help share learning on how best to ensure accurate medicines reconciliation on
admission to an inpatient setting, but also act as a lever to support renewed efforts
to deliver this important safety initiative.
Synopsis
Medicines reconciliation has been defined by the Institute for Healthcare Improvement as
“the process of identifying the most accurate list of a patient’s current medicines – including
the name, dosage, frequency and route – and comparing them to the current list in use,
recognizing and discrepancies, and documenting any changes, thus resulting in a complete
list of medications, accurately communicated”.
In the United States, the Joint Commission on Accreditation of Healthcare Organisations
(JCAHO) made medicines reconciliation on admission to hospital (or other transfers of care)
a National Patient Safety Goal (No 8) in 2005. The JCAHO Sentinel Event Alert No.35 (25
Jan 2006) refers to the Massachusetts Coalition for the Prevention of Medical Errors advising
that reconciliation should take place within specified time frames – “within 24 hours of
admission; shorter time frames for high-risk drugs, potentially serious dosage variances,
and/or upcoming administration times”. The NPSG states that health care organisations
should consider “creating a process for reconciling medications at all interfaces of care
(admission, transfer, discharge) and determining reasonable time frames for reconciling
medications. Patients, and responsible physicians, nurses and pharmacists should be
involved in the medication reconciliation process.”
In the United Kingdom, guidance on medicines reconciliation has been given by the National
Institute for Clinical and Healthcare Excellence, in conjunction with other national bodies
(see Key Publications listed below), and most National Health Service organisations have
produced their own policies for implementing this guidance locally.
Medicines reconciliation remains a very active field for both academic and practice-based
research worldwide, and this annotated bibliography lists (in order of the first author’s
name) papers published during the last two years.
Medication discrepancies warranting reconciliation have been found by studies across many
countries, in patient admission and discharge, and in a range of situations, including
emergency units (Caglar et al., De Winter et al. (i) and (ii), Hummel et al., Kimland et al.,
Knight et al., Mazer et al., Mills et al., Soler-Giner et al., Thomas), critical/intensive care
(Corbett and Shulman, Hatch et al.), mental health/psychiatry (Morrison, Nelson et al.,
Paton et al.), kidney dialysis (St Peter), orthopaedics (S Williams et al.), paediatrics
(Rappaport et al., Stone et al., Terry et al., White et al.) and the elderly (Gizzi et al.,
Perennes et al., Steurbaut et al., Stitt et al., Villanyi et al.).
High rates of discrepancies have been found at both admission (Gleason et al., Lindved
Karkov et al., Tschantz Unroe et al.) and discharge (Climente-Marti et al., Herrero-Herrero
and Garcia-Aparicio), while a study in Norway found incomplete information about
medication and medication changes in both admission and discharge letters (Frydenberg
and Brekke).
All sources of information about medicines have been found to be more or less inaccurate
(Balon et al., Elrod et al.), including electronic medical records (Platte et al.), and a study in
Sweden found major discrepancies between information on medicines in different electronic
systems (Ekedahl et al.).
On the other hand, a study in France with cardiovascular medicines showed good agreement
between doctors’ prescribing records and patients’ self-reports (Grimaldi-Bensouda et al.).
Reconciliation failures have been found to depend on a number of factors, including the
classes of drugs involved (Grimes et al. (iii)). Another study found that non-prescribed
medicines, and topical and inhaled preparations were most likely to be overlooked (OwusuAnkomah et al.).
Interviews with hospital-based pharmacists and doctors in the USA identified a number of
barriers to medicines reconciliation (Boockvar et al. (ii)).
One study showed that handwritten and electronically generated discharge summaries had
similar levels of error, possibly because in this case computerization was still in a relatively
early stage, with a continuing need for transcription (Callen et al.). Transcription should be
avoided where possible (Grimes et al. (ii)). Problems have also been found when different
electronic systems were used in different departments of a hospital (Corbett and Shulman).
One paper suggests that errors should be improved by using compatible IT systems based
on the ISO/CEN EN 13 606 standard (Farfan Sedano et al.)). Another study showed little
difference between the use of electronic or paper-based prescribing, or hybrid systems (Lee
et al.).
Medicines reconciliation is regarded as essential for patient safety (Greenwald et al.) as it
can reduce medicines discrepancies and potential adverse events (Platte et al., Villanyi et
al.), although there is little evidence of its effect on actual adverse events (Etchells).
Inadequate reconciliation has been shown to be a cause of medication errors in HIV patients
(Snyder et al.). Implementation of a formal reconciliation process on hospital admission
has been shown to have a favourable effect on outcomes, including reducing drug-related
readmissions (Hellstrom et al.), but in another study documentation of correct discharge
procedures did not affect readmission rates (Hansen et al.). Better control of blood
pressure has been demonstrated in hypertensives with fewer medication discrepancies
(Persell et al.). Medicines reconciliation reduced adverse events due to erroneous
medication changes on admission, but not those caused by all medication changes
(Boockvar et al. (i)). Reconciliation may reduce the level of inappropriate prescribing after
patients have been discharged (Hatch et al. (ii)).
A number of approaches have been proposed to improve medicines reconciliation. Various
electronic reconciliation tools have been shown to be effective (Gimenez Manzorro et al.,
Schnipper et al.) and such tools have been reviewed (Bassi et al.). Use of an automated
filtering process has also been suggested as a means of reducing discrepancies (Hasan et
al.).
Shared electronic health records may reduce discrepancies, but medication lists have been
found to have errors, and it has been suggested that both primary care and hospital doctors
would need to have read/write access (Moore et al.). The views of primary care doctors in
the USA on the best ways to provide medication lists in primary care record systems have
been surveyed (Weeks et al.).
Quality improvement methods with a range of interventions were found to be effective in
increasing the proportion of patients for whom reconciliation was performed within 24 hours
of admission at a paediatric hospital in the USA (White et al.). A multispecialty children's
integrated health care network in the USA made successful use of an electronic medical
record (EMR)-based quality improvement intervention to improve reconciliation rates from
zero to 71% over six years (Rappaport et al.).
Education of doctors was found to reduce the rate of discrepancies on admission to hospital
(Chan et al.), and specific training of non-medical, non-pharmacy staff in medicines
reconciliation was also found to be useful in the mental health field (Morrison).
Standardised documentation seems helpful, for example the use of standard forms (Bedard
et al.) or a standardised list of questions (De Winter et al. (ii)). At a French hospital,
revised paper documentation was introduced as an interim measure pending
computerisation, in order to reduce medication discrepancies on admission (Prevost et al.).
Standard processes for nurses to document medications have been tried in both home (DL
Green et al.) and hospital (Tessier et al.) settings.
Numerous studies have shown benefits from involving pharmacists in medicines
reconciliation (Corrigan et al., De Winter et al. (i), Galvin et al., Grimes et al. (i), Hatch et
al. (i), Hellstrom et al., Kennedy and Gatewood, Nynke Eggink et al., Peyton et al., Richards
et al., Steurbaut et al., CD Williams et al., S Williams et al.). This task calls upon the
pharmacist’s clinical skills (Thomas). Specific examples in the UK include the Safer Patients
Initiative (Ashley) and the use of the PREVENT tool by pharmacists to identify high-risk
patients at admission (Barnett et al.).
The role of the patient is also important. Cancer patients have been shown to have a high
level of knowledge of medications (Hwang et al.) and a study in Ireland suggested that
patients and their carers were the best source of information on medicines at admission
(Fitzsimons et al.), although a study in asthma patients showed only moderate agreement
between patient self-reports and pharmacy claims data (Lim et al.). A study in France of
concordance between patients’ and prescribers’ reports on the use of NSAIDs and coxibs
indicated better concordance for specific or serious conditions (Fourrier-Reglat et al.). The
health literacy of patients was found to be important in obtaining accurate information on
admission (Mervanova et al.). A study of tetracycline exposure during pregnancy
investigated the reliability of patients’ recall of medication use in interviews (Yau et al.).
In the context of who should take overall responsibility for maintaining an accurate
medication list (Gandhi and Lee), it has been proposed that patients be accountable for this
(Balon et al.) and that they should have a paper version of their medication list until it was
available electronically (Frydenberg and Brekke). However, it appears that patient-held
medication lists should be interpreted with caution (CF Green et al.) and another study
found that while patients said that they found medication lists useful, they did not in fact
improve their knowledge or adherence (Luca et al.). Information on drug allergies recorded
on patient-held smart cards in Taiwan has been found to be incomplete (Hsu et al.).
Inclusion of data from a range of sources can be helpful, for example GP practice records
(Nicholls and Wilcock). Use of information from community pharmacies (the MedCheck
process) was found to improve pre-operative medication records (Leung et al.) and other
studies have shown improved accuracy as a result of incorporating community pharmacy
dispensing records (Glintborg et al.) or contacting community pharmacists (Perennes et al.).
Opportunities for medicines reconciliation in community pharmacy have been discussed
(Johnson et al.) and a it has been suggested that home medicines review (as conducted in
Australia) provides a further opportunity for reconciliation after discharge from acute care
(Ellitt et al.). A study in Norway found a decrease in medication discrepancies in general
practitioners’ electronic records after the implementation of multidose dispensing by
pharmacies, although it is thought that this may be due to changes in workflow and greater
focus on the medication process, rather than multidose dispensing per se (Wekre et al.)
Some Key Publications Before 2010
Technical patient safety solutions for medicines reconciliation on
admission of adults to hospital
National Institute for Health and Clinical Excellence Patient Safety Guidance PSG001, Dec
2007
http://guidance.nice.org.uk/PSG001/Guidance/pdf/English
A systematic review of the effectiveness and cost-effectiveness of
interventions aimed at preventing medication error (medicines
reconciliation) at hospital admission
F Campbell, J Karnon, C Czoski-Murray, R Jones, University of Sheffield, School of Health
and Related Research (ScHARR)
National Institute for Health and Clinical Excellence, Sep 2007, 75pp.
http://www.nice.org.uk/nicemedia/live/11897/38591/38591.pdf
Medicines reconciliation: a guide to implementation
National Prescribing Centre, Mar 2008
http://www.npc.nhs.uk/improving_safety/medicines_reconciliation/resources/reconciliation_
guide.pdf
Moving patients, moving medicines, moving safely: Guidance on discharge
and transfer planning
Royal Pharmaceutical Society of Great Britain (RPSGB), Pharmaceutical Services Negotiating
Committee, Primary Care Pharmacists’ Association, Guild of Hospital Pharmacists, Feb 2006
2010 and 2011 Papers on Medicines Reconciliation
How can effective medicines reconciliation be achieved?
M Ashley
Pharmacy Management, Jan 2010, vol. 26, no. 1, p. 3-7
This paper outlines the background and policy regarding medication histories,
identifies the need for improvement in taking medication histories, describes a
medicines reconciliation project at Musgrove Park Hospital, Taunton, that utilises the
'Safer Patients Initiative, phase 2' (SPI2) approach, and confirms outcomes of
medicines reconciliation (MR) rates being consistently around 92%. (6 refs.)
http://pharman.co.uk/
Comparison of hospital admission medication lists with primary care
physician and outpatient pharmacy lists
J Balon, SA Thomas
Journal of Nursing Scholarship Sep 2011;43(3):292-300
Purpose: Medication reconciliation is a process to reduce errors and harm associated
with loss of medication information as the patient enters and moves through the
healthcare system. This study examines medication list accuracy upon hospital
admission.
Design: This prospective study enrolled 75 English-speaking medical and surgical
patients (18 years of age or older) who were taking prescription medications. The
study took place at a rural, tertiary teaching hospital in the northeastern United
States. Data collection occurred from Nov 2006 to Mar 2009.
Methods: Nursing admission team medication lists were reconciled with primary care
physician (PCP) and outpatient pharmacy (OP) lists. Outcome measures were
accuracy of medication history generated by admission nurses (ANs) compared with
PCP and OP lists, and identification of factors influencing probability of accurate
medication list generation by ANs. The Generalized Estimating Equations modelling
approach was used to compare AN, OP and PCP medication list accuracy.
Additionally, sex and age were analysed as covariates and included in the model.
Findings: 45 males and 30 females (N = 75) with a mean age of 60 years (SD 15)
participated. 57 subjects (76%) used over-the-counter or herbal medications, but
the AN recorded only 31 (41%) cases. Patients received outpatient care from 1 to
12 providers. 40 patients (67%) obtained medications from one pharmacy, 22
(29%) from two and 3 (4%) from three pharmacies. OP medication lists were
completely accurate more often than PCP but not AN lists (19/75 (25%) OP vs 6/75
(8%) PCP vs 14/75 (19%) AN; 95% CI of the difference, 0.07 to 0.50). No
difference between AN and PCP list accuracy was found. Completely accurate AN
lists were more than twice as likely with male and younger patients (95% CI of the
difference, 1.07 to 6.22 and 0.94 to 0.99, respectively).
Conclusions: Like other studies, this study showed admission medication
reconciliation lists are often inaccurate. Our results suggest that verification of
admission medication lists with outpatient provider lists may improve accuracy.
Patients, with guidance from outpatient care providers, should assume accountability
for maintaining accurate medication lists. A secure, universal, interactive electronic
medical record may be a future solution for organising and sharing medication data
between providers.
Clinical Relevance: Medication reconciliation upon inpatient admission remains a
high-volume and high-acuity problem. We found that not only hospital medication
lists, but source lists, including those maintained by the patient, the PCP and the OP,
are vastly inaccurate.
http://onlinelibrary.wiley.com/doi/10.1111/j.1547-5069.2011.01409.x/abstract
Medicines-related admissions: you can identify patients to stop that
happening
N Barnett, D Athwal, K Rosenbloom
Pharmaceutical Journal 16 Apr 2011;286(7649):471-472
The Harrow Integrated Medicines Management Service was established in 2008 as a
collaboration between Harrow Primary Care Trust and North West London Hospitals
Trust to reduce preventable medicines-related problems and readmissions. As part
of this service, the PREVENT tool was developed to identify patients at risk.
Pharmacists use the tool when visiting patients on admission to a ward, as part of
the consultation around medicines reconciliation. The PREVENT tool has helped to
identify 147 patients considered to be at high risk of a medicines-related
readmission.
http://www.pjonline.com/
Use of information technology in medication reconciliation: a scoping
review
J Bassi, F Lau, S Bardal
Annals of Pharmacotherapy May 2010;44(5):885-897
Objective: To identify studies involving information technology (IT) in medication
reconciliation (MedRec) and determine how IT is used to facilitate the MedRec
process.
Data Sources: The search strategy included a database search of MEDLINE and
Cumulative Index of Nursing and Allied Health Literature (CINAHL), hand-searching
of collected material, and references from articles retrieved. The database search
was limited to English-language papers. MEDLINE includes publications dating back
to 1950 and CINAHL includes those dating back to 1982. The search included
articles in both databases up to Mar 2009. Boolean queries were constructed using
combinations of search terms for medication reconciliation, IT and electronic records.
Study Selection and Data Extraction: Three inclusion criteria were used. The study
had to (1) involve the MedRec process, (2) be a primary study and (3) involve the
use of IT. Selection was performed by 2 reviewers through consensus. Data related
to study characteristics, focus and IT use were extracted.
Data Synthesis: The studies included described a range of IT used throughout the
MedRec process, from basic e-mail and databases to specialised MedRec tools. A
generic MedRec workflow was created and types of IT found in the studies were
mapped to the workflow activities as well as to a set of functionalities based on the
Institute of Medicine's Key Capabilities of an Electronic Health Record System. In the
studies reviewed, IT was mainly used to obtain medication information. Although
there were only a few MedRec tools in the studies, those that did exist supported the
central activities for MedRec: comparison of medications and clarification of
discrepancies.
Conclusions: MedRec is an important process to ensure patient medication safety.
Evidence was found that IT can and has been used to facilitate some MedRec
activities and new applications are being developed to support the entire MedRec
process.
http://www.theannals.com/cgi/content/abstract/44/5/885
A medication reconciliation form and its impact on the medical record in a
paediatric hospital
P Bedard, L Tardif, A Ferland, J-F Bussieres, D Lebel, et al.
Journal of Evaluation in Clinical Practice Apr 2011;17(2):222-227
Objectives: The objective of this study was to evaluate the quality of medication
information available in medical charts before and after the implementation of a
medication reconciliation form.
Patients and Methods: This study is a retrospective chart review of patients under 18
years who were taking two medications or more at home and were admitted to a
paediatric hospital in Canada for more than 24 hours and discharged from a general
paediatrics, infectious disease, gastroenterology or pneumology ward over two 20week periods (pre- and post-implementation). Each week, 10 medical records were
randomly chosen and reviewed. The quality of the medication information was
measured on admission (dose, route of administration and frequency) and on
discharge (dose, route of administration, frequency and duration of treatment). The
proportion of medications that fully met these criteria was compared between the
groups using the chi-squared test.
Results: Information was analysed for a total of 3275 medications in the preimplementation group, vs 3240 medications in the post-implementation group.
Baseline characteristics were similar in both groups. On admission, the quality of
medication information was comparable between the pre- and post-implementation
groups (29.1 vs 29.3%, respectively; P = 0.86). However, on discharge, an
improvement in the quality of information was observed in the post-implementation
group (51.7 vs 65.2%; P less than 0.001).
Conclusions: This study demonstrated that the forms used in the reconciliation
process, in particular the discharge prescription, could increase the quality of the
information related to drug use in medical charts. The authors believe that
medication reconciliation forms should be widely used by all the health care
professional teams involved in the drug history or prescription process.
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2753.2010.01424.x/abstract
Effect of admission medication reconciliation on adverse drug events from
admission medication changes
KS Boockvar, S Blum, A Kugler, E Livote, et al.
Archives of Internal Medicine 9 May 2011;171(9):860-861
This research letter describes the findings of a study that aimed to estimate the
effectiveness of inpatient medication reconciliation at the time of hospital admission
on adverse drug events (ADEs) caused by admission prescribing changes. This US
study was conducted in an urban, academic Department of Veterans Affairs medical
centre. A computerised medication reconciliation tool and admission process were
developed. The tool consisted of a dialogue with which a health care provider could
(1) view the patient's outpatient medication use for the last 90 days from VA
computerised pharmacy data
(2) view current inpatient orders
(3) record discrepancies between patient-reported medications and outpatient and
inpatient medications in the computerised database
(4) record diagnostic indications for each medication and a response to each
discrepancy.
The tool was implemented in a staggered fashion on the 2 general medical units,
with early and later implementation units. New admissions were assigned on an
alternating basis between the units. The main outcome measure was ADE "probably"
or "certainly" caused by an admission medication change. The study which involved
612 patients admitted 795 times, found an overall frequency of 0.165 ADEs caused
by an admission medication change per admission (131 during 795 admissions), of
which:
·
·
·
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98 (75%) were symptomatic
6 (4.5%) caused prolonged hospital stays
1 (0.8%) required intensive care
5 (3.8%) caused hospital readmission after discharge
In addition, 66 (50%) were classified as due to errors, for an overall frequency of
0.083 ADEs caused by admission prescribing changes that were errors per
admission. Medication reconciliation was associated with fewer ADEs caused by
admission prescribing changes that were errors (adjusted odds ratio, 0.57; 95% CI,
0.33-0.98; P = 0.04) but not with ADEs caused by all admission prescribing changes
(1.04; 95% CI, 0.68-1.61; P =0 .86). Of note, during intervention unit-months, 194
of 359 admissions (54%) received admission medication reconciliation (indicating
partial adherence), and during control unit-months 25 of 436 admissions (5.7%)
received medication reconciliation (indicating slight contamination).
The researchers conclude that their study found that medication reconciliation
reduced by 43% ADEs caused by admission prescribing changes classified as errors
but did not reduce ADEs caused by all admission prescribing changes; and though
these findings provide overall support for medication reconciliation, they suggest that
“the optimal form of medication reconciliation should include tools to track
prescribing changes that occurred on admission so that patients are not harmed by
their unmonitored propagation during the hospitalisation.”
http://archinte.ama-assn.org/cgi/content/extract/171/9/860
Medication reconciliation: barriers and facilitators from the perspectives of
resident physicians and pharmacists
KS Boockvar, SL Santos, A Kushniruk, C Johnson, JR Nebeker
Journal of Hospital Medicine Jul-Aug 2011;6(6):329-337
Background: Medication reconciliation can prevent medication errors and harm when
patients transition between hospital and other care settings. Though it has been a
US Joint Commission hospital Patient Safety Goal since 2006, organisations continue
to have difficulty implementing the process.
Objective: To determine factors that influence performance of medication
reconciliation in a hospital setting with a computerised medication reconciliation tool.
Design: Cognitive task analysis (CTA) and focus group interviews.
Setting: Urban, academic, tertiary-care US Veterans Affairs medical centre.
Participants: Internal medicine house staff physicians (n = 23) and inpatient staff
pharmacists (n = 12).
Measurements: CTA participants verbalised their thoughts while they completed
medication reconciliation with the computerised tool. Focus group participants
described the purpose and effectiveness of medication reconciliation, how they
completed the task, and its barriers and facilitators. Interviews were recorded and
analysed using social science methods for analysing qualitative data.
Results: Participants agreed that a central goal of medication reconciliation is to
prevent prescribing errors, but disagreed about whether it achieves this goal.
Computerisation facilitated the task, but participants said that computers and
patients can be unreliable sources of information. Participants varied in how they
sequenced components of the task. When time was limited, physicians considered
other responsibilities higher priority. Both physicians and pharmacists expressed low
self-efficacy, i.e. low perceived capability to achieve the objectives of the process.
Conclusions: Key barriers to medication reconciliation are unreliable sources of
medication information and tasks that compete for providers' time and attention that
they consider higher priority. Addressing these barriers while increasing providers'
self-efficacy might improve medication reconciliation and its outcomes.
http://onlinelibrary.wiley.com/doi/10.1002/jhm.891/abstract
Emergency department medication lists are not accurate
S Caglar, PL Henneman, FS Blank, HA Smithline, EA Henneman
Journal of Emergency Medicine Jun 2011;40(6):613-616
Background: Medication errors are a common source of adverse events. Errors in
the home medication list may have an impact on care in the emergency department
(ED), the hospital and the home. Medication reconciliation, a Joint Commission
requirement, begins with an accurate home medication list.
Objective: To evaluate the accuracy of the ED home medication list.
Methods: Prospective, observational study of patients aged over 64 years admitted
to a hospital in the USA. After obtaining informed consent, a home medication list
was compiled by research staff after consultation with the patient, their family and,
when appropriate, their pharmacy and primary care doctor. This home medication
list was not available to ED staff and was not placed in the ED chart. ED records
were then reviewed by a physician, blinded to the research-generated home
medication list, using a standardised data sheet to record the ED list of medications.
The research-generated home medication list was compared to the standard
medication list and the number of omissions, duplications and dosing errors was
determined.
Results: There were 98 patients enrolled in the study; 56% (55/98; 95% CI, 4666%) of the medication lists for these patients had an omission and 80% (78/98;
95% CI, 70-87%) had a dosing or frequency error; 87% of ED medication lists had
at least one error (85/98; 95% CI, 78-93%).
Conclusions: Our findings now add the ED to the list of other areas within health care
with inaccurate medication lists. Strategies are needed that support ED providers in
obtaining and communicating accurate and complete medication histories.
http://dx.doi.org/10.1016/j.jemermed.2008.02.060
Accuracy of medication documentation in hospital discharge summaries: a
retrospective analysis of medication transcription errors in manual and
electronic discharge summaries
J Callen, J McIntosh, J Li
International Journal of Medical Informatics Jan 2010;79(1):58-64
The objectives of this study were (1) to quantify and compare the medication
transcription error rate from handwritten medications on manual discharge
summaries to typed medications on electronic discharge summaries, and (2) to
examine the quality of medication documentation according to the level of medical
training of the doctors who created the discharge summaries. A retrospective
examination of 966 handwritten and 842 electronically generated discharge
summaries was conducted in an Australian metropolitan hospital. The electronic
discharge summaries at the study site were not integrated with an electronic
medication management system and hence discharge medications were typed into
the electronic discharge summary by the doctor. The discharge medication
documentation in both types of summaries was transcribed, either handwritten or
typed, from inpatient medication charts in paper-based medical records.
Documentation differences between medications in discharge summaries and
inpatient medication charts constituted medication errors. 12.1% of handwritten and
13.3% of electronic summaries contained medication errors. The highest number of
errors occurred with cardiovascular drugs. Medication omission was the commonest
error. The confidence intervals of all odds ratios indicate handwritten and electronic
summaries were similar for all areas of medication error. Error rates regarding all
13,566 individual medications for the 1808 summaries were similar by doctor
medical training level (intern, resident and registrar). Concludes that similar
medication error rates in handwritten and electronic summaries may be due to the
common factor of transcription, either handwritten or typed, known to be associated
with medication errors. Clinical information systems evolve and often in the early
stages of implementation electronic discharge summaries are integrated with
existing paper-based patient record systems. Automatic transfer of medications from
an electronic medication management system to the electronic discharge summary
holds the potential to reduce medication errors through the elimination of the
transcription process.
http://dx.doi.org/10.1016/j.ijmedinf.2009.09.002
Effect of education on the recording of medicines on admission to hospital
AHY Chan, E Garratt, B Lawrence, L Turnbull, P Pratapsingh, PL Black
Journal of General Internal Medicine Jun 2010;25(6):537-542
Background: The inaccurate recording of medicines on admission to hospital is an
important cause of medication error. Medication reconciliation has been used to
identify and correct these errors.
Objective: To determine if a multimodal intervention involving medication
reconciliation with real-time feedback and education would reduce the number of
errors made by medical staff when recording medicines at the time of admission to
hospital.
Design: Observational study.
Participants: Patients admitted to the general medical wards of a teaching hospital in
New Zealand were studied prospectively. Patients 75 years of age or older and on 5
or more medications were identified as the 'target group'.
Intervention: After admission, a second medication history was taken, and
discrepancies were identified and communicated to the medical teams. An
educational intervention to encourage prescribers to obtain accurate medication
histories was conducted at the same time.
Measurements: The discrepancy rate was measured before and after the
intervention.
Main Results: There were 470 admissions in the 'target group'. 338 of the
admissions (71.9%) had one or more unintentional discrepancies. Although many
discrepancies had little potential to cause harm, 33% were rated as clinically
significant. During the study the discrepancy rate (prior to reconciliation) fell from
2.6 (SD 2.6) to 1.0 (SD 1.1) per admission (p less than 0.0001). This decline in
discrepancy rate remained significant (p = 0.001) even when only clinically
important discrepancies were included. The proportion of admissions with one or
more clinically important discrepancies also decreased during the study from 46% to
24% (p = 0.023).
Conclusions: Errors in the recording of medicines at the time of hospital admission
are common. Combining the feedback provided by medication reconciliation with
prescriber education reduced the error rate. This approach may be useful when the
resources are not available to perform medication reconciliation for all patients
admitted to hospital.
http://www.springerlink.com/content/l51520r6w76t2770/
Potential risk of medication discrepancies and reconciliation errors at
admission and discharge from an inpatient medical service
M Climente-Marti, ER Garcia-Manon, A Artero-Mora, NV Jimenez-Torres
Annals of Pharmacotherapy Nov 2010;44(11):1747-1754
Background: Medication discrepancies, defined as unexplained variations among
drug regimens at care transitions, are common. Some are unintended and cause
reconciliation errors that are potentially detrimental for patients.
Objective: To determine the prevalence of medication discrepancies and
reconciliation errors at admission and discharge in hospitalised patients and explore
risk factors for reconciliation errors and their potential clinical impact.
Methods: An observational prospective study was conducted at a general teaching
hospital in Spain. Patients who were admitted to the internal medicine service and
were receiving chronic preadmission treatment were included in the study.
Preadmission treatment was compared with the treatment prescribed on admission
(first 48 hours) and at hospital discharge, and discrepancies and reconciliation errors
were identified. The primary endpoint was the presence of reconciliation errors at
admission and/or discharge. Potential risk factors (patient-, medication- and
system-related) for reconciliation errors were analysed using a multivariate logistic
regression model.
Results: Of the 120 patients enrolled in the study between Apr and Aug 2009, 109
(90.8%) showed 513 discrepancies. The prevalence of patients with reconciliation
errors was 20.8% (95% CI, 13.6 to 28.1). Intended medication discrepancies were
more frequent at admission (96.6%) than at discharge (75.5%), while reconciliation
errors were more frequent at discharge (24.5%) than at admission (3.4%). The
prevalence ratio (admission vs discharge) was 2.4 (95% CI, 1.9 to 3.0) for
discrepancies and 0.65 (95% CI, 0.32 to1.32) for reconciliation errors. The logistic
regression analysis revealed an association between the number of discrepancies at
admission (OR 1.21; 95% CI, 1.01 to 1.44) and age (OR 1.05; 95% CI, 0.99 to
1.10) and an increased risk of reconciliation errors.
Conclusions: Medication reconciliation strategies should focus primarily on avoiding
errors at discharge. Since medication discrepancies at admission may predispose
patients to reconciliation errors, early detection of such discrepancies would logically
reduce the risk of reconciliation errors. Medication reconciliation programmes must
implement a process for gathering accurate preadmission drug histories and must
submit this information to a critical assessment of patients' needs.
http://www.theannals.com/cgi/content/abstract/44/11/1747
Improving medicines reconciliation after discharge from a critical care unit
C Corbett, R Shulman
British Journal of Clinical Pharmacy Jun 2010;2(6):183-186
The medicines reconciliation process between a 'paper free' critical care unit and
other hospital wards that use paper notes was assessed at University College London
Hospitals NHS Trust. The authors describe the results from this audit and suggest
methods for future improvements. The audit highlights some of the problems that
occur in practice when a 'stand-alone' computerised CCU prescribing system is used
in settings where a paper-based system is present throughout the rest of the
hospital. This could equally be seen in hospitals that have a different hospital-wide
electronic prescribing system to the CCU system. Those involved in developing and
implementing such systems need to be aware of the confusion that this can cause.
(9 refs.)
http://www.clinicalpharmacy.org.uk/
Evaluation of pharmacy-implemented medication reconciliation directed at
antiretroviral therapy in hospitalized HIV/AIDS patients
MA Corrigan, KM Atkinson, BE Sha, CW Crank
Annals of Pharmacotherapy, Jan 2010, vol. 44, no. 1, p. 222-223 (letter)
A prospective study was performed between Nov 2006 and Apr 2007 at Rush
University Medical Center (Chicago, USA). The objective of the study was to evaluate
whether a difference existed between the appropriateness of antiretroviral therapy
(ART) 48 hours after hospital admission between standard practice in which
medication reconciliation was completed by a nurse and reviewed by staff
pharmacists 24-48 hours after patient admission, and a clinical pharmacist driven
medication reconciliation process. 21 and 20 patients respectively were included in
each phase. In phase 1, 11/21 (52.4%) regimens had errors at 48 hours and
generated a total of 17 pharmacy recommendations. In phase 2, 1/20 (5.0%)
regimens had an error at 48 hours after clinical pharmacist intervention. At the 24hour pharmacist medication history, 14/20 (70%) regimens had errors and
generated a total of 29 pharmacy interventions. 28 interventions were made, and all
were accepted in phase 2. Logistic regression demonstrated that pharmacist-driven
medication history was associated with an increased likelihood of an appropriate
regimen (OR 20.9; 95% CI, 2.3 to 185.9; p = 0.006). For every 2.1 patients for
whom a clinical pharmacist performed a medication history, 1 error was prevented.
The average time needed to perform a medication history was 19.75 minutes. (5
refs.)
http://www.theannals.com/cgi/reprint/44/1/222
Pharmacist- versus physician-acquired medication history: a prospective
study at the emergency department
S De Winter, I Spriet, C Indevuyst, P Vanbrabant, et al.
Quality and Safety in Health Care Oct 2010;19(5):371-375
Background: Recent literature revealed that medication histories obtained by
physicians and nurses are often incomplete. However, the number of patients
included was often low.
Study objective: In this study, the authors compare medication histories obtained in
the Emergency Department (ED) of a hospital in Belgium by pharmacists versus
physicians and identify characteristics contributing to discrepancies.
Methods: Medication histories were acquired by the pharmacist from patients
admitted to the ED, planned to be hospitalised. A structured form was used to guide
the pharmacist or technician to ensure a standardised approach. Discrepancies,
defined as any difference between the pharmacist-acquired medication history and
that obtained by the physician, were analysed.
Results: 3594 medication histories were acquired by pharmacy staff. 59% (95% CI,
58.2% to 59.8%) of medication histories recorded by physicians were different from
those obtained by the pharmacy staff. Within these inaccurate medication histories,
5963 discrepancies were identified. The most common type of error was omission of
a drug (61%; 95% CI, 60.4% to 61.6%), followed by omission of dose (18%; 95%
CI, 17.6% to 18.4%). Drugs belonging to the class of psycholeptics, acid
suppressors and beta blocking agents were associated with the highest discrepancy
rates. Acetylsalicylic acid, omeprazole and zolpidem were the most commonly
forgotten.
Conclusions: This large prospective study demonstrates that medication history
acquisition is very often incomplete in the ED. A structured form and a standardised
method is necessary. Pharmacists are especially suited to acquire and supervise
accurate medication histories, as they are educated and familiar with commonly used
drugs.
http://qualitysafety.bmj.com/content/19/5/371.abstract
A simple tool to improve medication reconciliation at the emergency department
S De Winter, P Vanbrabant, I Spriet, D Desruelles, C Indevuyst, D Knockaert, JB Gillet, L
Willems
European Journal of Internal Medicine Aug 2011;22(4):382-385
Background: Medication histories acquired upon admission are often incomplete.
Using a standardised approach warrants more complete medication reconciliation,
however, this is too time consuming to be performed. Other strategies guaranteeing
complete medication histories should be explored. We developed a limited list of
standardised questions and assessed its impact on completeness of medication
histories.
Methods: This prospective study enrolled adults presenting to a tertiary care
emergency department in Belgium. In the control group, medication histories were
conducted by physicians of general internal medicine and conform to standard care.
In the intervention group, the physicians were obliged to use, as well as standard
care, the 'limited questions list' for medication history acquisition. The clinical
pharmacist re-obtained medication histories of the patients in both groups using a
standardised approach. The primary outcome was the impact of the use of a 'limited
questions list' on the frequency of drug omissions in medication histories.
Results: 260 consecutive patients were enrolled: 130 in the intervention group and
130 in the control group. There was a significant reduction of 49.3% in drug
omissions in the intervention group. The omission rate per medication history was
1.1 for the control group, which was significantly lower (0.6) in the intervention
group. Antithrombotics were most frequently forgotten in the control care group as
opposed to dietary supplements in the intervention group.
Conclusions: Drug omission rate in medication histories can be significantly reduced
if a limited list of simple questions is used during anamnesis. Widespread use of this
tool should be considered for implementation.
http://dx.doi.org/10.1016/j.ejim.2011.03.010
Discrepancies between the electronic medical record, the prescriptions in
the Swedish national prescription repository and the current medication
reported by patients
A Ekedahl, H Brosius, J Jönsson, H Karlsson, M Yngvesson
Pharmacoepidemiology and Drug Safety Nov 2011;20(11):1177-1183
Purpose: To study discrepancies between (i) the prescribed current treatment stated
by patients with congestive heart failure (CHF) compared with patients with other
chronic diseases, (ii) the data in the medication list (ML) in the electronic medical
record and (iii) the data in the prescription list (PL) on the prescriptions stored in the
national prescription repository in Sweden, to determine current, noncurrent,
duplicate and missing prescriptions.
Methods: At one healthcare centre, a random sample of patients aged 18 years and
older with a diagnosis of CHF, diabetes mellitus (DM) or osteoarthritis (OA) provided
written informed consent to participate. Participants were interviewed by telephone
on the prescribed current treatment.
Results: Of 161 invited patients (61 CHF, 50 DM and 50 OA), 66 patients were
included. More than 80% of the patients had at least one discrepancy, a noncurrent,
a duplicate or a missing prescription, in the ML and PL. The overall congruence for
unique prescriptions on current treatment between the ML and the PL was only
55%. Patients with CHF had overall more discrepancies and patients with DM fewer
discrepancies in the ML.
Conclusions: Prescriptions for noncurrent treatment, duplicates and missing
prescriptions are common in both the ML in the electronic medical record and the list
on prescriptions stored in the Swedish National Prescription Repository. Patients
with CHF had more discrepancies in the ML. The risk for medication errors in
primary care due to incorrect information on prescribed treatment may be
substantial.
http://onlinelibrary.wiley.com/doi/10.1002/pds.2226/abstract
Drug related problems after discharge from an Australian teaching hospital
GR Ellitt, E Engblom, P Aslani, T Westerlund, TF Chen
Pharmacy World and Science Oct 2010;32(5):622-630
Objective: To reconcile patients' medicines and to classify drug-related problems
identified during medication review conducted after discharge from hospital.
Setting: Patients were discharged from the cardiology unit of Westmead Hospital
(NSW, Australia) after recruitment into the Westmead Medicines Project which ran
from 2004 to 2007.
Method: This retrospective study involved an analysis of drugs, diseases and drugrelated problems in medication review reports available for 76 out of 85 patients who
received a Home Medicines Review (HMR). Data sources for medication
reconciliation and analyses also included hospital discharge summaries (n = 70) and
GP referrals for HMR (n = 44). Comprehensive clinical profiles were constructed for
the 76 subjects whose drug related problems were identified, coded, and then
classified from their HMR reports.
Main outcome measures: Number, type, distribution and international classification
of drugs, diseases and drug-related problems.
Results: Patients were prescribed drugs for a broad range of cardiovascular,
circulatory, endocrine, respiratory and digestive system diseases. Mean number of
drugs per patient in discharge summaries: 8.7 +/- SD 3.3 (range 3-19); in GP
referrals: 8.9 +/- SD 4.3 (range 2-23); and in HMR reports: 10.8 +/- SD 4.0 (range
3-24). Mean number of diseases per patient in discharge summaries: 4.1 +/- SD 2.9
(range 1-11); and in HMR reports: 4.7 +/- SD 2.6 (range 1-12). A total of 398
drug-related problems were identified for 71 (93.3%) patients with mean 5.6 +/- SD
4.3 problems (range 1-21). The most frequently recorded problems were the
patient's uncertainty about drug aim: n = 128 (32.0%); potential interactions n = 89
(22.4%); and adverse reactions n = 60 (15.1%).
Conclusions: This study showed that patients recently discharged from a tertiary care
hospital had a significant number of drug-related problems. Classification of drugs
and diseases revealed a broad range of non-cardiovascular medicines and conditions
in the patients from an acute care cardiology unit. We found that home medicines
review provided continuity of care and an opportunity for medication reconciliation
which revealed marked differences in number of drugs, between hospital discharge
and medicines review. The patients' uncertainly about their drugs and their diverse
range of co-morbidities indicated the need for timely counselling by pharmacists in
the community.
http://www.springerlink.com/content/2w7678825325067l/
A description of medication discrepancies found after hospital
discharge of primary care patients
S Elrod, K Coley, M Saul, J Donchoo, G Fischer, WN Kapoor, DL Hall
Pharmacotherapy Oct 2010;30(10):372e
Abstract of presentation at the 2010 Annual Meeting of the American College of
Clinical Pharmacy, Austin, Texas, USA, 17-20 Oct 2010. Paper No. 24.
Purpose: To describe the number and type of medication discrepancies found after
hospital discharge of primary care clinic patients.
Methods: This study compared medication lists from the inpatient discharge
summary to the outpatient electronic medical record in patients recently discharged
from the hospital after primary care physician follow-up to identify possible
medication discrepancies over a 5-month period. A medication discrepancy is
defined, for the purposes of this study, as any difference in the name, dosage,
frequency or route between the two medication lists. Patients were included if they
were discharged home and if they followed-up with their primary care physician
within 15 days of date of discharge. Patient characteristics such as demographics,
number of medications at discharge, and length of hospital stay will also be
described.
Results: A total of 136 patients were identified for inclusion, with 135 patients
considered to have some type of medication discrepancy. Patients were discharged
from the hospital on an average of 10.4 medications. A total of 885 discrepancies
were found for all patients with an average of 6.5 per patient and a range of 0 to 25
discrepancies. Differences between the name of a product or complete omission of a
product entirely accounted for the vast majority of discrepancies (n = 667). In
addition, 130 discrepancies in dose, 68 discrepancies in frequency and two
discrepancies in route were found. A total of 559 discrepancies were found for
prescription medications, while 306 were for over-the-counter medications.
Conclusions: This study revealed that a patient is likely to experience a medication
discrepancy after hospital discharge even after follow-up with their primary care
physician. A description of these medication discrepancies will aid in the design and
improvement in transitional care programmes in primary care, potentially allowing
for an interdisciplinary approach to medication reconciliation after hospital discharge
http://pharmacotherapyjournal.org/doi/abs/10.1592/phco.30.10.1086
Admitting medication errors: five critical concepts
E Etchells
Quality and Safety in Health Care Oct 2010;19(5):369-370
Commentary referring to a paper by De Winter et al. (p.371-375). The author notes
that 'there are at least three good reasons to obtain an accurate medication history
at the time of hospital admission. First, more than 1 in 9 emergency department
visits are due to drug-related adverse events. An accurate medication history will be
the cornerstone for diagnosing this common problem. Second, medication history
errors may result in incorrect medication orders and incorrect treatment during the
admission, leading to patient harm. Third, an accurate medication history is the
foundation for accurate medication instructions and prescriptions at the time of
hospital discharge.
'Medication reconciliation (Med Rec) at admission is the process of obtaining the
best-possible medication history (BPMH), and using this list to provide correct
medications to patients at the time of hospital admission. Med Rec at admission is
the cornerstone of Med Rec during subsequent transfers and at discharge. Med Rec
is a major patient safety priority for safety improvement organisations such as the
WHO and hospital accreditors. Well-designed medication reconciliation programmes
can reduce medication discrepancies and potential adverse drug events, although
there are no studies to show a reduction in preventable adverse drug events.'
http://qualitysafety.bmj.com/content/19/5/371.abstract
Patient summary and medicines reconciliation: application of the
ISO/CEN EN 13606 standard in clinical practice
FJ Farfan Sedano, M Terron Cuadrado, Y Castellanos Clemente, P Serrano Balazote, D Moner
Cano, M Robles Viejo
Studies in Health Technology and Informatics 2011;166:189-196
The comparison of the patient's current medication list with the medication being
ordered when admitted to hospital, identifying omissions, duplications, dosing errors
and potential interactions, constitutes the core process of medicines reconciliation.
Access to the medication the patient is taking at home could be unfeasible as this
information is frequently stored in various locations and in diverse proprietary
formats. The lack of interoperability between those information systems, namely the
primary care and the specialised electronic health records (EHRs), facilitates
medication errors and endangers patient safety. Thus, the development of a patient
summary that includes clinical data from different electronic systems will allow
doctors access to relevant information allowing safer and more efficient care. Such a
collection of data from heterogeneous and distributed systems has been achieved in
this project through the construction of a federated view based on the ISO/CEN
EN13606 standard for architecture and communication of EHRs.
http://www.booksonline.iospress.nl/Content/View.aspx?piid=19723
An evaluation of the availability and accuracy of sources of pre-admission
medication history data
M Fitzsimons, T Grimes, M Galvin
Pharmacoepidemiology and Drug Safety Jun 2010;19(3):648-649
Abstract of a paper presented at the Drug Utilisation Research Group (UK and
Ireland) Conference, London, 4 Feb 2010 (see also International Journal of Pharmacy
Practice Dec 2011;19(6):408-416).
Little is known about sources of pre-admission medication information used on
admission to hospital in Ireland. This study sought to determine availability and
accuracy of these sources. Data were collected for 134 patients with chronic
conditions admitted acutely to two study hospitals. Structured patient/carer
interview was identified as the best source. Omission discrepancies were the most
common. Grading of sources was consistent across the two sites, strengthening
generalisability of findings beyond the study setting.
http://onlinelibrary.wiley.com/doi/10.1002/pds.1950/abstract
Concordance between prescriber- and patient-reported previous
medical history and NSAID indication in the CADEUS cohort
A Fourrier-Reglat, HM Cuong, R Lassalle, et al.
Pharmacoepidemiology and Drug Safety May 2010;19(5):474-481
Purpose: Various data sources may be used in pharmacoepidemiological studies.
When they cannot be obtained from valid databases, medical data must be obtained
from physicians or patients. In the CADEUS study, both patients and their
prescribers reported medical data allowing investigation of the concordance between
these sources.
Methods: CADEUS is a French national cohort study of traditional non-steroidal antiinflammatory drug (NSAID) and coxib users conducted between Sep 2003 and Aug
2004 in France that employed self-administered questionnaires to obtain medical
data from patients and their prescribers. The Kappa statistic (k) was used to
measure concordance between patients and prescribers in 18,530 pairs with regard
to previous medical history and index NSAID indication.
Results: For previous medical history, the proportion of agreement ranged from 70.7
to 99.2% and concordance was: substantial ( = 0.61-0.80) for hypertension,
myocardial infarction, stroke and diabetes; moderate ( = 0.41-0.60) for angina
pectoris, peripheral arterial disease and hypercholesterolaemia; fair ( = 0.21-0.40)
for unstable angina, cardiac insufficiency, dyspepsia, gastroesophageal reflux and
gastric ulcer; slight (less than 0.21) for upper gastrointestinal haemorrhage. For
index NSAID indication, the proportion of agreement ranged from 84.3 to 99.4% and
concordance was almost perfect ( = 0.81-1.00) for inflammatory rheumatism, flulike symptoms, dysmenorrhoea and dental pain; substantial for arthritis, back pain
and headache; moderate for osteoarticular pain.
Conclusions: Concordance was better for specific or serious conditions both regarding
previous medical history and indication. Prescriber or patient perception and
understanding may reduce concordance for certain items.
http://onlinelibrary.wiley.com/doi/10.1002/pds.1951/abstract
Communication about medication use in referrals, acute admissions
and discharge letters
(Kommunikasjon om medikamentbruk i henvisninger, innleggelsesskriv og epikriser)
K Frydenberg, M Brekke
Tidsskrift for den Norske Laegeforening 20 May 2011;131(9-10):942-945
Background: It is critical to communicate properly about drug use across health care
levels, to avoid adverse drug effects and medication errors. We have investigated
communication about drug use between a hospital and the primary health care
services through an assessment of referrals and discharge letters.
Material and Methods: At Innlandet Hospital Trust Gjovik, Norway, all elective
referrals to the medical outpatient clinic and discharge letters from the medical
department during two periods (in 2009) were copied and anonymised. The
documents were searched for information about drug use and for completeness of
that information. We also assessed whether admission letters for acute admissions
to the medical department included a medication list.
Results: 92 (47%) of 194 of elective referrals, and 167 (91%) of 184 of discharge
letters, contained complete information about drug use. In 61 (49%) of 125 of
discharge letters that contained information about altered drug use, these changes
were not discussed in the medication list. Among 196 acutely admitted patients who
used drugs, medication lists were missing in 76 (39%). When the admitting doctor
was a regular GP the lists were missing in 10 (16%) of 63 of admissions.
Interpretation: Proper communication about drug use seems to have low priority and
patients are often admitted to and discharged from the hospital with insufficient
information. Patients should have a paper version of their medication list until such
information is available electronically.
http://tidsskriftet.no/lts-pdf/pdf2011/942-5.pdf
Clinical pharmacy input into the admission medication reconciliation
process in Ireland
M Galvin, T Grimes, M Fitzsimons, MC Jago-Byrne
Pharmacoepidemiology and Drug Safety Jun 2010;19(6):649
Abstract of a paper presented at the Drug Utilisation Research Group (UK and
Ireland) Conference, London, 4 Feb 2010.
A prospective, observational survey was undertaken across two study sites in
Ireland. Adults admitted via the emergency department, from a non-acute setting,
who reported the use of at least three regular prescription medications, were eligible
for inclusion. Medication reconciliation was provided by clinical pharmacists to
randomly-selected patients within 24-hours of admission. 134 patients, involving
1555 medications, were included in the survey. Over 97% of patients and 58% of
medications required medication reconciliation. Over 90% of patients and 28% of
medications warranted clinical pharmacy input. In total, 227 (50%) suggested
interventions were amended. Concludes that this study provides an evidence base
for clinical pharmacy input in admission medication reconciliation in Ireland.
http://onlinelibrary.wiley.com/doi/10.1002/pds.1950/abstract
Patient safety beyond the hospital
TK Gandhi, TH Lee
New England Journal of Medicine 9 Sep 2010;363(11):1001-1003
Commentary noting that 'the vast majority of health care is delivered in ambulatory
settings, yet we are only just beginning to understand the safety risks that exist
outside of hospital walls.'
'Medication safety is probably the most studied topic in outpatient safety research.
One study showed that adverse drug events occurred in 25% of primary care
patients and that 11% of these events were preventable. Solutions such as
electronic prescribing have been advocated, and now national incentives exist for
their adoption. But we still have much to learn about the effects of e-prescribing
systems on errors and about how these systems can be optimised. For example, we
need a better understanding of how to support clinically important decisions without
causing unnecessary disruptions in clinicians' workflow.'
'We also need better strategies for maintaining accurate medication lists in electronic
medical records. Many integrated delivery systems, including ours, are currently
struggling with knotty issues such as who is responsible for maintaining the accuracy
of the medication list - for example, the deletion of medications that the patient is no
longer taking, regardless of which provider prescribed them. If a specialist is the
only physician in an organisation who sees the patient, does that specialist have the
obligation to enter all the patient's medications and dosages in the medical record?
How can we best reconcile differences in medication lists at each ambulatory visit?
Addressing these issues usually means more work for clinicians who already consider
themselves overworked.'
http://www.nejm.org/doi/pdf/10.1056/NEJMp1003294
Developing a programme for medication reconciliation at the time of
admission into hospital
A Gimenez Manzorro, AC Zoni, C Rodriguez Rieiro, E Duran-Garcia, AN Trovato Lopez, et al.
International Journal of Clinical Pharmacy Aug 2011;33(4):603-609
The aim of this article is to describe the methods used to develop the medication
reconciliation programme implemented in a tertiary care hospital in Spain, and to
discuss the main problems encountered and lessons learned during the process. A
quasi-experimental study was carried out, analysing discrepancies between routine
medication and drugs prescribed in the hospital, before and after an electronic
reconciliation tool was introduced at admission. This tool was integrated into the
computerised provider order entry system. The implementation of the electronic
reconciliation tool has shown a reduction of the rate of discrepancies, decreasing
from 7.24% (95% CI, 6.0 to 8.5) before the intervention to 4.18% (95% CI, 3.2 to
5.1) afterwards. Projects like this are costly, but this study has made it possible to
detect numerous areas where interventions could be useful and proved the
importance of a medication reconciliation programme.
http://www.springerlink.com/content/n246552566378707/
Assessment of a safety enhancement to the hospital medication
reconciliation process for elderly patients
LA Gizzi, D Slain, JT Hare, R Sager, F Briggs, CH Palmer
American Journal of Geriatric Pharmacotherapy Apr 2010;8(2):127-135
Background: Medication history taking is important because clinicians rely on the
information that is collected; however, medication histories are often inaccurate and
incomplete. The use of a medication at home without a corresponding disease or
condition in the patient's records (i.e. 'unspecified' medication) warrants
investigation of the need for that medication. The process of reconciling medications
with current diseases or conditions on hospital admission has not been officially
advocated by the Joint Commission, but it could help clinicians better assess the
continued need for home medications and possibly decrease the use of
polypharmacy.
Objectives: The objectives of this study were to expand on a previous study
conducted at a university hospital in the USA by estimating the prevalence of
discrepancies between medication histories and reported diseases or conditions in a
larger and more diverse patient population, and to determine whether a pharmacist
could clarify the reasons for the unspecified medications, thereby enhancing the
medication reconciliation process.
Methods: Patients aged 50 years or older who were taking 4 or more home
medications were randomly selected within 24 hours of hospital admission. Medical
chart information and home medication lists, obtained shortly after admission, were
reviewed retrospectively for the selected patients. Patients were excluded if they
were admitted directly to an intensive care unit. Only home medications that the
patient continued to take after admission were included in the analysis. Therapeutic
hospital formulary substitutes (e.g. atorvastatin given instead of pravastatin) were
considered to be the same medication. Nonprescription medications, 'as needed'
medications, and vitamins/supplements taken at home were excluded from analysis.
If an unspecified medication was found, a pharmacist proceeded through an
algorithm designed to clarify the reason for the unspecified medication. In the event
of a common off-label (unapproved) use of a drug, the drug was not considered
unspecified.
Results: Home medication lists were available for 300 patients (154 women, 146
men; mean (SD) age, 69 (10.6) years; more than 98% white) admitted to a 541bed university hospital between Dec 2007 and Jun 2008; a total of 114 patients
(38%) had 1 or more unspecified medication. Of the 200 unspecified medications
reported in patient charts, the 2 most frequently reported drug classes were proton
pump inhibitors and selective serotonin reuptake inhibitors, used by 21% and 11%
of patients, respectively. Patients with unspecified medications received a higher
mean number of home medications (9.7 vs 7.6 per patient; odds ratio = 1.18; 95%
CI, 1.11–1.28; P less than 0.001). Rates of discordance were independent of age,
sex and pathway to admission to the emergency department. Ultimately, the study
pharmacist was able to clarify 96% of the unspecified medications by applying the
study algorithm. Answers were provided by patients (80%), old clinic or hospital
chart notes (12%) or physicians (4%); 4% could not be clarified.
Conclusions: Many of the unspecified medications that were identified in this study
have been associated with polypharmacy in the literature. The results of this study
suggest that matching home medications with indications for those medications on
admission to the hospital enhanced the medication reconciliation process. Direct
patient questioning by the pharmacist clarified medication use and contributed to
more accurate and complete medication history taking.
http://www.ajgeripharmacother.com/article/S1543-5946(10)00023-1/abstract
Results of the Medications At Transitions and Clinical Handoffs (MATCH)
study: an analysis of medication reconciliation errors and risk factors at
hospital admission
KM Gleason, MR McDaniel, J Feinglass, DW Baker, et al.
Journal of General Internal Medicine May 2010;25(5):441-447
Background: This study was designed to determine risk factors and potential harm
associated with medication errors at hospital admission.
Methods: Study pharmacist and hospital-physician medication histories were
compared with medication orders to identify unexplained history and order
discrepancies in 651 adult medicine service inpatients with 5701 prescription
medications. Discrepancies resulting in order changes were considered errors.
Logistic regression was used to analyse the association of patient demographic and
clinical characteristics including patients' number of pre-admission prescription
medications, pharmacies, prescribing physicians and medication changes; and
presentation of medication bottles or lists. These factors were tested after
controlling for patient demographics, admitting service and severity of illness.
Results: More than one-third of study patients (35.9%) experienced 309 order
errors; 85% of patients had errors originate in medication histories, and almost half
were omissions. Cardiovascular agents were commonly in error (29.1%). If
undetected, 52.4% of order errors were rated as potentially requiring increased
monitoring or intervention to preclude harm; 11.7% were rated as potentially
harmful. In logistic regression analysis, patient's age 65 or older (odds ratio (OR),
2.17; 95% CI, 1.09–4.30) and number of prescription medications (OR, 1.21; 95%
CI, 1.14–1.29) were significantly associated with errors potentially requiring
monitoring or causing harm. Presenting a medication list (OR, 0.35; 95% CI, 0.19–
0.63) or bottles (OR, 0.55; 95% CI, 0.27–1.10) at admission was beneficial.
Conclusions: More than one-third of the patients in our study had a medication error
at admission, and of these patients, 85% had errors originate in their medication
histories. Attempts to improve the accuracy of medication histories should focus on
older patients with a large number of medications. Primary care physicians and
other clinicians should help patients utilise and maintain complete, accurate and
understandable medication lists.
http://www.springerlink.com/content/y123197m86431v18/
Prescription data improve the medication history in primary care
B Glintborg, SK Andersen, HE Poulsen
Quality and Safety in Health Care Jun 2010;19(3):164-168
Background: Incomplete medication lists increase the risk of medication errors and
adverse drug effects. In Denmark, dispensing data and pharmacy records are
available directly online to treating physicians. We aimed (1) to describe if use of
pharmacy records improved the medication history among patients consulting their
general practitioner and (2) to characterise inconsistencies between the medication
history reported by the patient and that recorded by the GP.
Methods: Patients attending a GP clinic were interviewed about their current
medication use. Subsequently, the patients were contacted by phone and asked to
verify the medication list previously obtained. Half of the patients were randomly
selected for further questioning guided by their dispensing data: during the
telephone interview, these patients were asked to clarify whether drugs registered in
their pharmacy records were still in use. Pharmacy records show all drugs acquired
on prescription from any national pharmacy in the preceding 2 years. The
medication list was corrected accordingly. In all patients, the medication lists
obtained on the in-clinic and telephone interviews were compared to the GP's
registrations.
Results: The 150 patients included in the study had a median age of 56 years (range
18-93 years), and 90 (60%) were women. Patients reported use of 849 drugs
(median 5, range 0–16) at the in-clinic interview. Another 41 drugs (median 0,
range 0–4) were added during the telephone interview. In the subgroup of 75
patients interviewed guided by pharmacy records, an additional 53 drugs (10%)
were added to the 474 drugs already mentioned. The 27 patients adding more drugs
guided by pharmacy records were significantly older and used more drugs (both p
less than 0.05) than the 48 patients not adding drugs. When the medication lists
were compared with the GP's lists, specifically use of over-the-counter products and
prescription-only medications from Anatomical Therapeutic Chemical Classification
System group J, A, D, N and R were not recorded by the GP.
Discussion: Dispensing data provide further improvement to a medication history
based on thorough in-clinic and telephone interviews. Use of pharmacy records as a
supplement when recording a medication history seems beneficial, especially among
older patients treated with polypharmacy.
http://qualitysafety.bmj.com/content/19/3/164.abstract
A study of the use of medicine lists in medicines reconciliation: please
remember this, a list is just a list
CF Green, K Burgul, DJ Armstrong
International Journal of Pharmacy Practice Apr 2010;18( 2): 116-121
Medication lists are suggested as a way of improving medicines reconciliation, but,
anecdotally, can falsely reassure prescribers that they have an accurate list of
medicines if used in isolation. In this study data were collated regarding medicationhistory discrepancies, their source and whether a prescription amendment was
made.
120 patients were reviewed and the median time for pharmacists to complete
medicines reconciliation was 15 min. 83 patients (69.2%) had only one medication
list, 31 (26%) had two, 5 (4%) had three and one patient (0.8%) had four lists. In
total, 447 discrepancies were identified of which 49 (11.0%) were initiated by the
patient, including 32 (65.3%) to adjust a dosage regimen or not to comply with a
dosing regime. For the 279 (62.4%) discrepancies attributable to secondary care
staff, 119 (42.6%) prescribed medicines were omitted unintentionally. For the 119
(26.6%) discrepancies attributable to the primary care medicines lists, 48 (40.3%)
related to inadequate or inaccurate information regarding medicine doses, frequency,
strength or form. Each patient required a mean of 1.6 amendments to their
prescription despite bringing a list of medicines with them. The authors concluded
medication lists should be interpreted with caution and assessed in combination with
other sources of information, particularly the patient or their carer.
http://onlinelibrary.wiley.com/doi/10.1211/ijpp.18.02.0007/abstract
Use of a codified medication process for documentation of home
medications
DL Green, JA Boonstra, MA Bober
Journal of the American Medical Informatics Association Sep 2010;17(5):608-612
To determine the quality and completeness of the list of home medications
documented by nurses using a codified process, authors conducted a comparative
study of home medications using a non-codified and codified process for
documentation of required data fields including drug, dose, route of administration,
frequency and schedule. Each documented home medication (DHM) was evaluated
based on the ability to convert to an inpatient medication order. The home
medication was classified as non-convertible if one or more of the required data
fields were missing, inaccurate or incomplete. The study compared 176 patients
with 1618 DHM in the non-codified group to 94 patients with 646 DHM in the codified
group. All DHM could be converted to inpatient orders for 70% of the patients in the
codified group compared with 42% in the non-codified group. Based on each DHM,
the codified process resulted in 92% of the DHM being able to convert to inpatient
orders compared with 82% for the non-codified process. Authors conclude that use
of a codified process to document home medications has the potential to increase the
number of complete drug entries and in the number of patients with a DHM list in
which all of the medication entries have all of the dosing information.
http://jamia.bmj.com/content/17/5/608.abstract
Making inpatient medication reconciliation patient centered, clinically
relevant, and implementable: a consensus statement on key principles and
necessary first steps
JL Greenwald, LK Halasyamani, J Greene, C LaCivita, E Stucky, B Benjamin, W Reid, FA
Griffin, AJ Vaida, MV Williams
Joint Commission Journal on Quality and Patient Safety Nov 2010;36(11):504-513 (see
also: Journal of Hospital Medicine Oct 2010;5(8):477-485)
Statement prepared for the Joint Commission.
Medication errors and adverse events caused by them are common during and after
a hospitalisation. The impact of these events on patient welfare and the financial
burden, both to the patient and the healthcare system, are significant. In 2005, The
Joint Commission put forth medication reconciliation as National Patient Safety Goal
(NPSG) No. 8 in an effort to minimise adverse events caused during these types of
care transitions in the USA. However, the meaningful and systematic
implementation of medication reconciliation, as expressed through NPSG No. 8,
proved to be extraordinarily difficult for healthcare institutions around the country.
Given the importance of accurate and complete medication reconciliation for patient
safety occurring across the continuum of care, the Society of Hospital Medicine
convened a stakeholder conference in 2009 to begin to identify and address: (1)
barriers to implementation; (2) opportunities to identify best practices surrounding
medication reconciliation; (3) the role of partnerships among traditional healthcare
sites and nonclinical and other community-based organisations; and (4) metrics for
measuring the processes involved in medication reconciliation and their impact on
preventing harm to patients. The focus of the conference was oriented toward
medication reconciliation for a hospitalised patient population; however, many of the
themes and concepts derived would also apply to other care settings. This paper
highlights the key domains needing to be addressed and suggests first steps toward
doing so.
An overarching principle derived at the conference is that medication reconciliation
should not be viewed as an accreditation function. It must, first and foremost, be
recognised as an important element of patient safety. From this principle, the
participants identified ten key areas requiring further attention in order to move
medication reconciliation toward this focus.
1. There is need for a uniformly acceptable and accepted definition of what
constitutes a medication and what processes are encompassed by reconciliation.
Clarifying these terms is critical to ensuring more uniform impact of medication
reconciliation.
2. The varying roles of the multidisciplinary participants in the reconciliation process
must be clearly defined. These role definitions should include those of the patient
and family/caregiver and must occur locally, taking into account the need for
flexibility in design given the varying structures and resources at healthcare sites.
3. Measures of the reconciliation processes must be clinically meaningful (i.e. of
defined benefit to the patient) and derived through consultation with stakeholder
groups. Those measures to be reported for national benchmarking and accreditation
should be limited in number and clinically meaningful.
4. While a comprehensive reconciliation system is needed across the continuum of
care, a phased approach to implementation, allowing it to start slowly and be tailored
to local organisational structures and work flows, will increase the chances of
successful organisational uptake.
5. Developing mechanisms for prospectively and proactively identifying patients at
risk for medication-related adverse events and failed reconciliation is needed. Such
an alert system would help maintain vigilance toward these patient safety issues and
help focus additional resources on high risk patients.
6. Given the diversity in medication reconciliation practices, research aimed at
identifying effective processes is important and should be funded with national
resources. Funding should include varying sites of care (e.g. urban and rural,
academic and nonacademic, etc.).
7. Strategies for medication reconciliation - both successes and key lessons learned
from unsuccessful efforts - should be widely disseminated.
8. A personal health record that is integrated and easily transferable between sites of
care is needed to facilitate successful medication reconciliation.
9. Partnerships between healthcare organisations and community-based
organisations create opportunities to reinforce medication safety principles outside
the traditional clinician-patient relationship. Leveraging the influence of these
organisations and other social networking platforms may augment population-based
understanding of their importance and role in medication safety.
10. Aligning healthcare payment structures with medication safety goals is critical to
ensure allocation of adequate resources to design and implement effective
medication reconciliation processes.
Medication reconciliation is complex and made more complicated by the disjointed
nature of the American healthcare system. Addressing these ten points with an
overarching goal of focusing on patient safety rather than accreditation should result
in improvements in medication reconciliation and the health of patients.
http://onlinelibrary.wiley.com/doi/10.1002/jhm.849/pdf
Agreement between patients' self-report and physicians' prescriptions on
cardiovascular drug exposure: the PGRx database experience
L Grimaldi-Bensouda, M Rossignol, E Aubrun, et al. (PGRx Study Group)
Pharmacoepidemiology and Drug Safety Jun 2010;19(6):591-595
Purpose: Patients' self-reported drug exposure is subjected to memory errors and
different sources of bias. Utilisation of prescription records is impaired with noncompliance and over-the-counter (OTC) drug utilisation. This study compared
patients' self-report (PS) to physicians' prescriptions of cardiovascular drugs (CVDs).
Methods: The PGRx database has been created by networks of specialised centres
that recruited cases of 15 different diseases including myocardial infarction (MI), and
a network of general practitioners recruiting a pool of potential referents. For MI
cases and referents, data on all drug utilisation within the 2 years preceding the
index date were obtained from PS and from physician's report of their prescriptions
(PP). Patients' reports were obtained using a structured telephone interview
complemented by an interview guide containing names of diseases and pictures of
drug packages. Comparisons were made of exposure to each class of CVDs, for
different time-windows, 2 months, 3-12 months and 13-24 months prior to the index
date.
Results: Concordance between physician and patient report was assessed on 2702
patient-physician pairs. Agreement was excellent overall (kappa = 0.83; 95% CI,
0.81-0.85). Prevalences of exposure were very close between PS and PP for all
classes of prescription CVDs.
Conclusions: Using standardised and systematic collection of information on drug
exposure directly from patients appeared to provide similar information to using
physician prescription records over a 2-year recall period.
See also erratum: Pharmacoepidem Drug Saf Nov 2010;19(11):1209.
http://onlinelibrary.wiley.com/doi/10.1002/pds.1952/abstract
Pharmacy services at admission and discharge in adult, acute, public
hospitals in Ireland
T Grimes, C Duggan, T Delaney
International Journal of Pharmacy Practice Dec 2010;18(6):346-352
Objectives: To describe hospital pharmacy involvement in medication management
in Ireland, both generally and at points of transfer of care, and to gain a broad
perspective of the hospital pharmacy workforce.
Methods: A survey of all adult, acute, public hospitals with an accident and
emergency (A+E) department (n = 36), using a semi-structured telephone interview.
Key findings: There was a 97% (n = 35) response rate. The majority (n = 25,
71.4%) of hospitals reported delivery of a clinical pharmacy service. On admission,
pharmacists were involved in taking or verifying medication histories in a minority
(n = 15, 42.9%) of hospitals, while few (n = 6, 17.1%) deployed staff to the
A+E/acute medical admissions unit. On discharge, the majority (n = 30, 85.7%) did
not supply any take-out medication, a minority (n = 5, 14.3%) checked the
discharge prescription, 51.4% (n = 18) counselled patients, 42.9% (n = 15)
provided medication compliance charts and one hospital (2.9%) communicated with
the patient's community pharmacy. The number of staff employed in the pharmacy
department in each hospital was not proportionate to the number of inpatient beds,
nor the volume of admissions from A+E. There were differences identified in service
delivery between hospitals of different type: urban hospitals with a high volume of
admissions from A+E were more likely to deliver clinical pharmacy.
Conclusions: The frequency and consistency of delivering pharmacy services to
facilitate medication reconciliation at admission and discharge could be improved.
Workforce constraints may inhibit service expansion. Development of national
standards of practice may help to eliminate variation between hospitals and support
service development.
http://onlinelibrary.wiley.com/doi/10.1111/j.2042-7174.2010.00064.x/abstract
Medication reconciliation on discharge from acute hospital care in Ireland
T Grimes, C Duggan, T Delaney, I Graham, K Conlon, M Jago-Byrne, P O'Brien
Pharmacoepidemiology and Drug Safety Jun 2010;19(6):649-650
Abstract of a paper presented at the Drug Utilisation Research Group (UK and
Ireland) Conference, London, 4 Feb 2010.
Medical record review survey of consecutive discharges within convenience samples
of patients discharged from two acute Irish hospitals between Jan 2006 and May
2008. Medication use across the entire episode from admission to discharge was
assessed using a medication reconciliation approach. Two processes were surveyed:
handwritten (high transcription burden) and computer generated (low). Non-
reconciliation was identified in 50% of 1245 inpatient episodes, representing 16% of
9569 medication orders. Types of non-reconciliation were omission of medication,
lack of communication about intentional discontinuation of a pre-admission
medication and prescribing error. The findings underpin the importance of
undertaking medication reconciliation procedures in Irish hospitals. Patients with
chronic illness, on higher number of medications should be prioritised to receive
medication reconciliation. Processes which decrease transcription burden on
discharge should be used.
http://onlinelibrary.wiley.com/doi/10.1002/pds.1950/abstract
Medication details documented on hospital discharge: cross-sectional
observational study of factors associated with medication nonreconciliation
TC Grimes, CA Duggan, TP Delaney, IM Graham, KC Conlon, E Deasy, M-C Jago-Byrne, P O'
Brien
British Journal of Clinical Pharmacology Mar 2011;71(3):449-457
Aims: Movement into or out of hospital is a vulnerable period for medication safety.
Reconciling the medication a patient is using before admission with the medication
prescribed on discharge, and documenting any changes (medication reconciliation) is
recommended to improve safety. The aims of the study were to investigate the
factors contributing to medication reconciliation on discharge, and identify the
prevalence of non-reconciliation.
Methods: The study was a cross-sectional, observational survey using consecutive
discharges from purposively selected services in two acute public hospitals in
Ireland. Medication reconciliation, potential for harm and unplanned re-admission
were investigated.
Results: Medication non-reconciliation was identified in 50% of 1245 inpatient
episodes, involving 16% of 9569 medications. The majority of non-reconciled
episodes had potential to result in moderate (63%) or severe (2%) harm.
Handwritten rather than computerised discharges (adjusted OR 1.60; 95% CI, 1.11,
2.99), increasing number of medications (adjusted OR 1.26; 95% CI, 1.21, 1.31) or
chronic illness (adjusted OR 2.08; 95% CI, 1.33, 3.24) were associated with nonreconciliation. Omission of endocrine, central nervous system and nutrition and
blood drugs was more likely on discharge, whilst omission on admission and
throughout inpatient care, without documentation, was more likely for obstetric,
gynaecology and urinary tract (OGU) or respiratory drugs. Documentation in the
discharge communication that medication was intentionally stopped during inpatient
care was less likely for cardiovascular, musculoskeletal and OGU drugs. Errors
involving the dose were most likely for respiratory drugs.
Conclusons: The findings inform strategies to facilitate medication reconciliation on
discharge from acute hospital care
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2125.2010.03834.x/abstract
Hospital discharge documentation and risk of rehospitalisation
LO Hansen, A Strater, L Smith, J Lee, R Press, N Ward, JA Weigelt, P Boling, MV Williams
BMJ Quality and Safety Sep 2011;20(9):773-778
Background: Avoidable hospital readmission is a focus of quality improvement
efforts. The effectiveness of individual elements of the standard discharge process in
reducing rehospitalisation is unknown.
Methods: The authors conducted a case-control study of 1039 patients experiencing
rehospitalisation within 30 days of discharge and 981 non-rehospitalised patients
matched on admission diagnosis, discharge disposition, and severity of illness. In
separate models for each discharge process component, the authors measured the
relationship between readmission and discharge summary completion, contents of
discharge summary, completion of discharge instructions, contents of discharge
instructions, presence of caregiver for discharge instruction, completion of
medication reconciliation, and arrangement of ambulatory follow-up prior to
discharge.
Results: Adjusting for patient and hospital characteristics, including severity of illness
and discharge disposition, the study failed to find an association between
readmission and most components of the discharge process. There was no
association between readmission and medication reconciliation, transmission of
discharge summary to an outpatient physician, or documentation of any specific
aspect of discharge instruction. Associations were found between readmission and
discharge with follow-up arranged (adjusted odds ratio (OR) 1.21; 95% CI, 1.05 to
1.37) and increasing number of medicines (adjusted OR 1.02; 95% CI, 1.01 to
1.04).
Conclusions: Documentation of discharge process components in the medical record
may not reflect actual discharge process activities. Alternatively, mandated
discharge processes are ineffective in preventing readmission. The observed
absence of an association between discharge documentation and readmission
indicates that discharge quality improvement initiatives should target metrics of
discharge process quality beyond improving rates of documentation.
http://qualitysafety.bmj.com/content/20/9/773.abstract
Automatic detection of omissions in medication lists
S Hasan, GT Duncan, DB Neill, R Padman
Journal of the American Medical Informatics Association Jul 2011;18(4):449-458
Objective: Evidence suggests that the medication lists of patients are often
incomplete and could negatively affect patient outcomes. In this article, the authors
propose the application of collaborative filtering methods to the medication
reconciliation task. Given a current medication list for a patient, the authors employ
collaborative filtering approaches to predict drugs the patient could be taking but are
missing from their observed list.
Design: The collaborative filtering approach presented in this paper emerges from
the insight that an omission in a medication list is analogous to an item a consumer
might purchase from a product list. Online retailers use collaborative filtering to
recommend relevant products using retrospective purchase data. In this article, the
authors argue that patient information in electronic medical records, combined with
artificial intelligence methods, can enhance medication reconciliation. The authors
formulate the detection of omissions in medication lists as a collaborative filtering
problem. Detection of omissions is accomplished using several machine-learning
approaches. The effectiveness of these approaches is evaluated using medication
data from three long-term care centres. The authors also propose several decisiontheoretic extensions to the methodology for incorporating medical knowledge into
recommendations.
Results: Results show that collaborative filtering identifies the missing drug in the
top-10 list about 40-50% of the time and the therapeutic class of the missing drug
50%-65% of the time at the three clinics in this study.
Conclusions: Results suggest that collaborative filtering can be a valuable tool for
reconciling medication lists, complementing currently recommended process-driven
approaches. However, a one-size-fits-all approach is not optimal, and consideration
should be given to context (e.g. types of patients and drug regimens) and
consequence (e.g. the impact of omission on outcomes).
http://jamia.bmj.com/content/18/4/449.abstract
Difference between pharmacist-obtained and physician-obtained
medication histories in the intensive care unit
J Hatch, T Becker, JT Fish
Hospital Pharmacy Apr 2011;46(4):262-268
Purpose: To quantify the differences between medication histories obtained by
physicians and pharmacists from critically ill patients in the intensive care unit (ICU)
and to identify patient types at greatest risk of medication errors.
Methods: Retrospective medical record review of 200 consecutively admitted
critically ill patients to the medical/surgical ICU of a university-affiliated hospital in
the USA. The pharmacist-obtained medication history was compared to the
physician-obtained medication history. Variations assessed included the number of
drugs identified, drug name, drug formulation, dose, and frequency of
administration. Inpatient medication orders were reviewed to obtain the number and
accuracy of home medications prescribed in the ICU. Patients were divided into
predefined groups: trauma, medical and nontrauma surgical to assess the risk of
medication error by patient type.
Results: Pharmacists and physicians identified a total of 981 and 665 medications,
respectively. The mean (+/- SD) number of home medications per history was 4.2
(+/- 4.9) for physicians and 6.2 (+/- 5.7) for pharmacists (P less than 0.0001).
Physician-obtained medication histories contained 1628 variances relative to the
pharmacist-obtained medication histories. The variances by type included the
frequency of administration, 37%; drug dose, 34.6%; missing drugs, 22.3%; extra
drugs, 3.6%; and drug formulation, 2.5%. 39 patients received continuation of their
home medications in the ICU totaling 97 orders (9.9% of home medications
identified by pharmacists). 30 of these orders varied from the pharmacy history and
27 were subsequently corrected.
Conclusions: Pharmacists identified more home medications than physicians when
obtaining a medication history in the ICU. This may improve the accuracy of home
medications ordered in the ICU.
http://thomasland.metapress.com/content/0873352r65333460/?p=351193f530874efa8da2
b49332c7baf8&pi=7
Stress ulcer prophylaxis: reducing non-indicated prescribing after hospital
discharge
JB Hatch, L Schulz, JT Fish
Annals of Pharmacotherapy Oct 2010;44(10):1565-1571
Background: Gastric acid suppressant medications used as stress ulcer prophylaxis
(SUP) in the intensive care unit (ICU) are often prescribed inappropriately after
discharge. We present tools to reduce the use and cost of non-indicated SUP.
Objective: To reduce the non-indicated use of SUP after hospital discharge originally
started in the ICU, using an education intervention and pharmacist-led medication
reconciliation on patient care rounds and at hospital discharge.
Methods: In a retrospective medical record review using a historic control, 356
consecutively admitted patients to the medical/surgical ICU at the University of
Wisconsin Hospital were assessed for the appropriate use of SUP at admission to the
ICU, at transfer to a general care unit, and at hospital discharge. The education
intervention involved teaching both the medical and pharmacist staff about
indications for SUP using a memorandum and a pocket guide. Pharmacists also
conducted medication reconciliation during daily patient care rounds and at discharge
to justify medication use. The outcome of this study is the percentage of patients
prescribed non-indicated gastric acid suppressants at hospital discharge. This
outcome is compared to a previous study conducted at our hospital.
Results: Of 356 eligible patients, 308 (86.5%) received SUP while in the ICU.
39 (11%) were given continuing SUP after discharge from the hospital, for which
there was no clear indication in 31 (8.7%). This was a 64.3% reduction from the
24.4% found in the prior study (p less than 0.0001).
Conclusions: Educational materials that guide prescribing, pharmacist interaction on
patient care rounds, and pharmacist-conducted medication reconciliation significantly
reduced the prescribing of non-indicated gastric acid suppressant medications after
hospital discharge.
http://www.theannals.com/cgi/content/abstract/44/10/1565
Impact of the Lund Integrated Medicines Management (LIMM) model
on medication appropriateness and drug-related hospital revisits
LM Hellström, Å Bondesson, P Höglund, P Midlöv, L Holmdahl, E Rickhag, T Eriksson
European Journal of Clinical Pharmacology Jul 2011;67(7):741-752
Purpose: To examine the impact of systematic medication reconciliations upon
hospital admission and of a medication review while in hospital on the number of
inappropriate medications and unscheduled drug-related hospital revisits in elderly
patients.
Methods: This was a prospective, controlled study in 210 patients, aged 65 years or
older, who were admitted to one of three internal medicine wards at a University
Hospital in Sweden. Intervention patients received the complete Lund Integrated
Medicines Management model (medication reconciliation upon admission and
discharge, and medication review and monitoring) provided by a multi-professional
team, including a clinical pharmacist. Control patients received standard care and
medication reconciliation upon discharge. Blinded reviewers evaluated the
appropriateness of the prescribing (using the Medication Appropriateness Index) on
admission and discharge, and assessed the probability that a drug-related problem
was the reason for any patient readmitted to hospital or visiting the emergency
department within 3 months of discharge (using World Health Organisation causality
criteria).
Results: There was a greater decrease in the number of inappropriate drugs in the
intervention group than in the control group for both the intention-to-treat
population {51%; 95% CI, 43-58% vs 39%; 95% CI, 30-48%); p = 0.0446} and
the per-protocol population (60%; 95% CI, 51-67% vs 44%; 95% CI; 34-52%; p =
0.0106). There were 6 revisits to hospital in the intervention group which were
judged as 'possibly, probably or certainly drug-related', compared with 12 in the
control group (p = 0.0469).
Conclusions: In this study, medication reconciliation and review provided by a clinical
pharmacist in a multi-professional team significantly reduced the number of
inappropriate drugs and unscheduled drug-related hospital revisits among elderly
patients.
http://www.springerlink.com/content/286840426v0pwq37/
Medication discrepancies at discharge from an internal medicine
service
JI Herrero-Herrero, J Garcia-Aparicio
European Journal of Internal Medicine Feb 2011;22(1):43-48
Background: Medication errors most commonly occur at the time of medication
prescribing and particularly at the moment of the transitions of care. The objectives
of this study were to identify and characterise the discrepancies between the
physicians' discharge medication orders and the medication lists at admission
obtained by an internal medicine specialist physician in a general internal medicine
service.
Methods: This descriptive, retrospective, study was carried out at a tertiary care
university teaching hospital in Spain. It was based on the review of non-selected,
consecutive, hospital discharge reports. Discrepancies were identified, categorised
and characterised through the analysis of the information (medication lists,
laboratory tests results, diagnosis and clinical evolution) contained in them.
Results: We analysed 954 discharge reports. In the medication reconciliation
process, we find discrepancies in 832 (87.2%) of them. Justified discrepancies were
found in 828 (86.8%) reports and unjustified discrepancies in 52 (5.4%). Omission
of a medication was the most frequent medication error, detected in 86.4% of cases,
followed by incomplete prescription (9.6%). The number of diagnoses, the length of
hospital stay and the number of permanent medications at admission were the
characteristics of cases associated with medication discrepancies in multivariate
linear regression (P less than 0.01).
Conclusions: Considering the limitations in its design, the low number of medication
errors detected in our study is remarkable. Appropriate routines to ensure accurate
collection of medication history and methodical establishing of the medication list at
discharge, when performed by trained internists, are important for an adequate
medication reconciliation process.
http://dx.doi.org/10.1016/j.ejim.2010.10.003
Using health smart cards to check drug allergy history: the
perspective from Taiwan's experiences
M-H Hsu, J-C Yen, W-T Chiu, S-L Tsai, C-T Liu, Y-C Li
Journal of Medical Systems Aug 2011;35(4):555-558
In Taiwan, national health insurance coverage began in 1994, and the Bureau of
National Health Insurance has issued health smart cards since 2004. In addition to
tracking medical reimbursements, these smart cards store healthcare information,
including electronic prescriptions, medical procedure and vaccination records, drug
allergy histories, and information about a patient's willingness to be an organ donor.
We conducted this study 4 years after the smart cards had been introduced in order
to review how drug allergy history is recorded using this system. The results reveal
that the drug allergy histories are incomplete in many cases, and the format used to
record a patient's drug allergy history is not consistent. Suggestions to promote the
standardisation of drug allergy history records are offered.
http://www.springerlink.com/content/5mj6u16781850818/
Medication reconciliation in the emergency department:
opportunities for workflow redesign
J Hummel, PC Evans, H Lee
Quality and Safety in Health Care Dec 2010;19(6):531-535
Aim: To examine the role of workflow redesign to improve medication reconciliation
at four Washington State, USA, community hospital emergency departments.
Method: Lean redesign methodology was used for workflow process mapping and
redesign workshops attended by emergency department staff. Observations were
made about barriers to successful operation of current medication reconciliation
workflows, and ideal future process maps were developed to improve the efficacy of
creating a current, complete and accurate medication list for each patient seen in the
emergency department.
Conclusions: Ideas for an optimal workflow to generate a medication list include
involving patients and utilising clerical staff to a greater extent in medication
information gathering, identifying and flagging patients with missing medication
information, and gathering only the medication information needed to make clinical
decisions in the emergency department.
http://qualitysafety.bmj.com/content/19/6/531.abstract
Accuracy of reporting current medications by cancer patients presenting to
an emergency center
JP Hwang, HM Holmes, MA Kallen, J Ensor, J Etchegaray, et al.
Supportive Care in Cancer Oct 2010;18(10):1347-1354
Background: Due to high coexistence of comorbidity, cancer patients take many
medications and are susceptible to negative consequences of polypharmacy. To
avoid adverse events during care transitions, patients need to correctly communicate
their medications. The emergency centre (EC) presents opportunities to assess
patients' knowledge of medications and reconcile medication profiles.
Objective: The purpose was to evaluate the medication knowledge of cancer patients
presenting to the EC and to identify factors associated with higher knowledge.
Design and measurements: For the cross-sectional self-administered survey, 254
patients were enrolled and gave name, dose, frequency, route and indication for
medications. Responses were checked for accuracy against outpatient pharmacy
dispensing records within or outside M.D. Anderson Cancer Center (Houston, Texas,
USA). Demographic data were obtained from medical records. For each patient, we
calculated a patient medication knowledge (PMK-overall) score indicating percentage
of correct responses.
Results: Median PMK-overall score was 80%. Patients who used a medication aid to
fill out the survey were 6.5 times more likely to have a high level of medication
knowledge, or PMK-overall score of 80% or higher. Predictors of using a medication
aid included lower education level, solid tumour, more than five medications,
married, and using a medication list at home.
Conclusions: Though our findings may not be generalisable to settings outside the
EC, we found cancer patients to have high levels of medication knowledge. Future
studies should validate the use of PMK scores to predict medication adherence and
other outcomes. Patients should be encouraged to use a medication aid when
presenting information to the health care system.
http://springerlink.metapress.com/content/y60428q5mrq2h254/
Medication reconciliation in a community pharmacy setting
CM Johnson, TR Marcy, DL Harrison, RE Young, EL Stevens, J Shadid
Journal of the American Pharmacists Association Jul-Aug 2010;50(4):523-526
Objectives: To describe the types and frequencies of medication discrepancies
identified through medication reconciliation in a community pharmacy setting, to
identify potential correlations between a patient's electronic medical record (EMR)
and pharmacy medication list, and to determine the relationship between patients
who use prescribers and/or pharmacies outside of the Family Medicine Center (FMC)
and the occurrence of medication discrepancies.
Methods: Cross-sectional comparison of patients' EMR medication lists and pharmacy
medication fill history for a sample of patients presenting to the Family Medicine
Pharmacy (FMP), which is located in the FMC on the University of Oklahoma Health
Sciences Center campus in Oklahoma City. Discrepancies identified were classified
according to one of six categories that included therapeutic duplication, medication
exclusion, medications that should be designated inactive in the EMR medication list,
and differences in medication strength, dosage form, or dosing regimen.
Results: A total of 100 patients were included. Most patients reported having all of
their medications dispensed from FMP (89%), and most patients had prescriptions
prescribed by FMC physicians only (57%). Each patient had an average of six
medication discrepancies. Most discrepancies belonged to the inactive medication
category (41%). The correlation between patients' FMP medication lists and their
EMR medication lists was 0.73. Patients with one or more non-FMC prescribers had
a greater number of medication discrepancies than patients with FMC prescribers
only, but this relationship was not identified for those who used pharmacies outside
of FMP (P = 0.0264 and 0.2580, respectively).
Conclusions: A variety of medication discrepancies were observed, signalling a need
for medication reconciliation in the outpatient setting. Future research on this topic
should focus on the implications of such discrepancies in the outpatient setting,
interventions to reduce the number of discrepancies, and identifying patients at high
risk for such discrepancies.
http://japha.metapress.com/openurl.asp?genre=article&id=doi:10.1331/JAPhA.2010.09121
Medication reconciliation: an important piece of the medication puzzle
AK Kennedy, SBS Gatewood
Consultant Pharmacist Dec 2010;25(12):829-833
Medication errors continue to cause significant morbidity and mortality. This, in turn,
costs health care system large sums each year in preventable costs. Medication
reconciliation, an important piece of medication therapy management (MTM), is vital
to reducing medication errors. By verifying, clarifying and reconciling medications at
each point of care, pharmacists can play a vital role in improving health care and
lowering costs. This case study describes an MTM session with a 66-year-old
Caucasian female who is referred by the nurse practitioner in the clinic for
pharmacist services. The patient has a history of portal hypertension, alcoholic liver
damage and chronic obstructive pulmonary disease. After obtaining a detailed
history, the pharmacist identified significant medication-related problems including
polypharmacy, nonadherence, drug-alcohol interactions and inappropriate use of
medication. After discussions with the patient and her nurse practitioner, a
medication plan was created for the patient to follow.
http://ascp.metapress.com/content/6833q216w60u2737/?p=919dec8026794f94afff533196
1bff43&pi=3
Recent drug history in children visiting a pediatric emergency room and
documentation in medical records
E Kimland, Y Bottiger, S Lindemalm
European Journal of Clinical Pharmacology Oct 2011;67(10):1085-1089
Aims: We performed a systematic analysis of which drugs, prescribed, over the
counter (OTC), and/or natural remedies, children had used prior to visiting a
paediatric emergency room (ER) in Sweden, and compared this information with the
documentation of drug use in the medical records.
Methods: A questionnaire study was performed at a paediatric ER in a Swedish
university hospital during 3 weeks in Apr 2008. The questionnaire was validated
through an interview with a subgroup of participants. Only drug use associated with
the time of that hospital visit was requested. Information was compared with
information in medical records related to the same visit.
Results: 274 children aged 0-18 (median 2) years were enrolled, representing 28%
of the total number of patients visiting the ER within the time frame. 40% (n = 109)
of participants reported use of prescribed drugs, 65% (n = 172) OTC drugs and 8%
(n = 17) natural remedies prior to the ER visit. The most common drugs in the three
groups were salbutamol, paracetamol and omega fatty acids, respectively. In the
medical records, no more than 50% of the reported drug intake could be found,
representing 74% of prescribed drugs but only 34% of OTC drugs and 27% of
natural remedies.
Conclusions: The majority of children had used drugs, both prescribed and OTC,
before coming to the ER, but this drug intake, and especially that of nonprescribed
drugs, was often not documented in the medical records.
http://www.springerlink.com/content/70253741313r463u/fulltext.pdf
Pharmacy technicians obtaining medication histories within the
emergency department
H Knight, L Edgerton, R Foster
American Journal of Health-System Pharmacy 1 Apr 2010;67(7):512,514
Letter describing a process implemented at a hospital in North Carolina, USA, for
pharmacy technicians to collect medication histories for patients admitted through
the emergency department. Two FTE positions were allocated to provide coverage
for 12 hours daily, 7 days a week. During the first 3 months of operation, pharmacy
technicians collected histories from 1783 patients. A survey of physicians found that
the technician-driven process had improved the accuracy of the medication
reconciliation process. (8 refs.)
http://www.ajhp.org/content/67/7.toc
Medication reconciliation during internal hospital transfer and
impact of computerized prescriber order entry
JY Lee, K Leblanc, OA Fernandes, J-H Huh, et al.
Annals of Pharmacotherapy Dec 2010;44(12):1887-1895
Background: Internal hospital transfer is a vulnerable time during which patients are
at high risk of medication discrepancies that can result in clinically significant harm,
medication errors, and adverse drug events.
Objective: To identify, characterise and assess the clinical impact of unintentional
medication discrepancies during internal hospital transfer and to investigate the
influence of computerised prescriber order entry (CPOE) on medication
discrepancies.
Methods: All patients transferred between 10 inpatient units at 2 tertiary care
hospitals in Ontario, Canada were prospectively assessed to identify discrepancies.
Interfaces included transfers between (1) units that both used paper-based
medication ordering systems; (2) units that both used CPOE-based systems; and (3)
units that used both paper-based and CPOE-based systems (hybrid transfer). The
primary endpoint was the number of patients with at least 1 unintentional medication
discrepancy during internal hospital transfer. Discrepancies were identified through
assessment and comparison of a best possible medication transfer list with the actual
transfer orders. A multidisciplinary team of clinicians assessed the potential clinical
impact and severity of unintentional discrepancies.
Results: Overall, 190 patients were screened and 129 patients were included.
80 patients (62.0%) had at least 1 unintentional medication discrepancy at the time
of transfer, and the most common discrepancy was medication omission (55.6%).
Factors that independently increased the risk of a patient's experiencing at least 1
unintentional discrepancy included lack of best possible medication history,
increasing number of home medications, and increasing number of transfer
medications. 47 patients (36.4%) had at least 1 unintentional discrepancy with the
potential to cause discomfort and/or clinical deterioration. The risk of discrepancies
was present regardless of the medication-ordering system (paper, CPOE or hybrid).
Conclusions: Clinically significant medication discrepancies occur commonly during
internal hospital transfer. A structured, collaborative, and clearly defined medication
reconciliation process is needed to prevent internal transfer discrepancies and patient
harm
http://www.theannals.com/cgi/content/abstract/44/12/1887
Perioperative Medication Management (POMM) pilot: Integrating a
community-based medication history (MedsCheck) into medication
reconciliation for elective orthopedic surgery inpatients
V Leung, K Mach, E Charlesworth, S Hicks, K Kizemchuk, C Stumpo
Canadian Pharmacists Journal Mar-Apr 2010;143(2):82-87
Background: Medication safety along the continuum of care is dependent on the
quality of medication information at each point of transfer. The purpose of our study
was to assess the impact of integrating a community-based medication history
(MedsCheck) into perioperative medication reconciliation for elective orthopedic
surgery patients by assessing postoperative unintentional medication discrepancies.
Secondary objectives were to evaluate community pharmacist participation and
patient satisfaction.
Methods: Patients scheduled for elective hip or knee surgery between Apr and Sep
2008 at Toronto East General Hospital (TEGH) were identified as the study
population. Patients and community pharmacies were contacted to coordinate the
MedsCheck prior to the pre-admission clinic visit. At the visit, the MedsCheck
document was used to prepare a best possible medication history, which was
documented in the patient chart. Medications were reconciled postoperatively.
Participants were surveyed for feedback on the process.
Results: 82 patients were included in the study. A MedsCheck was completed for
73.8% (31/42) of eligible patients who were contacted prior to their pre-admission
clinic visit. The average number of medications per patient was 8.4. The percentage
of patients with at least one unintentional medication discrepancy decreased from
68.4% (13/19) to 47.6% (39/82) post-intervention. Total unintentional medication
discrepancies decreased from 25.6% to 10.6%.
Discussion: Integrating MedsCheck into the perioperative medication reconciliation
process resulted in positive outcomes. The main challenge was coordination of the
MedsCheck service prior to the patient's pre-admission clinic visit.
Conclusion: Integrating MedsCheck into routine perioperative care for orthopedic
patients is a feasible way to facilitate pharmacist medication reconciliation and
increase patient satisfaction.
http://www.cpjournal.ca/doi/pdf/10.3821/1913-701X-143.2.82
How well does patient self-report predict asthma medication
possession? Implications for medication reconciliation and
adherence assessment
KG Lim, MA Rank, JTC Li, A Patel, et al.
Journal of Asthma Oct 2010;47(8):878-882
Background: Self-report is the most commonly used method for collecting
information regarding asthma medication possession and adherence in clinical
practice.
Objective: To determine the agreement between self-report and pharmacy claims
data for asthma medication possession.
Methods: This is a retrospective study that examined pharmacy claims data 12
months before and after participants completed a structured asthma survey. This
study was performed in a sample of health care workers and dependents older than
17 years in a large, self-insured Midwestern United States health care centre. The
main outcome measure was agreement (kappa calculation) between self-report and
pharmacy claims data of asthma medication possession.
Results: Self-report of asthma medication use agreed moderately with pharmacy
claims data for short-acting salbutamol (albuterol) (kappa = 0.47 +/- 0.03),
salmeterol (kappa = 0.79 +/- 0.04) and montelukast (kappa = 0.69 +/- 0.03) but
only slightly for inhaled corticosteroids (kappa = 0.18 +/- 0.03) and prednisone
(kappa = 0.10 +/- 0.03) (n = 1050 respondents). Both under self-reporting and
over self-reporting were common with inhaled corticosteroids (14.4% and 23.1%,
respectively) and varied significantly by specific drug type.
Conclusions: Self-report moderately agrees with asthma medication possession
http://informahealthcare.com/doi/abs/10.3109/02770903.2010.491143
Discrepancies between sources providing the medication histories of
acutely hospitalised patients
L Lindved Karkov, S Schytte-Hansen, LS Haugbolle
Pharmacy World and Science Aug 2010;32(4):449-454
Objective: The aim of this study was to clarify the number and type of discrepancies
between four medication sources as well as their potential clinical significance to the
patient.
Method: The study was conducted as a cross-sectional study comprising all patients
hospitalised with hip fractures in the Orthopaedic Surgery Ward at Amager Hospital,
Denmark. Data were collected from four sources. All information was counted, and
the potential clinical significance of discrepancies was evaluated on a 5-point scale.
The four sources are: patients, the Personal Electronic Medication Profile (PEM), the
general practitioner (GP) and the in-home care provider. A discrepancy was defined
as any disagreement or omission of information between the four sources concerning
name, form, strength and dose for each drug with which the patient was being
treated.
Main outcome measure: The number of discrepancies between the data sources.
Results: A total of 69 medications were registered for 9 patients or an average of 7.7
medications per patient. 10.1 discrepancies per patient and 1.3 discrepancies per
drug were registered. Two discrepancies were assessed as having potentially lethal
clinical significance. 41 discrepancies were assessed as clinically significant, while 36
discrepancies were assessed as possessing minor clinical significance. The PEM
added 9 prescription drugs that no other sources mentioned. The addition of these
medicines was largely clinically significant.
Conclusions: A total of 91 discrepancies were registered for 9 patients. Two of these
discrepancies were potentially fatal and 41 were clinically significant.
http://www.springerlink.com/content/62541300140712x0/
Using a novel patient medication list for ambulatory pediatric patients
within a hospital-based complex care program
P Luca, M Coffey, S Adams, A Ragone, E Cohen, A Matlow
Joint Commission Journal on Quality and Patient Safety Dec 2011;37(12):560-3AP(-556)
Background: Medication errors are common in the paediatric outpatient setting, and
children with multiple prescriptions are at increased risk. Little is known about
medication reconciliation's application in the ambulatory setting. Caregivers'
perceptions of a patient medication list (PML), created for children with complex
health needs, were assessed.
Methods: Caregivers of children followed by a tertiary care hospital ambulatory
complex care programme from Feb to Dec 2009 were enrolled in the study. An
electronic PML software was nested within a clinical database. At the clinic visit, the
medications were updated in the database by a nurse practitioner, and a PML was
created and printed for the caregivers. Caregivers were asked to complete a prequestionnaire before using the PML and a post-questionnaire 12 weeks later.
Results: The pre-questionnaire demonstrated that 19 (68%) of 28 caregivers
expected the PML to be very helpful. After a mean of 19.3 weeks, on the postquestionnaire, 14 (50%) of the 28 caregivers reported that the PML was very helpful,
10 (40%) of 25 caregivers used the PML at every follow-up clinic visit, and 18 (67%)
of 27 caregivers were satisfied with the PML. 5 (18%) of 28 caregivers strongly
agreed that the PML increased their knowledge of the child's medications, and 3
(11%) of 28 caregivers strongly agreed that the PML helped them remember to give
the child's medications at home.
Conclusions: A subset of caregivers in a complex care programme reported that a
PML was helpful during interactions with their medical team. Yet in general,
caregivers did not find the PML helpful in increasing their medication knowledge or
reminding them to administer their child's medications.
http://www.ingentaconnect.com/content/jcaho/jcjqs/2011/00000037/00000012/art00005
Health literacy and medication understanding among hospitalized adults
M Marvanova, CL Roumie, SK Eden, C Cawthon, JL Schnipper, S Kripalani
Journal of Hospital Medicine Nov-Dec 2011;6(9):488-493
Background: Patients' ability to accurately report their preadmission medications is a
vital aspect of medication reconciliation, and may affect subsequent medication
adherence and safety. Little is known about predictors of preadmission medication
understanding.
Methods: We conducted a cross-sectional evaluation of patients at two hospitals in
the USA using a novel Medication Understanding Questionnaire (MUQ). MUQ scores
range from 0 to 3 and test knowledge of the medication purpose, dose and
frequency. We used multivariable ordinal regression to determine predictors of
higher MUQ scores.
Results: Among the 790 eligible patients, the median age was 61 (interquartile range
(IQR) 52, 71), 21% had marginal or inadequate health literacy, and the median
number of medications was 8 (IQR 5, 11). Median MUQ score was 2.5 (IQR 2.2,
2.8). Patients with marginal or inadequate health literacy had a lower odds of
understanding their medications (odds ratio (OR) = 0.53; 95% CI, 0.34 to 0.84; P =
0.0001; and OR = 0.49; 95% CI, 0.31 to 0.78; P = 0.0001; respectively), compared
to patients with adequate health literacy. Higher number of prescription medications
was associated with lower MUQ scores (OR = 0.52; 95% CI, 0.36 to 0.75; for those
using 6 medications vs 1; P = 0.0019), as was impaired cognitive function (OR =
0.57; 95% CI, 0.38 to 0.86; P = 0.001).
Conclusions: Lower health literacy, lower cognitive function, and higher number of
medications each were independently associated with less understanding of the
preadmission medication regimen. Clinicians should be aware of these factors when
considering the accuracy of patient-reported medication regimens and
when counselling patients about safe and effective medication use.
http://onlinelibrary.wiley.com/doi/10.1002/jhm.925/abstract
Medication history taking in emergency department triage is inaccurate
and incomplete
M Mazer, F DeRoos, JE Hollander, C McCusker, N Peacock, J Perrone
Academic Emergency Medicine Jan 2011;18(1):102-104
Objectives: Medication error prevention has become a priority in health care. The
Joint Commission recommends that a list of medications, dosages and allergies be
obtained from all patients. The authors sought to determine the accuracy of
medication history taking in emergency department (ED) triage. The hypothesis was
that there would be significant discrepancies between medications listed in triage and
those the patient was actually taking.
Methods: This was a prospective, cross-sectional survey of adult patients presenting
to the ED of a US university hospital. As a part of regular care, nurses recorded a
medication list during triage in the electronic medical record (EMR). For this study,
the triage medication list was rechecked during an independent patient interview.
Results: Of 1797 patients approached, 1657 completed the survey (92%). The
mean age was 39 years (standard deviation (SD) +/- 16 years). Discrepancies in
medication lists obtained during triage were documented in 626 (37%) patients.
Discontinued medications (163, 9.8%) were included, additional medications (463,
27.9%) were omitted and 632 patients (38%) reported taking a nonprescription
medication not listed in the EMR.
Conclusions: Medication histories performed in ED triage are inaccurate and
incomplete.
http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.2010.00959.x/pdf
Formal medicine reconciliation within the emergency department reduces
the medication error rates for emergency admissions
PR Mills, AC McGuffie
Emergency Medicine Journal Dec 2010;27(12):911-915
Aim: To improve medication history accuracy and reduce prescribing errors for
unscheduled patients admitted via the emergency department (ED).
Design: A prospective observational study of 100 adult unscheduled admissions with
50 patients in both pre and post-intervention groups. One investigator completed
the required information including patient demographics, admitting speciality,
number and types of any medication errors detected. In the post-intervention
group, the investigator (a pharmacist independent prescriber) completed systematic
medicine reconciliation in the ED before patient transfer and initiated the original
inpatient prescription chart, as appropriate.
Background and Setting: The ED in a busy district general hospital with an
emergency admission rate of 24,000 patients per annum.
Key Measures for Improvement: An increase in medicine reconciliation and initial
prescribing within the ED with a reduction in prescribing error rates.
Strategies for Improvement: Change needed to be communicated to all staff
involved in process: ED medical and nursing staff; appropriate clinical directors;
pharmacy staff.
Effects of Change: Medicine reconciliation completed within 24 hours of admission
increased from 50% to 100% and prescription chart initiation in the ED increased
from 6% to 80%. The prescribing error rate was reduced from 3.3 errors to 0.04
errors per patient (difference 95% CI, 2.5 to 5.1).
Lessons Learnt: Streamlining the admission process for unscheduled patients leads
to improvement in care, decreases prescribing errors and reduces either potential or
actual harm. Moving pharmacists' work to the ED better aligns their input to the
patient journey and utilises their knowledge and skills to the patient's benefit.
http://emj.bmj.com/content/27/12/911.abstract
Medicines reconciliation using a shared electronic health care record
P Moore, G Armitage, J Wright, S Dobrzanski, N Ansari, I Hammond, A Scally
Journal of Patient Safety Sep 2011;7(3):147-153
Objective: This study aimed to evaluate the use of a shared electronic primary health
care record (EHR) to assist with medicines reconciliation in the hospital from
admission to discharge.
Methods: This is a prospective cross-sectional, comparison evaluation for 2 phases,
in a short-term elderly admissions ward in the United Kingdom. In phase 1, full
reconciliation of the medication history was attempted, using conventional methods,
before accessing the EHR, and then the EHR was used to verify the reconciliation. In
phase 2, the EHR was the initial method of retrieving the medication historyvalidated by conventional methods.
Results: Where reconciliation was led by conventional methods, and before any
access to the EHR was attempted, 28 (28%) of hospital prescriptions were found to
contain errors. Of 99 prescriptions subsequently checked using the EHR, only 50
(50%) matched the EHR. Of the remainder, 25% of prescriptions contained errors
when verified by the EHR. However, 26% of patients had an incorrect list of current
medications on the EHR.
Using the EHR as the primary method of reconciliation, 33 (32%) of 102
prescriptions matched the EHR. Of those that did not match, 39 (38%) of
prescriptions were found to contain errors. Furthermore, 37 (36%) of patients had
an incorrect list of current medications on the EHR.
The most common error type on the discharge prescription was drug omission; and
on the EHR, wrong drug. Common potentially serious errors were related to
unidentified allergies and adverse drug reactions.
Conclusions: The EHR can reduce medication errors. However, the EHR should be
seen as one of a range of information sources for reconciliation; the primary source
being the patient or their carer. Both primary care and hospital clinicians should
have read-and-write access to the EHR to reduce errors at care transitions. We
recommend further evaluation studies.
http://journals.lww.com/journalpatientsafety/Abstract/2011/09000/Medicines_Reconciliatio
n_Using_a_Shared_Electronic.7.aspx
Medicines reconciliation on admission: a joint working solution for
the implementation of policy
H Morrison
Pharmacy Management Oct 2010;26(4):10-15
Implementing National Institute for Health and Clinical Excellence (NICE) Patient
Safety Guidance PSG001 regarding medicines reconciliation on admission of adults to
hospital is challenging, especially in community hospitals and mental health facilities
where access to pharmacists is limited.
This paper outlines how a team of people from the NHS and pharmaceutical industry
worked together to develop a practical solution.
The project highlights the importance of promoting the benefits of medicines
reconciliation to change organisational culture and the need to embed tried and
tested documentation into the admissions process to change behaviour.
Developing a programme of competency assessed accreditation and training
enables a range of non-pharmacy staff to undertake medicines reconciliation.
As a result of this project, organisations across the South West have access to elearning tools designed to support the implementation of medicines reconciliation
policy and are provided with local assurance of staff skills.
http://pharman.co.uk/
Characterization of medication discrepancies occurring at the time of
discharge from an adult state psychiatric inpatient facility
LA Nelson, MR Graham, MG Schaefer
Hospital Pharmacy Apr 2011;46(4):254-261
Purpose: To measure retrospectively the frequency of medication discrepancies
occurring at hospital discharge and to characterise these discrepancies.
Methods: All consecutive discharges from an adult state psychiatric hospital in the
USA with a length of stay of 2 days or longer were retrospectively evaluated for
medication discrepancies occurring at the time of discharge. The content of the
handwritten discharge plan was compared to the medication administration record
from the last day of admission to identify medication discharge discrepancies. The
primary endpoint was to determine the number of patients with a medication
discharge discrepancy (MDD). Secondary objectives were to characterise the MDD
by type of discrepancy and medication class (psychiatric vs nonpsychiatric).
Results: From 1 Oct 2008 to 31 Dec 2008, 205 patients were screened for eligibility;
163 patients were included. 38 patients (23.3%) had at least 1 MDD, with 10
(26.3%) of these patients having more than one MDD (range, 2-6). Characterisation
of the MDDs determined that 63.2% of the discrepancies occurred because a
scheduled medication was omitted on the discharge plan whereas 36.8% were due to
a dosing discrepancy. MDDs occurred at a similar rate for both classes of
medications (psychiatric and nonpsychiatric), but omission discrepancies occurred
more commonly with nonpsychiatric medications and dosing discrepancies occurred
more commonly with psychiatric medications.
Conclusions: Medication discrepancies occur commonly on hospital discharge.
Understanding the frequency and types of MDDs occurring at this interface of care
can assist in the development of more effective and targeted medication
reconciliation procedures.
http://thomasland.metapress.com/content/g4n49g8124265824/?p=0d81bcd2bff5441491d5
accf64959554&pi=6
A primary care initiative to support medicines reconciliation
I Nicholls, M Wilcock
Prescriber Jan 2010;21(1-2):35-37
The authors describe a new approach they have developed to provide a reliable
medical history on admission from GP practice records, which has been implemented
at Royal Cornwall Hospitals NHS Trust. This involves a template which is populated
as far as possible from information held in GP computer systems.
http://onlinelibrary.wiley.com/doi/10.1002/psb.582/pdf
The effect of a clinical pharmacist discharge service on medication
discrepancies in patients with heart failure
R Nynke Eggink, AW Lenderink, JWMG Widdershoven, PMLA van den Bemt
Pharmacy World and Science Dec 2010;32(6):759-766
Objective: Heart failure patients are regularly admitted to hospital and frequently
use multiple medication. Besides intentional changes in pharmacotherapy,
unintentional changes may occur during hospitalisation. The aim of this study was to
investigate the effect of a clinical pharmacist discharge service on medication
discrepancies and prescription errors in patients with heart failure.
Setting: A general teaching hospital in Tilburg, the Netherlands.
Method: An open, randomised intervention study was performed comparing an
intervention group, with a control group receiving regular care by doctors and
nurses. The clinical pharmacist discharge service consisted of review of discharge
medication, communicating prescribing errors with the cardiologist, giving patients
information, preparation of a written overview of the discharge medication and
communication to both the community pharmacist and the general practitioner about
this medication. Within 6 weeks after discharge all patients were routinely scheduled
to visit the outpatient clinic and medication discrepancies were measured.
Main outcome measure: The primary endpoint was the frequency of prescription
errors in the discharge medication and medication discrepancies after discharge
combined.
Results: 44 patients were included in the control group and 41 in the intervention
group. 68% of patients in the control group had at least one discrepancy or
prescription error against 39% in the intervention group (RR 0.57; 95% CI, 0.370.88). The percentage of medications with a discrepancy or prescription error in the
control group was 14.6% and in the intervention group it was 6.1% (RR 0.42; 95%
CI, 0.27-0.66).
Conclusions: This clinical pharmacist discharge service significantly reduces the risk
of discrepancies and prescription errors in medication of patients with heart failure in
the first month after discharge.
http://www.springerlink.com/content/h52652755671u207/fulltext.pdf
Medicines 'overlooked' or taken outside of regular prescriptions that are
not documented on admission to an acute medical unit
R Owusu-Ankomah, S Srivastava, E Baker, J Archer
British Journal of Clinical Pharmacology Aug 2010;70(2):288
Paper presented at the British Pharmacological Society Clinical Pharmacological Section,
London, 15-17 Dec 2009.
The aim of this study was to assess documentation of non-prescribed and
'overlooked' medicines by doctors and pharmacists for patients admitted to the acute
medical unit (AMU) at a London teaching hospital. 52 unselected adult patients were
included in the study (29 women; mean age 70 +/- 18 years). 43 patients were
taking 108 non-prescribed medicines, of which 3 (2.8%) were identified by the
admitting doctor and 5 (4.6%) by the admitting pharmacist. 32 patients were taking
59 'overlooked' medicines, of which 15 (25.4%) were identified by the admitting
doctor and 26 (44.1%) by the admitting pharmacist. The most commonly used nonprescribed medicines were cod liver oil, paracetamol and cough medicines. The most
commonly used 'overlooked' medicines were short-acting beta-adrenoceptor agonist
inhalers, long-acting beta-adrenoceptor agonist inhalers and topical creams (steroid,
antihistamine and generic emulsions).
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2125.2010.03678.x/abstract
Medicines reconciliation on admission to inpatient psychiatric care:
findings from a UK quality improvement programme
C Paton, S McIntyre, SF Bhatti, A Shingleton-Smith, R Gray, D Gerrett, TRE Barnes
Therapeutic Advances in Psychopharmacology Aug 2011;1(4):101-110
Objective: Medication errors are a common cause of avoidable morbidity, and
transfer between clinical settings is a known risk factor for such errors. Medicines
reconciliation means there is no unintended discrepancy between the medication
prescribed for a patient prior to admission and on admission. Our aim was to
improve the quality of practice supporting medicines reconciliation at the point of
admission to a psychiatric ward.
Methods: An audit-based quality improvement programme (QIP), using the proxy
measure for medicines reconciliation of two or more sources of information being
consulted about current medicines, and compared.
Results: At baseline audit, 42 Trusts submitted data for 1790 patients. At re-audit
16 months later, 43 Trusts submitted data for 2296 patients. While doctors were
most commonly identified in Trust policies as having overall responsibility for
medicines reconciliation, the task was most often undertaken by pharmacy staff,
with most activity occurring within 24 hours of admission. The proportion of patients
in whom medicines reconciliation was possible was 71% at baseline and 79% at reaudit. In such patients, discrepancies were identified in 25% at baseline and 31% at
re-audit; a small proportion of these discrepancies were clearly clinically significant.
Conclusions: This QIP achieved modest improvement in medicines reconciliation
practice.
http://tpp.sagepub.com/content/1/4/101.short
Medication reconciliation: innovative experience in an internal
medicine unit to decrease errors due to inaccurate medication
histories
(Conciliation médicamenteuse: une expérience innovante dans un service de médecine
interne pour diminuer les erreurs d’anamnèse médicamenteuses)
M Perennes, A Carde, X Nicolas, M Dolz, R Bihannic, P Grimont, T Chapot, H Granier
Presse Medicale 2011;DOI : 10.1016/j.lpm.2011.09.016 (early online publication 22 Nov
2011)
Purpose: An inaccurate medication history may prevent the discovery of a preadmission iatrogenic event or lead to interrupted drug therapy during
hospitalisation. Medication reconciliation is a process that ensures the transfer of
medication information at admission to the hospital. The aims of this prospective
study were to evaluate the interest in clinical practice of this concept and the
resources needed for its implementation.
Methods: We chose to include patients aged 65 years or over admitted to the
internal medicine unit of a military hospital in France between Jun and Oct 2010. We
obtained an accurate list of each patient's home medications. This list was then
compared with medication orders. All medication variances were classified as
intended or unintended. An internist and a pharmacist classified the clinical
importance of each unintended variance.
Results: 61 patients (mean age 78 +/- 7.4 years) were included in our study. We
identified 38 unintended discrepancies. The average number of unintended
discrepancies was 0.62 per patient. 25 patients (41%) had one or more unintended
discrepancies at admission. Contacting the community pharmacist permitted us to
identify 21 (55%) unintended discrepancies. The most common errors were the
omission of a regularly used medication (76%) and an incorrect dosage (16%). Our
intervention resulted in order changes by the physician for 30 (79%) unintended
discrepancies. 50% of the unintended variances were judged by the internist and
76% by the pharmacist to be clinically significant.
Conclusions: Admission to hospital is a critical transition point for the continuity of
care in medication management. Medication reconciliation can identify and resolve
errors due to inaccurate medication histories
http://www.em-consulte.com/article/674030
Medication reconciliation and hypertension control
SD Persell, SC Bailey, J Tang, et al.
American Journal of Medicine Feb 2010;123(2):182.e9-182.e15
Discrepancies between the medical record and patient medication list are common,
but the relationship of discrepancies to chronic disease control has not been
established. A cross-sectional study of 315 adults with medically treated
hypertension from 6 safety-net clinics in 3 US states was performed to determine the
frequency and type of antihypertensive medication discrepancies between patientnamed antihypertensive medications and the medical record. The association
between medication discrepancies and uncontrolled blood pressure (140/90 mm Hg
or higher, or 130/80 mm Hg or higher if diabetes) was determined using multivariate
logistic regression models. Discrepancies were present for 75.2% of patients; 25.7%
of patients could not provide the name of any antihypertensive medication they took;
49.5% could name 1 or more antihypertensive medications but had discrepancies
between patient-reported antihypertensive medications and those listed in the
medical record. Both patients who were unable to name any of their antihypertensive
medications and patients with discrepancies between patient-named medications and
the medical record were significantly more likely to have uncontrolled blood pressure
than patients who named the same medications as the medical record in adjusted
analyses, adjusted risk ratios 1.66 (95% CI, 1.31-2.10) and 1.51 (95% CI, 1.112.07), respectively. 12% of patients reporting medications took antihypertensive
medication that altered potassium metabolism that was not in their medical record.
Concludes that, among patients at safety-net clinics, inability to name one's
antihypertensive medications and discrepancies between patient-reported
medications and the medical record were very common. Both were strongly
associated with inadequate hypertension control. Performing medication
reconciliation at the point of care may be an important way to identify patients at
high risk for inadequate disease control or safety problems.
http://www.amjmed.com/article/S0002-9343(09)00720-7/abstract
Evaluation of medication reconciliation in an ambulatory setting before and
after pharmacist intervention
L Peyton, K Ramser, G Hamann, D Patel, D Kuhl, L Sprabery, B Steinhauer
Journal of the American Pharmacists Association Jul-Aug 2010;50(4):490-495
Objectives: To determine the accuracy of medication reconciliation in an internal
medicine clinic and to evaluate pharmacist interventions targeted at improving the
accuracy of medication reconciliation.
Design: Prospective case series.
Setting: Memphis, TN, USA, from Oct 2007 to Mar 2008.
Patients: 180 adults attending an internal medicine appointment.
Intervention: On patient arrival, a nurse completed the medication reconciliation
form. In Phase 1 of the study, a pharmacist randomly selected and reviewed a
patient's medication reconciliation form, interviewed the patient, and verified
information if indicated. A total of 90 forms were reviewed and compared to
determine baseline medication reconciliation accuracy. Education interventions were
held with the medical and nursing staff, targeting areas for improvement. In Phase
2 of the study, 90 additional medication reconciliation forms were reviewed in the
same manner. Phase 1 and Phase 2 results were compared to evaluate differences
in accuracy after the pharmacist's education interventions.
Main outcome measures: Accuracy of medication reconciliation forms and number of
potentially significant errors at baseline and after pharmacist interventions.
Results: In Phase 1, 14.4% of medication reconciliation forms were correct. The
remaining forms contained 190 potentially significant errors. After the education
interventions, 18.9% of medication reconciliation forms were correct and the others
contained 139 potentially significant errors.
Conclusions: Medication reconciliation accuracy is poor. Although education
interventions showed a trend toward improvement, continued education training for
staff and patients is needed in addition to other interventions to optimise this
process and prevent medication errors.
http://japha.metapress.com/openurl.asp?genre=article&id=doi:10.1331/JAPhA.2010.09055
Assessing the accuracy of drug profiles in an electronic medical record
system of a Washington State hospital
B Platte, F Akinci, Y Guc
American Journal of Managed Care Oct 2010;16(10):e245-e250
Objectives: To determine the accuracy of patients' electronic medical record (EMR)
drug profiles, to assess the relationship of copayment status with errors of
commission and omission within drug profiles, and to evaluate the association
between errors of commission in primary and secondary sections of the drug profiles.
Study Design: Cross-sectional analysis of patients' EMR drug profiles at a 46-bed
hospital in Washington state, USA, that treats more than 11,000 patients per year
and uses a medication reconciliation programme.
Methods: Patients' drug profiles were compared against hospital staff interviews.
Drug profiles listing each medication the patient was taking, without listing drugs the
patient was not taking, exhibited perfect accuracy. We evaluated associations
between errors of commission and omission, copayment status between errors of
commission and omission, and associations between errors of commission in primary
and secondary sections of the drug profiles.
Results: Demographics of study patients are similar to previously published research,
and accuracy outcomes seem to be better than those of previously published
studies. 56% of drug profiles in our study hospital exhibited perfect accuracy.
Errors of commission and omission were unassociated with copayment status; errors
of commission in the primary section of the drug profile were unassociated with
errors of commission in the secondary section of the drug profile.
Conclusions: A medication reconciliation programme might have led to a high rate of
perfectly accurate drug profiles; while its purpose is to increase accuracy and to
decrease errors, it may also assist in reducing adverse drug events. Results show
that copayment amounts influence drug utilisation; these may be associated with
errors of commission and omission and not simply with copayment status.
(15 refs.)
http://www.ajmc.com/articles/AJMC_10octPlatte_eXcl_e245to250
Evaluation of the quality of pharmaceutical records used for inpatients
admitted to a general hospital
(Évaluation de la qualité des dossiers pharmaceutiques utilisés pour les patients hospitalisés
dans un hôpital général)
E Prevost, K Mangerel, P Vonna, I Garreau, M-F Beck-Cantin, M Juste
Pharmacien Hospitalier et Clinicien Dec 2011;46(4):231-244
Since Oct 2004 at a hospital in Epernay, France, a pharmaceutical record has been
created for each patient admitted to one of seven wards using unit dose packaging
for inpatient medications orders. The aim of this study was to evaluate
the completeness and the quality of information contained in these records. On a
given day, all pharmaceutical records from a ward were evaluated by two
pharmacists during prescription analysis. The following data were sought: patient
characteristics, medication history, therapeutic drug monitoring. Explanations and
the consequences of lack of information were discussed with each ward pharmacist.
Out of 107 pharmaceutical records analysed, patient characteristics were complete
for only 7%, medication history for 15% and therapeutic follow-up for 31%. The
main explanations for the lack of information in pharmaceutical records were
the failure of the referring pharmacist to seek information (31%) or the lack of data
in the patient record (25%). For 39% of records where information were lacking,
pharmaceutical interventions were delayed. The quality of records can be improved,
mainly as regards the collection of patient data and drug history. Pending
computerisation of patient files that could permit greater exchange of information,
the pharmacy team has modified their paper record model.
http://www.lepharmacienhospitalier.fr/article/678623
Implementing medication reconciliation in outpatient pediatrics
DI Rappaport, B Collins, A Koster, A Mercado, J Greenspan, S Lawless, J Hossain, I Sharif
Pediatrics Dec 2011;128(6):e1600-e1607
Objective: To describe the implementation of a system-wide, electronic medical
record (EMR)-based quality improvement intervention targeting medication
reconciliation (MedRec) in outpatient paediatrics and to test variables associated with
the performance of MedRec.
Methods: This was a retrospective study using serial cross-sections of outpatient
paediatric visits over a 5-year period set in a multispecialty children's integrated
health care network in Florida, Delaware, Pennsylvania and New Jersey, USA. We
reviewed 2,745,523 outpatient paediatric visits between 2005 and 2010. In 2007,
the performance of MedRec was identified as critical to improving patient safety at
our organisation. A comprehensive intervention involved changes in the EMR,
automated generation of medication lists, educational modules and provider
compliance reports. In 2009, quality-based financial incentives to physicians to
perform MedRec were added. The outcome measure was documentation of MedRec
performance.
Results: MedRec improved consistently over time, from a nadir of 0% in 2005 to a
maximum of 71% in 2010. Performance of MedRec varied according to practice
location as the intervention was rolled out. Throughout the study period,
documentation of MedRec was consistently less likely for sick visits (adjusted odds
ratio (aOR) for each year ranged from 0.44 to 0.68) but more likely if the provider
placed a medication order during the visit (aOR: 1.70 to 2.15). Beginning in 2009,
visits with providers eligible for the quality-based financial incentive were more likely
to have had MedRec performed (aOR: 2.02 in 2009 and 2.31 in 2010).
Conclusions: A system-wide, EMR-based, outpatient paediatric quality improvement
intervention was successful in improving documentation of the performance of
MedRec, a national patient safety goal.
http://pediatrics.aappublications.org/content/128/6/e1600.abstract
What errors can be identified by pharmacy-led medicines reconciliation? A
prospective study
M Richards, D Ashiru-Oredope, N Chee
Acute Medicine 2011;10(1):18-21
Aim: To establish the nature and frequency of discrepancies identified by pharmacy
staff during medicines reconciliation (MR).
Methods: Pharmacy staff collected data prospectively from 161 patients over a 1week period, including information on any prescription errors identified.
Results: In total, 62 patients (48%) taking one or more medications prior to
admission to hospital had one or more discrepancies found by pharmacy staff during
MR. The most common discrepancy was omission of one or more drugs.
Conclusions: Pharmacy staff identified several unintentional discrepancies in
prescribing of medications at admission to hospital. Doctors should ensure that
intentional changes to patient prescriptions are clearly documented.
http://www.rila.co.uk/site/modules.php?name=Journals&file=journal2&func=showab&jid=0
30&aid=5826&iid=506
Improving medication safety in chronic kidney disease patients on dialysis
through medication reconciliation
WL St Peter
Advances in Chronic Kidney Disease Sep 2010;17(5):413-419
Patients with chronic kidney disease on dialysis are prescribed an average of 10 to
12 medications. Most haemodialysis patients encounter health care professionals 3
times a week, and peritoneal dialysis patients at least once a quarter; however,
medication-related problems continue to be present in large numbers. A significant
proportion of medication-related problems in hospitalised dialysis patients have been
attributed to a medical information gap that occurs during transitions between
healthcare settings. Information regarding the effect of medication reconciliation on
the rates of medication-related errors and outcomes of dialysis patients is sparse.
Information from hospital-based medication reconciliation programmes suggests that
dedicated multidisciplinary medication reconciliation teams using electronic or paperbased medication reconciliation tools can work to reduce medication errors and rates
of rehospitalisation. The dialysis centre staff has intimate knowledge of patient
medical histories, comorbid conditions, and dialysis-related medications; dialysis
centre practitioners are known to often prescribe other routine medications for
patients undergoing dialysis. Therefore, the dialysis centre is the most logical place
for carrying out medication reconciliation. Data necessary for medication review and
reconciliation, and data on the dialysis team's role in reconciling information after
care transitions, have been outlined. Reducing medication errors through a
systematic multidisciplinary approach may ultimately reduce hospitalisation rates.
Adequately powered trials are necessary to demonstrate that medication
reconciliation can improve dialysis patient outcomes and cost.
http://www.ackdjournal.org/article/S1548-5595(10)00112-6/abstract
Development of a tool within the electronic medical record to facilitate
medication reconciliation after hospital discharge
JL Schnipper, CL Liang, C Hamann, AS Karson, MB Palchuk, PC McCarthy, M Sherlock, A
Turchin, DW Bates
Journal of the American Medical Informatics Association May 2011;18(3):309-313
Serious medication errors occur commonly in the period after hospital discharge.
Medication reconciliation in the post-discharge ambulatory setting may be one way
to reduce the frequency of these errors. The authors describe the design and
implementation of a novel tool built into an ambulatory electronic medical record
(EMR) to facilitate post-discharge medication reconciliation. The tool compares the
preadmission medication list within the ambulatory EMR to the hospital discharge
medication list, highlights all changes, and allows the EMR medication list to be easily
updated. As might be expected for a novel tool intended for use in a minority of
visits, use of the tool was low at first: 20% of applicable patient visits within 30 days
of discharge. Clinician outreach, education and a pop-up reminder succeeded in
increasing use to 41% of applicable visits. Review of feedback identified several
usability issues that will inform subsequent versions of the tool and provide
generalisable lessons for how best to design medication reconciliation tools for this
setting
http://jamia.bmj.com/content/18/3/309.abstract
An in-depth analysis of medication errors in hospitalized patients with HIV
AM Snyder, K Klinker, JJ Orrick, J Janelle, AG Winterstein
Annals of Pharmacotherapy Apr 2011;45(4):459-468
Background: It is well recognised that medication errors occur and can affect success
in treating patients with HIV/AIDS. However, little information is available describing
the prevalence, nature, and causes of medication errors.
Objective: To determine the incidence of combination antiretroviral therapy (ART)and opportunistic infection (OI)-related medication errors and describe the nature
and cause(s) of errors to guide future interventions.
Methods: A daily antiretroviral utilisation report was used to identify adults who were
receiving ART and had been admitted to a tertiary care teaching hospital during 2
consecutive months in 2005. Patients' charts, medication profiles and medication
administration records were reviewed for medication errors such as improper dosing,
interactions, drug omissions and missing doses. Once identified, aetiology and cause
were further investigated through provider interviews. An interdisciplinary team
reviewed each case to establish validity of the error, severity and cause.
Results: 69 combined ART- and OI-related medication errors were identified in 20 of
26 (77%) evaluated patients, with 2.7 medication errors per patient. 54% of the
errors occurred within the first 24 hours after admission. Inadequate medication
reconciliation on admission caused 21 of 37 (57%) admission-related errors. The
most prevalent error types included missing doses (20%), underdosing (13%),
overdosing (13%), therapy omission (13%) and drug-drug interaction (12%). The
primary cause of errors was provider lack of knowledge.
Conclusions: Prospective investigation of medication errors provided in-depth insight
into the diverse nature of HIV-related medication errors, risk factors and potential
preventive strategies. System changes such as hard stops in the clinical decision
support software and improved medication reconciliation training, and changes in
cart-fill time could prevent specific types of errors. Further studies are warranted to
evaluate the impact of various strategies for preventing medication errors in the HIV
population.
http://www.theannals.com/content/45/4/459.abstract
Quality of recollection of home medication in the emergency department:
reconciliation discrepancies
(Calidad de la recogida de la medicación domiciliaria en urgencias: discrepancias en la
conciliación)
E Soler-Giner, M Izuel-Rami, I Villar-Fernandez, JM Real Campana, P Carrera Lasfuentes, MJ
Rabanaque Hernandez
Farmacia Hospitalaria Jul-Aug 2011;35(4):165-171
Introduction: The objective of the study was to assess home medication data
collected at the emergency department of a tertiary hospital in Spain. It also aimed
to identify whether any possible deficiencies in this collection were translated into
reconciliation errors on admission, to analyse and classify these data and identify the
pharmacological groups involved.
Method: A prospective observational study was carried out which analysed the
pharmacotherapeutic data collected at the emergency department. Patients who
were admitted to the pneumology and internal medicine wards at the Miguel Servet
University Hospital in Zaragoza, Spain. were included. A list of the home drugs
taken before the hospital stay was compiled, assessing whether quality deficiencies
in data collected in the emergency department translated into reconciliation errors at
admission. Unjustified discrepancies were considered and classified in line with the
criteria of the consensus document on terminology, classification and assessment of
the drug reconciliation programmes for 2009.
Results: We included 136 patients, finding reconciliation errors in 86.8%. The total
number of reconciliation errors found was 519. The most frequent types were:
omitting a drug, missing dose information, missing administration frequency
information. Nearly 40% of the reconciliation errors found in the internal medicine
ward were not resolved, which was double the total for the pneumology ward. Most
discrepancies were found for the Digestive System and Metabolism group (24%).
Conclusions: The percentage of patients who experienced reconciliation errors was
high (86%), highlighting an important opportunity to improve processes at patient
admission to the emergency department.
http://www.sciencedirect.com/science/article/pii/S113063431100033X
Medication history reconciliation by clinical pharmacists in elderly
inpatients admitted from home or a nursing home
S Steurbaut, L Leemans, T Leysen, E De Baere, P Cornu, T Mets, AG Dupont
Annals of Pharmacotherapy Oct 2010;44(10):1596-1603
Background: Accurate medication histories at hospital admission are an important
element of medication safety. Discrepancies may have clinically significant
consequences, especially in the elderly population.
Objective: To assess the clinical pharmacist's performance in obtaining patients'
medication histories and in reconciling these data with the medical records and
medication orders and whether the patients' residential situation prior to
hospitalisation influences the number of drug discrepancies.
Methods: A prospective observational study was conducted at a 29-bed acute
geriatric ward of a Belgian university hospital. Medication histories acquired by
clinical pharmacists were compared with those documented in the medical records by
the attending physicians. All discrepancies were identified and categorized by an
independent pharmacist and were scored for their clinical relevance in consensus by
a senior internist and a senior geriatrician.
Results: Of the 215 screened geriatric (aged 65 years or older) patients admitted
between 27 Oct 2007 and 23 Sep 2008, 197 were enrolled in the study. For patients
living in the community, as well as those residing in a nursing home prior to
hospitalization, clinical pharmacists identified significantly more preadmission drugs
compared with physicians, with a median number of 8 correctly identified
medications versus 6, respectively (p less than 0.001). Extra drugs identified
included over-the-counter as well as prescription medications. Furthermore, 117
other medication discrepancies were noted, mainly related to erroneous drug
identification and incorrect drug dose. In all, the clinical pharmacists identified 379
(24.2%) medication discrepancies, of which 188 (49.6%) were judged clinically
relevant.
Conclusions: Pharmacist-acquired medication histories enhance the medication
reconciliation process, both in patients residing at home and in a nursing home prior
to hospitalisation. A focus should be placed on seamless care procedures that
facilitate the transfer of medication histories between primary and secondary care in
both of these populations.
http://www.theannals.com/cgi/content/abstract/44/10/1596
Medication discrepancies identified at time of hospital discharge in a
geriatric population
DM Stitt, DP Elliott, SN Thompson
American Journal of Geriatric Pharmacotherapy Aug 2011;9(4):234-240
Background: It has been reported that 14.1% of geriatric patients experience one or
more medication discrepancies after hospitalisation.
Objective: The goal of this study was to identify and characterise discharge
medication list discrepancies among geriatric patients and to describe characteristics
associated with discrepancies.
Methods: An institutional review board-approved retrospective review was conducted
of patients aged 65 years or older discharged from hospitalist and internal medicine
services at a large tertiary care hospital in the USA from Aug 2008 to Dec 2009. A
random cohort of 200 patients was selected and categorised by age, gender,
attending medical service, and the absence or presence of a pharmacist on the
service. Medication lists were obtained from physician discharge summaries,
discharge orders and nursing discharge lists.
Results: A total of 1923 medication discrepancies were identified, consisting of 402
related to the absence or presence of a medication, 298 related to the dosage
administered at one time, 223 related to the number of daily doses and 1000 related
to the route of administration. Physician discharge summaries contained the most
medication discrepancies. There was no relationship between patient age and the
number of medication discrepancies (r2 = 0.006; P = 0.279), whereas there was a
linear relationship between the number of medications and the number of
discrepancies (r2 = 0.249; P less than 0.001). The internal medicine team with a
pharmacist had a lower average number of discrepancies per patient compared with
other medicine services that did not have a pharmacist present.
Conclusions: Medication discrepancies at the time of hospital discharge are a
common occurrence for geriatric patients. Physician summaries might be the least
reliable source of discharge medication lists. The number of discrepancies appears
to not be associated with patient age, but rather with the number of medications at
discharge. Discrepancies among medication lists are common, and the presence of a
pharmacist may reduce the number that occur.
http://www.sciencedirect.com/science/article/pii/S1543594611001152
Hospital admission medication reconciliation in medically complex
children: an observational study
BL Stone, S Boehme, MB Mundorff, CG Maloney, R Srivastava
Archives of Disease in Childhood Apr 2010;95(4):250-255
Objective: To evaluate admission medication reconciliation in children with medically
complex conditions (MCC) by determining the availability and accuracy of 5
information sources and characterising admitting order errors.
Design: Prospective quality improvement cohort study.
Setting: Tertiary care free-standing children's hospital in the Intermountain west,
USA.
Participants: 23 children with MCC identified from 219 admissions between 16 Dec
2004 and 7 Jan 2005.
Intervention: Medication reconciliation at hospital admission using information
from 5 sources.
Main outcomes: The accuracy of information sources was determined by sensitivity
and specificity compared with verified outpatient medication lists. Errors were
determined by comparing admitting orders with reconciled inpatient medication lists
and categorised by frequency, type and clinical risk.
Results: Children with MCC averaged 5.3 chronic medications. The reconciliation
process took an average of 90 min. Availability/sensitivity/specificity respectively
were parents 52%/0.75/0.96, pharmacy 61%/0.64/0.74, primary provider
43%/0.25/0.86, last admission electronic health record 87%/0.74/0.33 and
admitting history 65%/0.31/0.94. 39 errors were identified in 182 admission
medications (21%) including 17 omissions, affecting 13 patients (57%). The
estimated clinical risk, if an adverse drug event had occurred, was serious or lifethreatening in 5 instances.
Conclusions: In children with MCC admitted at our institution during the study
period, no medication information source was optimally available, sensitive and
specific. Admitting order medication errors affected more than half of patients, the
most common being omissions. Efforts to improve medication reconciliation at
hospital admission in this population must account for availability and accuracy of
information sources and medication omissions at the time of hospital admission.
http://adc.bmj.com/content/95/4/250.abstract
Clinical significance of medication reconciliation in children admitted to a
UK pediatric hospital: observational study of neurosurgical patients
DRP Terry, GA Solanki, AG Sinclair, JF Marriott, KA Wilson
Pediatric Drugs Oct 2010;12(5):331-337
Background: In Dec 2007, the National Institute for Health and Clinical Excellence
and the National Patient Safety Agency in the UK (NICE-NPSA) published guidance
that recommends all adults admitted to hospital receive medication reconciliation,
usually by pharmacy staff. A costing and report tool was provided indicating a
resource requirement of GBP 12.9 million for England per year. Paediatric patients
are excluded from this guidance.
Objective: To determine the clinical significance of medication reconciliation in
children on admission to hospital.
Methods: A prospective observational study included paediatric patients admitted to
a neurosurgical ward at Birmingham Children's Hospital, Birmingham, England,
between Sep 2006 and Mar 2007. Medication reconciliation was conducted by a
pharmacist after the admission of each of 100 consecutive eligible patients aged 4
months to 16 years. The clinical significance of prescribing disparities between preadmission medications and initial admission medication orders was determined by an
expert multidisciplinary panel and quantified using an analogue scale. The main
outcome measure was the clinical significance of unintentional variations between
hospital admission medication orders and physician-prescribed pre-admission
medication for repeat (continuing) medications.
Results: Initial admission medication orders for children differed from prescribed preadmission medication in 39% of cases. Half of all resulting prescribing variations in
this setting had the potential to cause moderate or severe discomfort or clinical
deterioration. These results mirror findings for adults.
Conclusions: The introduction of medication reconciliation in children on admission to
hospital has the potential to reduce discomfort or clinical deterioration by reducing
unintentional changes to repeat prescribed medication. Consequently, there is no
justification for the omission of children from the NICE-NPSA guidance concerning
medication reconciliation in hospitals, and costing tools should include paediatric
patients.
http://adisonline.com/pediatrics/Abstract/2010/12050/Clinical_Significance_of_Medication_
Reconciliation.5.aspx
Pharmacy–nursing intervention to improve accuracy and
completeness of medication histories
EG Tessier, EA Henneman, B Nathanson, K Plotkin, M Heelon
American Journal of Health-System Pharmacy 15 Apr 2010;67(8):607,608,610,611
A step-by-step approach to collecting medication histories for use by the staff nurse
as part of the initial patient assessment and to facilitate open-ended inquiry about
patients' medication use. The six-step approach was peer reviewed by content
experts who practice in acute care, chronic care, ambulatory care and home care
settings. The tool (reproduced in the article) was evaluated first in a controlled
academic setting with senior nursing students and later in the clinical setting in two
acute care hospitals in the USA. (14 refs.)
http://www.ajhp.org/content/67/8.toc
A practical approach to medication reconciliation by pharmacists in a
community hospital emergency department
M C Thomas
Hospital Pharmacy Jan 2010;45(1):41-44
Purpose: The purpose of this paper is to describe the process of medication
reconciliation by an emergency department (ED) pharmacist.
Summary: The ED pharmacist has many opportunities to interact with patients.
Medication reconciliation by a pharmacist helps ensure a complete and accurate list
of medications is obtained and documented. The process can be broken down into 3
categories—database, validation, and documentation. The database and validation
steps involve gathering and confirming information related to medications patients
are taking. These are the most challenging and time-consuming steps. The database
step involves gathering current and previous information about the patient and using
clinical skills to ensure a patient’s medical problems are adequately treated. Many
times patients do not know their medications well enough to provide the necessary
information. To overcome this barrier, calls to pharmacies, physician offices, and
other health care facilities may be necessary. At times, the use of electronic drug
information databases to show patients images of medications is necessary for
validation. Standard questions have been developed that probe patients on
medications commonly left off of medication lists. The documentation step completes
the process because it demonstrates a complete and accurate medication list for the
patient’s next health care provider.
Conclusion: The process of medication reconciliation is more than a translation of a
medication list. Clinical skills are often necessary to ensure medication reconciliation
is performed accurately and completely. Following the process of database,
validation, and documentation helps ensure optimal pharmaceutical care.
http://thomasland.metapress.com/content/y167146pm71774k2/fulltext.pdf
Inpatient medication reconciliation at admission and discharge: a
retrospective cohort study of age and other risk factors for medication
discrepancies
K Tschantz Unroe, T Pfeiffenberger, S Riegelhaupt, J Jastrzembski, Y Lokhnygina, C ColonEmeric
American Journal of Geriatric Pharmacotherapy Apr 2010;8(2):115-126
Background: Medication discrepancies are unintended differences between
medication regimens (i.e. between a patient's home regimen and medications
prescribed on admission to the hospital).
Objective: The goal of this study was to describe the incidence, drug classes and
probable importance of hospital admission medication discrepancies and discharge
regimen differences, and to determine whether factors such as age and specific
hospital services were associated with greater frequency of medication discrepancies
and differences.
Methods: This was a retrospective cohort study of a random sample of adult patients
admitted to the general medicine, cardiology or general surgery services of a tertiary
care academic teaching hospital in the USA between 1 Jul 2006 and 31 Aug 2006. A
chart review was performed to collect the following information: patient demographic
characteristics, comorbid conditions, number of preadmission medications,
discrepant medications identified by the hospital's reconciliation process, reasons for
the discrepancies, and discharge medications that differed from the home regimen.
Potentially high-risk discrepancies and differences were identified by determining if
the medications were included on either the Institute for Safe Medication Practices
high-alert list or the North Carolina Narrow Therapeutic Index list. Univariate and
multivariate logistic regression analyses were used to identify factors associated with
medication discrepancies and differences.
Results: Of the 205 patients (mean age, 59.9 years; 116 men, 89 women; 60%
white) included in the study, 27 did not have any medications recorded on
admission. Of the 178 patients who did have medications listed, 41 had 1 or more
discrepancy identified by the reconciliation process on admission (23%; 95% CI, 17–
29); 19% (95% CI, 11–31) of these medications were considered to be potentially
high risk. In the multivariate logistic regression model, age (odds ratio (OR) per 5year increase = 1.16; 95% CI, 1.01–1.33; P = 0.035), presence of high-risk
medications on admission (OR = 76.68; 95% CI, 9.13-643.76; P less than 0.001),
and general surgery service (OR = 3.31; 95% CI, 1.40-7.87; P less than 0.007)
were associated with a higher proportion of patients with discrepancies on admission.
At discharge, 196 patients (96%; 95% CI, 93-98) had 1 or more medication change
from their home regimen, with 1102 total differences for 205 patients. Less than
half (44%; 95% CI, 37-51) of these patients were explicitly alerted at discharge to
new medications or dose changes; 12% (95% CI, 7–18) were given written
instructions to stop taking discontinued home medications. Cardiovascular drugs
were the most frequent class involved at both admission (31%) and discharge (27%)
in medication discrepancies or differences.
Conclusions: Medication discrepancies on admission and medication differences at
discharge were prevalent for adult patients admitted to the general medicine,
cardiology and general surgery services in this academic teaching hospital.
Medication reconciliation processes have a high potential to identify clinically
important discrepancies for all patients.
http://dx.doi.org/10.1016/j.amjopharm.2010.04.002
Medication reconciliation: identifying medication discrepancies in acutely
ill hospitalized older adults
D Villanyi, M Fok, RYM Wong
American Journal of Geriatric Pharmacotherapy Oct 2011;9(5):339-344
Background: Medication discrepancies may occur during transitions from community
to acute care hospitals. The elderly are at risk for such discrepancies due to multiple
comorbidities and complex medication regimens. Medication reconciliation involves
verifying medication use and identifying and rectifying discrepancies.
Objective: The aim of this study was to describe the prevalences and types of
medication discrepancies in acutely ill older patients.
Methods: Patients who were aged 70 years or older and were admitted to any of 3
acute care for elders (ACE) units in Canada over a period of 2 nonconsecutive
months in 2008 were prospectively enrolled. Medication discrepancies were
classified as intentional, undocumented intentional, and unintentional. Unintentional
medication discrepancies were classified by a blinded rater for potential to harm.
This study was primarily qualitative, and descriptive (univariate) statistics are
presented.
Results: 67 patients (42 women; mean +/- SD age, 84.0 +/- 6.5 years) were
enrolled. There were 37 unintentional prescription-medication discrepancies in 27
patients (40.3%) and 43 unintentional over-the-counter (OTC) medication
discrepancies in 19 patients (28.4%), which translates to Medication Reconciliation
Success Index (MRSI) of 89% for prescription medications and 59% for OTC
medications. The overall MRSI was 83%. More than half of the prescriptionmedication discrepancies (56.8%) were classified as potentially causing
moderate/severe discomfort or clinical deterioration.
Conclusions: Despite a fairly high overall MRSI in these patients admitted to ACE
units, a substantial proportion of the prescription-medication discrepancies were
associated with potential harm.
http://dx.doi.org/10.1016/j.amjopharm.2011.07.005
Beliefs of ambulatory care physicians about accuracy of patient medication
records and technology-enhanced solutions to improve accuracy
DL Weeks, CF Corbett, G Stream
Journal for Healthcare Quality Sep-Oct 2010;32(5):12-21
The continuing problem of inaccurate medication records and resultant harm from
medication errors has prompted the Institute of Medicine and others to encourage
information technology (IT) solutions to improve medication list accuracy. There are
few studies on how ambulatory care documentation contributes to medication list
inaccuracies and medication reconciliation failures. To address medication
reconciliation issues in ambulatory care, office-based physicians in a region of the
USA with a high adoption rate for electronic medical records (EMRs) were surveyed
about current reconciliation practices, the need for redesigning reconciliation
processes, and acceptable IT solutions for improving availability of medication
information. Physicians selected from a list of potential IT platforms that would
create a single reconciled record of prescription medications, nonprescription
medications, and supplements accessible wherever patients go. The two most
popular platforms were either an aggregated list within existing EMRs accessible by
inpatient and outpatient providers regardless of their EMR system, or a web-based
repository that was not integrated into an EMR. Respondents felt that
implementation of such platforms would not require major changes to clinical
workflow, perhaps due to the region's existing familiarity with health IT. Leveraging
community acceptance of health IT could result in rapid implementation of
universally accessible medication list platforms.
http://onlinelibrary.wiley.com/doi/10.1111/j.1945-1474.2010.00097.x/abstract
Multidose drug dispensing and discrepancies between medication records
LJ Wekre, O Spigset, O Sletvold, J Kutschera Sund, A Grimsmo
Quality and Safety in Health Care 2010; doi:10.1136/qshc.2009.038745 (published early
online 4 Aug 2010)
Background: The objective of this study was to investigate whether implementation
of multidose drug dispensing (MDD) for elderly outpatients is associated with a
change in the number of discrepancies in the medication record at the general
practitioners (GPs) and at the community home-care services in Trondheim, Norway.
Methods: A controlled follow-up study with paired design of patients' medication
records was performed during implementation of MDD. Medication records from the
home care units and from the GPs were reviewed, and the discrepancies were noted.
The discrepancies were rated into four classes based upon the potential harm, and a
risk score system was applied, giving the potentially most harmful discrepancies the
highest score.
Results: Medication records from 59 patients with a mean age of 80 years were
included. The number of discrepancies was reduced from 203 to 133 (p less than
0.001), and the total risk score decreased from 308 to 181 (p less than 0.001) after
the implementation of MDD. For both drugs subject to MDD and drugs not suitable
for MDD, the reductions in discrepancies were significant (39% and 31% reduction
respectively).
Conclusions: Calculated health risk due to discrepancies between the medication
records from the home-care service and from the GPs decreased during the time of
implementation of the MDD system. It seems likely that most of the positive effect
was caused by the change in routines and enhanced focus on the medication process
rather than by MDD per se.
http://qualitysafety.bmj.com/content/early/2010/08/04/qshc.2009.038745.full.pdf
Utilising improvement science methods to optimise medication
reconciliation
CM White, PJ Schoettker, PH Conway, M Geiser, J Olivea, R Pruett, UR Kotagal
BMJ Quality and Safety Apr 2011;20(4):372-380
Background: In 2005, the Joint Commission included medication reconciliation as a
National Patient Safety Goal in the USA to reduce medication errors related to
omissions, duplications and interactions. Hospitals continue to struggle to implement
successful programmes that meet these objectives.
Methods: The authors used improvement methods and reliability principles to
develop and implement a process for medication reconciliation completion at
admission at a large, paediatric medical centre in the USA. Medication reconciliation
was defined as recording a complete and accurate list of each patient's medications
within 20 min of admission by the nurse and reconciliation of those medications
within 24 hours of admission by the physician. Interventions focused on five main
areas: leadership and support from senior physicians and nurses to sustain a culture
of safety; simplification and standardisation of the electronic medication
reconciliation application; clarifying roles and responsibilities; creating a highly
reliable and visible system; and sustainability.
Results: At baseline, only 62% of patients had their medications reconciled within 24
hours of admission. Over a 9-month period, 90% or more medication reconciliations
were achieved within 24 hours of admission. These results have been sustained for
27 months.
Conclusions: Through the use of improvement methods and reliability science, a
sustainable process for medical reconciliation completion at admission was
successfully achieved at a large, busy academic children's hospital.
http://qualitysafety.bmj.com/content/20/4/372.full.pdf
Addition of a clinical pharmacist to an inpatient family medicine service
CD Williams, JC Marrs, SA Fields
American Journal of Health-System Pharmacy 15 Jun 2010;67(12):965-966
Letter reporting the effects of adding a clinical pharmacist position to the family
medicine inpatient service at Oregon Health and Science University hospital, for
activities including medication reconciliation on newly admitted patients, inpatient
medication management and discharge reconciliation with both primary providers
and outpatient pharmacies. The new pharmacist service is believed to have played a
role in a reduction of patient admissions from outpatient clinics. (8 refs.)
http://www.ajhp.org/content/67/12.toc
Evaluating the impact of a pharmacy medicines reconciliation service at an
orthopaedic pre-admission clinic
S Williams, S Jones, K Hodson
British Journal of Clinical Pharmacy Jan 2011;3(1):23-26
Aims: To evaluate the impact of a pharmacist undertaking medicines reconciliation at
an orthopaedic preadmission clinic (PAC) on the number and types of medicinesrelated errors and omissions on admission to hospital.
Methods: A two-phase study was devised. In phase one, the number and type of
interventions made by a pharmacist during medicines reconciliation at the PAC was
recorded. A comparative analysis of the interventions needed at admission for
patients whose medicines reconciliation had been undertaken by a pharmacist in the
PAC (the active arm) and those whose had not (the control arm) was then
undertaken. In phase two, the clinical significance of the interventions was assessed
by 8 senior healthcare professionals working within the field of elective surgery at
the University Hospital Llandough.
Results: The number of patients whose medication regimen required at least one
intervention at ward level reduced from 89.7% (61/68) in the control arm to 18.1%
(15/83) in the active arm. Although complete agreement between assessors was not
obtained, all interventions were classed to be of clinical significance by 6 of the 8
assessors. The mean time spent making and resolving (or attempting to resolve)
interventions by the ward pharmacist reduced from 8.1 minutes in the control arm to
2.2 minutes in the active arm.
Conclusions: Pharmacy involvement at the PAC led to a significant reduction in the
number of interventions required at admission and was therefore likely to have
improved patient safety.
http://www.clinicalpharmacy.org.uk/home
Drug certainty-response in interview-based studies
W-P Yau, KJ Lin, MM Werler, C Louik, AA Mitchell, S Hernandez-Díaz
Pharmacoepidemiology and Drug Safety Nov 2011;20(11):1210-1216
Purpose: Imperfect recall of exposure timing challenges the ascertainment of
medications in interview-based studies.
Methods: We propose an algorithm to classify medication exposure, taking into
account recall certainty. The availability of medication use details, including duration
of use, start and stop dates, and maternal estimates of how certain they were about
these dates, allowed classification of subjects as either likely or possibly exposed in
the first trimester of pregnancy. We applied the algorithm to study an association
between prenatal tetracycline exposure and risk of congenital heart defects
previously reported by the National Birth Defects Prevention Study, using 1993-2008
data from 11,517 subjects in the Slone Epidemiology Center Birth Defects Study.
Results: Among women exposed to tetracyclines during pregnancy (n = 58), 50%
and 19% were likely and possibly exposed, respectively, in the first trimester, and
31% were exposed outside the first trimester. Compared with non-use during
pregnancy, the crude OR for exposure outside the first trimester was 1.0 (95% CI,
0.4 to 2.5), and that for exposed (likely or possibly, combined) in the first trimester
was 1.7 (95% CI, 0.9 to 3.2); however, the ORs based on the algorithms were 0.9
(95% CI, 0.3 to 3.0) for possibly exposed and 2.2 (95% CI, 1.0 to 4.6) for likely
exposed.
Conclusions: A 'certainty-response' (stronger association with higher level of
certainty) was found within exposures in the window of aetiological interest.
Algorithms for exposure classification that incorporate recall certainty may be useful
in interview-based studies.
http://onlinelibrary.wiley.com/doi/10.1002/pds.2234/abstract