Developing a programme for medication reconciliation at the time of admission into hospital

Electronic Medication Reconciliation Tools Aimed at Healthcare Professionals to Support Medication Reconciliation: a Systematic Review

The development of health information technology available and accessible to professionals is increasing in the last few years. However, a low number of electronic health tools included some kind of information about medication reconciliation. To identify all the electronic medication reconciliation tools aimed at healthcare professionals and summarize their main features, availability, and clinical impact on patient safety. A systematic review of studies that included a description of an electronic medication reconciliation tool (web-based or mobile app) aimed at healthcare professionals was conducted. The review protocol was registered with PROSPERO: registration number CRD42022366662, and followed PRISMA guidelines. The literature search was performed using four healthcare databases: PubMed, EMBASE, Cochrane Library, and Scopus with no language or publication date restrictions. We identified a total of 1227 articles, of which only 12 met the inclusion criteria.Through these articles,12 electronic tools were detected. Viewing and comparing different medication lists and grouping medications into multiple categories were some of the more recurring features of the tools. With respect to the clinical impact on patient safety, a reduction in adverse drug events or medication discrepancies was detected in up to four tools, but no significant differences in emergency room visits or hospital readmissions were found. 12 e-MedRec tools aimed at health professionals have been developed to date but none was designed as a mobile app. The main features that healthcare professionals requested to be included in e-MedRec tools were interoperability, "user-friendly" information, and integration with the ordering process.

Cost-effectiveness of medication reconciliation performed by a pharmacist in pediatrics of a hospital: A randomized clinical trial protocol linked to a pharmacoeconomic study

INTRODUCTION

Each patient admitted to the hospital is subject to one medication error per day, since the occurrence of this one with the potential to cause harm is three times more common in pediatric hospitalized patients than in adults. These harms can result from inaccurate or incomplete drug use histories when patients undergo a clinical evaluation, which jeopardizes patient safety and compromises hospitalization costs. Thus, medication reconciliation (MC) emerges as a possible solution to avoid the occurrence of these in pediatric patients and directly contributes to reducing costs in the hospital environment and increasing quality of life). Therefore, this study proposes to determine whether pharmacist-led medication reconciliation is a cost-effective strategy to improve health outcomes in pediatric patients.

METHODS

A randomized clinical trial will be carried out, over eight months, to carry out the cost analysis. Micro-costing pharmacoeconomic model through a questionnaire and clinical interview to collect the variables necessary for the study and comparison of the control and intervention groups. Participants in this study will be children aged 0 days to 12 years, admitted to the hospital. The perspective adopted will be that of the hospital. To assess the economic outcomes of MC, the cost-effect pairs will be categorized and visually represented in the cost-effectiveness plan to compare the intervention and control groups. Monte Carlo simulation and univariate sensitivity analysis will be performed to test the robustness of the findings.

ETHICS AND DISSEMINATION

The clinical trial was approved by the Research Ethics Committee of the Federal University of Sergipe (CAAE: 19625319.6.0000.5546 and opinion number: 3,630,579). This protocol fully adhered to the recommendations of the 2010 CONSORT Declaration and was registered in the Brazilian Registry of Clinical Trials (ReBEC): RBR-25dnqsk.

Medication discrepancies in transition of care of hospitalised children in Brazil: a multicentric study

OBJECTIVE

To determine the incidence of medication discrepancies in transition points of care of hospitalised children.

DESIGN

A prospective observational multicentre study was carried out between February and August 2019. Data collection consisted of the following steps: sociodemographic data collection, clinical interview with the patient's caregiver, review of patient prescriptions and evaluation of medical records. Medication discrepancies were classified as intentional (documented or undocumented) and unintentional. In addition, discrepancies identified were categorised according to the medication discrepancy taxonomy. Unintentional discrepancies were assessed for potential clinical harm to the patient.

SETTING

Paediatric clinics of four teaching hospitals in Brazil.

PATIENTS

Children aged 1 month-12 years.

FINDINGS

A total of 248 children were included, 77.0% (n=191) patients had at least one intentional discrepancy; 20.2% (n=50) patients had at least one unintended discrepancy and 15.3% (n=38) patients had at least one intentional discrepancy and an unintentional one. The reason for the intentional discrepancy was not documented in 49.6% (n=476) of the cases. The most frequent unintentional discrepancy was medication omission (54.1%; n=66). Low potential to cause discomfort was found in 53 (43.4%) unintentional discrepancies, while 55 (45.1%) had the potential to cause moderate discomfort and 14 (11.5%) could potentially cause severe discomfort.

CONCLUSIONS

Although most medication discrepancies were intentional, the majority of these were not documented by the healthcare professionals. Unintentional discrepancies were often related to medication omission and had a potential risk of causing harm to hospitalised children.

Prevalence of medication discrepancies in pediatric patients transferred between hospital wards

Background Children are more susceptible to harm from medication errors and adverse drug reactions when compared to adults. Such events may occur from medication discrepancies while transitioning patients throughout the healthcare system. Contributing factors include medication discontinuity and lack of information by the healthcare team. Objective To analyze the prevalence of medication discrepancies in transition points of care in a pediatric department. Setting Pediatric department of a public hospital in Northeast Brazil. Method A cross-sectional study was carried out from August 2017 to March 2018. Data collection consisted of the following steps: collection of sociodemographic data, clinical interview with the patient's caregiver, registration of patient prescriptions, and evaluation of medical records. Medication discrepancies were classified as intentional and unintentional. The unintentional medication discrepancies were classified as omission of medication, therapeutic duplicity, and differences in dose, frequency, or route of administration. Main outcomes measure Discrepancy profile identified at admission, internal transfer and hospital discharge. Results Among the 114 patients included in the study, 85 (74.5%) patients had at least one unintentional medication discrepancy, of which 16 (14.0%) patients presented medication discrepancies at hospital admission, 42 (36.8%) patients at internal transfer, and 52 (45.6%) patients during discharge. Omission of medication represented 20 (74.1%) errors at admission, 26 (37.7%) errors at internal transfer, and 80 (100.0%) errors at hospital discharge. Conclusions The main transition points of care where unintentional discrepancies occurred in the studied pediatric department were at internal transfer and hospital discharge, with omission being the most common type of unintentional discrepancy.

A web application to involve patients in the medication reconciliation process: a user-centered usability and usefulness study

Objective

Medication reconciliation (MedRec) can improve patient safety by resolving medication discrepancies. Because information technology (IT) and patient engagement are promising approaches to optimizing MedRec, the SEAMPAT project aims to develop a MedRec IT platform based on two applications: the "patient app" and the "MedRec app." This study evaluates three dimensions of the usability (efficiency, satisfaction, and effectiveness) and usefulness of the patient app.

Methods

We performed a four-month user-centered observational study. Quantitative and qualitative data were collected. Participants completed the system usability scale (SUS) questionnaire and a second questionnaire on usefulness. Effectiveness was assessed by measuring the completeness of the medication list generated by the patient application and its correctness (ie medication discrepancies between the patient list and the best possible medication history). Qualitative data were collected from semi-structured interviews, observations and comments, and questions raised by patients.

Results

Forty-two patients completed the study. Sixty-nine percent of patients considered the patient app to be acceptable (SUS Score ≥ 70) and usefulness was high. The medication list was complete for a quarter of the patients (7/28) and there was a discrepancy for 21.7% of medications (21/97). The qualitative data enabled the identification of several barriers (related to functional and non-functional aspects) to the optimization of usability and usefulness.

Conclusions

Our findings highlight the importance and value of user-centered usability testing of a patient application implemented in "real-world" conditions. To achieve adoption and sustained use by patients, the app should meet patients' needs while also efficiently improving the quality of MedRec.

Electronic medication reconciliation in hospitals: a systematic review and meta-analysis

OBJECTIVE

Medication reconciliation (MedRec) is recognised as a multiprofessional process for the prevention of medication discrepancies. The goal of this study is to evaluate the available electronic medication reconciliation (eMedRec) tools and their effect on unintended discrepancies that occur in hospital institutions.

METHOD

PubMed, EMBASE, the Cochrane Library, Web of Science, the ClinicalTrials.gov website and four other Chinese databases were searched for relevant studies starting from their inception through October 2017. Methodological quality was assessed using the nine standard criteria of Cochrane Effective Practice and Organisation of Care Review Group (EPOC) and meta-analysis was performed using RevMan5.3 software.

RESULTS

A total of 13 studies (three randomised controlled trials and 10 non-randomised controlled trials) were identified. Meta-analysis results demonstrated a reduced number of medications with unintended discrepancies (relative risk (RR)=1.85, 95% confidence interval (CI) 1.55 to 2.21), while no statistically significant differences were observed in the number of patients with unintended medication discrepancies (RR=2.74, 95% CI 0.59 to 12.73). Common discrepancies included medication omission, dose discrepancy, and frequency discrepancy. We found that the clinical impact of medication discrepancy was mild. A total of 12 electronic tools were reported and were mostly integrated into the hospital's information system. However, the usability, user adherence, and user satisfaction were found to lack sufficient evidence.

CONCLUSION

eMedRec was shown to reduce the incidence of medication with unintended discrepancies and improve medication safety. However, the electronic tools are diversified and the effects on other outcomes still require a comprehensive evaluation.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017067528.

Medication reconciliation as a medication safety initiative in Ethiopia: a study protocol

INTRODUCTION

Medication related adverse events are common, particularly during transitions of care, and have a significant impact on patient outcomes and healthcare costs. Medication reconciliation (MedRec) is an important initiative to achieve the Quality Use of Medicines, and has been adopted as a standard practice in many developed countries. However, the impact of this strategy is rarely described in Ethiopia. The aims of this study are to explore patient safety culture, and to develop, implement and evaluate a theory informed MedRec intervention, with the aim of minimising the incidence of medication errors during hospital admission.

METHODS AND ANALYSES

The study will be conducted in a resource limited setting. There are three phases to this project. The first phase is a mixed methods study of healthcare professionals' perspectives of patient safety culture and patients' experiences of medication related adverse events. In this phase, the Hospital Survey on Patient Safety Culture will be used along with semi-structured indepth interviews to investigate patient safety culture and experiences of medication related adverse events. The second phase will use a semi-structured interview guide, designed according to the 12 domains of the Theoretical Domains Framework, to explore the barriers and facilitators to medication safety activities delivered by hospital pharmacists. The third phase will be a single centre, before and after study, that will evaluate the impact of pharmacist conducted admission MedRec in an emergency department (ED). The main outcome measure is the incidence and potential clinical severity of medication errors. We will then analyse the differences in the incidence and severity of medication errors before and after initiation of an ED pharmacy service.

The medication reconciliation process and classification of discrepancies: a systematic review

AIMS

Medication reconciliation is a part of the medication management process and facilitates improved patient safety during care transitions. The aims of the study were to evaluate how medication reconciliation has been conducted and how medication discrepancies have been classified.

METHODS

We searched MEDLINE, EMBASE, CINAHL, PubMed, International Pharmaceutical Abstracts (IPA), and Web of Science (WOS), in accordance with the PRISMA statement up to April 2016. Studies were eligible for inclusion if they evaluated the types of medication discrepancy found through the medication reconciliation process and contained a classification system for discrepancies. Data were extracted by one author based on a predefined table, and 10% of included studies were verified by two authors.

RESULTS

Ninety-five studies met the inclusion criteria. Approximately one-third of included studies (n = 35, 36.8%) utilized a 'gold' standard medication list. The majority of studies (n = 57, 60%) used an empirical classification system and the number of classification terms ranged from 2 to 50 terms. Whilst we identified three taxonomies, only eight studies utilized these tools to categorize discrepancies, and 11.6% of included studies used different patient safety related terms rather than discrepancy to describe the disagreement between the medication lists.

CONCLUSIONS

We suggest that clear and consistent information on prevalence, types, causes and contributory factors of medication discrepancy are required to develop suitable strategies to reduce the risk of adverse consequences on patient safety. Therefore, to obtain that information, we need a well-designed taxonomy to be able to accurately measure, report and classify medication discrepancies in clinical practice.

Impact of electronic medication reconciliation interventions on medication discrepancies at hospital transitions: a systematic review and meta-analysis

Background

Medication reconciliation has been identified as an important intervention to minimize the incidence of unintentional medication discrepancies at transitions in care. However, there is a lack of evidence for the impact of information technology on the rate and incidence of medication discrepancies identified during care transitions. This systematic review was thus, aimed to evaluate the impact of electronic medication reconciliation interventions on the occurrence of medication discrepancies at hospital transitions.

Methods

Systematic literature searches were performed in MEDLINE, PubMed, CINHAL, and EMBASE from inception to November, 2015. We included published studies in English that evaluated the effect of information technology on the incidence and rate of medication discrepancies compared with usual care. Cochrane’s tools were used for assessment of the quality of included studies. We performed meta-analyses using random-effects models.

Results

Ten studies met our inclusion criteria; of which only one was a randomized controlled trial. Interventions were carried out at various hospital transitions (admission, 5; discharge, 2 and multiple transitions, 3 studies). Meta-analysis showed a significant reduction of 45 % in the proportion of medications with unintentional discrepancies after the use of electronic medication reconciliation (RR 0.55; 95 % CI 0.51 to 0.58). However, there was no significant reduction in either the proportion of patients with medication discrepancies or the mean number of discrepancies per patient. Drug omissions were the most common types of unintended discrepancies, and with an electronic tool a significant but heterogeneously distributed reduction of omission errors over the total number of medications reconciled have been observed (RR 0.20; 95 % CI 0.06 to 0.66). The clinical impact of unintended discrepancies was evaluated in five studies, and there was no potentially fatal error identified and most errors were minor in severity.

Conclusion

Medication reconciliation supported by an electronic tool was able to minimize the incidence of medications with unintended discrepancy, mainly drug omissions. But, this did not consistently reduce other process outcomes, although there was a lack of rigorous design to conform these results.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-016-0353-9) contains supplementary material, which is available to authorized users.

Electronic tools to support medication reconciliation: a systematic review

OBJECTIVES

Medication reconciliation (MedRec) is essential for reducing patient harm caused by medication discrepancies across care transitions. Electronic support has been described as a promising approach to moving MedRec forward. We systematically reviewed the evidence about electronic tools that support MedRec, by (a) identifying tools; (b) summarizing their characteristics with regard to context, tool, implementation, and evaluation; and (c) summarizing key messages for successful development and implementation.

MATERIALS AND METHODS

We searched PubMed, the Cumulative Index to Nursing and Allied Health Literature, Embase, PsycINFO, and the Cochrane Library, and identified additional reports from reference lists, reviews, and patent databases. Reports were included if the electronic tool supported medication history taking and the identification and resolution of medication discrepancies. Two researchers independently selected studies, evaluated the quality of reporting, and extracted data.

RESULTS

Eighteen reports relative to 11 tools were included. There were eight quality improvement projects, five observational effectiveness studies, three randomized controlled trials (RCTs) or RCT protocols (ie, descriptions of RCTs in progress), and two patents. All tools were developed in academic environments in North America. Most used electronic data from multiple sources and partially implemented functionalities considered to be important. Relevant information on functionalities and implementation features was frequently missing. Evaluations mainly focused on usability, adherence, and user satisfaction. One RCT evaluated the effect on potential adverse drug events.

CONCLUSION

Successful implementation of electronic tools to support MedRec requires favorable context, properly designed tools, and attention to implementation features. Future research is needed to evaluate the effect of these tools on the quality and safety of healthcare.

[Prospective study in 2 hospitals]

OBJECTIVES

The purpose of this study is to know the incidence rate of medication reconciliation at admission and discharge in patients of La Rioja and to improve the patient safety on medication reconciliation.

MATERIAL AND METHODS

An observational prospective study, part of the Joint Action PaSQ, Work Package 5, European Union Network for Patient Safety and Quality of Care. The study has taken into account the definitions of the Institute for Safe Medication Practices. Any unintended discrepancy in medication between chronic treatment and the treatment prescribed in the hospital was considered as a reconciliation error.

RESULTS

A total of 750 patients were included, 9 (1.2%) of whom showed at least one discrepancy. The patients had a total of 3,156 mediations registered: 2,313 prescriptions (73.4%) showed no differences, while 821 prescriptions (26%) were intended discrepancies and 21 prescriptions (0.6%) unintended discrepancies were considered by the physician as reconciliation errors. A percentage of 1.2 of the patients, which represents 0.6% of the medicines (one in 166 medications registered) had reconciliation errors during their hospital stay.

CONCLUSIONS

A proceeding has been implemented by means of the physician doing the medication reconciliation and reviewing it with the help of a medication reconciliation form. The medication reconciliation is a priority strategic objective to improve the safety of patients.

Effectiveness of pharmacist-led medication reconciliation programmes on clinical outcomes at hospital transitions: a systematic review and meta-analysis

OBJECTIVES

Pharmacists play a role in providing medication reconciliation. However, data on effectiveness on patients' clinical outcomes appear inconclusive. Thus, the aim of this study was to systematically investigate the effect of pharmacist-led medication reconciliation programmes on clinical outcomes at hospital transitions.

DESIGN

Systematic review and meta-analysis.

METHODS

We searched PubMed, MEDLINE, EMBASE, IPA, CINHAL and PsycINFO from inception to December 2014. Included studies were all published studies in English that compared the effectiveness of pharmacist-led medication reconciliation interventions to usual care, aimed at improving medication reconciliation programmes. Meta-analysis was carried out using a random effects model, and subgroup analysis was conducted to determine the sources of heterogeneity.

RESULTS

17 studies involving 21,342 adult patients were included. Eight studies were randomised controlled trials (RCTs). Most studies targeted multiple transitions and compared comprehensive medication reconciliation programmes including telephone follow-up/home visit, patient counselling or both, during the first 30 days of follow-up. The pooled relative risks showed a more substantial reduction of 67%, 28% and 19% in adverse drug event-related hospital revisits (RR 0.33; 95% CI 0.20 to 0.53), emergency department (ED) visits (RR 0.72; 95% CI 0.57 to 0.92) and hospital readmissions (RR 0.81; 95% CI 0.70 to 0.95) in the intervention group than in the usual care group, respectively. The pooled data on mortality (RR 1.05; 95% CI 0.95 to 1.16) and composite readmission and/or ED visit (RR 0.95; 95% CI 0.90 to 1.00) did not differ among the groups. There was significant heterogeneity in the results related to readmissions and ED visits, however. Subgroup analyses based on study design and outcome timing did not show statistically significant results.

CONCLUSION

Pharmacist-led medication reconciliation programmes are effective at improving post-hospital healthcare utilisation. This review supports the implementation of pharmacist-led medication reconciliation programmes that include some component aimed at improving medication safety.

Effectiveness of an electronic tool for medication reconciliation in a general surgery department

BACKGROUND

Medication reconciliation is a key tool in the prevention of adverse drug events.

OBJECTIVE

To assess the impact of an electronic reconciliation tool in decreasing unintended discrepancies between medications prescribed after surgery and the patient's usual treatment.

SETTING

General Surgery Department of Gregorio Marañón's University General Hospital, Madrid.

METHOD

A pre-post intervention study with no equivalent control group was carried out between June 2009 and December 2010. Patients hospitalized in the General Surgery Department for 24 h or more, and whose prescriptions prior to admission included three or more drugs were included in the study. Patients were interviewed to gather information about their usual treatment drugs. Discrepancies between the latter and the drugs prescribed after surgery were assessed before and after the medication reconciliation electronic tool was implemented.

MAIN OUTCOME MEASURE

Proportion of patients with at least one unintended discrepancy.

RESULTS

A total of 107 patients in the pre-intervention phase and 84 patients in the post-intervention phase were included. We detected 1,678 discrepancies, 167 were found to be unintended. The number of patients with at least one unintended discrepancy was 43 (40.2 %) in the pre-intervention phase, and 38 (38.1 %) in the post-intervention phase, p = 0.885. The percentage of unintended discrepancies over the total amount of drugs reconciled was lower in the post-intervention phase than in the pre-intervention phase (6.6 vs. 10.6 %), p = 0.002. Regarding unintended discrepancies 79.2 % were grade C severity (the error reached the patient but caused no harm), 13.6 % grade D (the error reached the patient and required monitoring or intervention to preclude harm) and 7.1 % grade E (the error may have contributed to or resulted in temporary harm to the patient and required intervention).

CONCLUSION

Implementation of an electronic tool facilitated the process of medication reconciliation in a general surgery unit. The proportion of unintended discrepancies over the total amount of drugs reconciled was reduced after the implementation of the reconciliation programme. However, we could not demonstrate a more significant impact due to some methodological limitations.

The impact of medication reconciliation program at admission in an internal medicine department

BACKGROUND

Medication reconciliation process has proved to be an effective tool to improve the safety of drug use. The objective of this study was to assess the impact of an intervention aimed to decrease unintended discrepancies between patient's usual treatment and medications prescribed on admission to the Department of Internal Medicine.

METHODS

A quasi-experimental study was carried out from June 2009 to May 2010, analyzing discrepancies between home medication and drugs prescribed in a tertiary care hospital, before (first phase) and after (second phase) an electronic reconciliation tool was introduced at admission. This tool connected patients' usual medication with the electronic prescription program. The research team was made up of two hospital pharmacists, two nurses and three physicians from the Internal and Preventive Medicine Departments.

RESULTS

During the two phases of the study, 162 patients were included with a total of 1,959 medicines reconciled. The incidence of unintended discrepancies decreased from 3.5% to 1.8% after the intervention (p value 0.03). The proportion of patients with at least one unintended discrepancy was 23.7% in the first phase and 14.6% in the second phase (p value 0.20). Omission was the most common unintended discrepancy. Asthmatic patients showed 6 times higher risk of being affected by an unintended discrepancy (OR 6.37, 95%CI 1.6-25.5; p value 0.009).

CONCLUSIONS

Implementing a computerized tool integrated into the electronic prescribing program could be very helpful to develop a medication reconciliation process. It is essential to involve all hospital staff in this process.

Medication reconciliation: passing phase or real need?

Medication reconciliation errors occur across transitions in patient care. Of all medication errors in a hospital, 25 % in hospitalised patients are caused by a failure to reconcile new prescriptions with ongoing home treatments. These errors are more common at discharge, but the critical moment for detecting and resolving them is at the time of admission. This commentary reviews the different ways in which reconciliation errors can be prevented. The reconciliation process should be standardised and implemented in daily practice as a routine part of healthcare provision. To achieve this, professional development of hospital pharmacists is of paramount importance. The commentary goes on to describe the factors that affect the reconciliation process and the stages involved in its implementation. Finally, we discuss the use of information technology as a means to help integrating medication reconciliation into clinical practice.