Development and multi-centre evaluation of a method for assessing the severity of potential harm of medication reconciliation errors at hospital admission in elderly

Implementation and effectiveness of pharmacist-led interviews at patient hospital admission in a rheumatology department

OBJECTIVES

Medication reconciliation is time-consuming and its complete deployment can be difficult. The implementation of a simplified process, such as patient interviews at admission without full reconciliation, may contribute to improve patient care. The objective of the present study was to describe the feasibility and assess the potential effectiveness of implementing pharmacist-led interviews at patient admission to a rheumatology department.

METHODS

This is a prospective observational study of pharmacist-led interviews at patient admission conducted between April 2015 and May 2017 in the 34-bed rheumatology department of Edouard Herriot Hospital, a French university hospital. These interviews were structured to explore patient medication management at home. The main outcome was the number of medication errors at admission. Other outcomes were the total number of interviews, the number of interviews with at least one new item of information provided by the patient, the number of interviews with at least one medication error detected, and the number of interviews leading to a modification of the hospital medication order.

RESULTS

A total of 247 interviews were carried out; there was an increase in the number of interviews over the study period (n=54 in 2015, n=98 in 2016, and n=95 for the first 5 months of 2017). Among the interviews conducted, 135 (55%) provided new information concerning patient medication management and 117 medication errors were identified in hospital orders (0.47/patient). There were 76 interviews (31%) with at least one medication error; all led to a medication order modification.

CONCLUSIONS

The study found that pharmacist-led interviews at patient admission were effective in detecting medication errors. They could be an alternative to a full medication reconciliation process in targeted situations. When the patient interview does not provide sufficiently robust information, full medication reconciliation may be performed.

Development and validation of a score to assess risk of medication errors detected during medication reconciliation process at admission in internal medicine unit: SCOREM study

BACKGROUND

Medication errors (ME) can be reduced through preventive strategies such as medication reconciliation. Such strategies are often limited by human resources and need targeting high risk patients.

AIMS

To develop a score to identify patients at risk of ME detected during medication reconciliation in a specific population from internal medicine unit.

METHODS

Prospective observational study conducted in an internal medicine unit of a French University Hospital from 2012 to 2016. Adult hospitalised patients were eligible for inclusion. Medication reconciliation was conducted by a pharmacist and consisted in comparing medication history with admission prescription to identify MEs. Risk factors of MEs were analysed using multivariate stepwise logistic regression model. A risk score was constructed using the split-sample approach. The split was done at random (using a fixed seed) to define a development data set (N = 1256) and a validation sample (N = 628). A regression coefficient-base scoring system was used adopting the beta-Sullivan approach (Sullivan's scoring).

RESULTS

Pharmacists detected 740 MEs in 368/1884 (19.5%) patients related to medication reconciliation. Female gender, number of treatments >7, admission from emergency department and during night or weekend were significantly associated with a higher risk of MEs. Risk score was constructed by attributing 1 or 2 points to these variables. Patients with a score ≥3 (OR [95% CI] 3.10 [1.15-8.37]) out of 5 (OR [95% CI] 8.11 [2.89-22.78]) were considered at high risk of MEs.

CONCLUSIONS

Risk factors identified in our study may help prioritising patients admitted in internal medicine units who may benefit the most from medication reconciliation (ClinicalTrials.gov number NCT03422484).

Unintended discontinuation of medication following hospitalisation: a retrospective cohort study

OBJECTIVES

Whether unintended discontinuation of common, evidence-based, long-term medication occurs after hospitalisation; what factors are associated with unintended discontinuation; and whether the presence of documentation of medication at hospital discharge is associated with continuity of medication in general practice.

DESIGN

Retrospective cohort study between 2012 and 2015.

SETTING

Electronic records and hospital supplied discharge notifications in 44 Irish general practices.

PARTICIPANTS

20 488 patients aged 65 years or more prescribed long-term medication for chronic conditions.

PRIMARY AND SECONDARY OUTCOMES

Discontinuity of four evidence-based medication drug classes: antithrombotic, lipid-lowering, thyroid replacement drugs and respiratory inhalers in hospitalised versus non-hospitalised patients; patient and health system factors associated with discontinuity; impact of the presence of medication in the hospital discharge summary on continuity of medication in a patient's general practitioner (GP) prescribing record at 6 months follow-up.

RESULTS

In patients admitted to hospital, medication discontinuity ranged from 6%-11% in the 6 months posthospitalisation. Discontinuity of medication is significantly lower for hospitalised patients taking respiratory inhalers (adjusted OR (AOR) 0.63, 95% CI (0.49 to 0.80), p<0.001) and thyroid medications (AOR 0.62, 95% CI (0.40 to 0.96), p=0.03). There is no association between discontinuity of medication and hospitalisation for antithrombotics (AOR 0.95, 95% CI (0.81 to 1.11), p=0.49) or lipid lowering medications (AOR 0.92, 95% CI (0.78 to 1.08), p=0.29). Older patients and those who paid to see their GP were more likely to experience increased odds of discontinuity in all four medicine groups. Less than half (39% to 47.4%) of patients had medication listed on their hospital discharge summary. Presence of medication on hospital discharge summary is significantly associated with continuity of medication in the GP prescribing record for lipid lowering medications (AOR 1.64, 95% CI (1.15 to 2.36), p=0.01) and respiratory inhalers (AOR 2.97, 95% CI (1.68 to 5.25), p<0.01).

CONCLUSION

Discontinuity of evidence-based long-term medication is common. Increasing age and private medical care are independently associated with a higher risk of medication discontinuity. Hospitalisation is not associated with discontinuity but less than half of hospitalised patients have medication recorded on their hospital discharge summary.

Évaluation de la gravité potentielle des erreurs interceptées par la conciliation des traitements médicamenteux en unité d’hospitalisation de courte durée

Introduction : La conciliation des traitements médicamenteux (CTM) à l’admission hospitalière permet en mode rétroactif d’intercepter puis de corriger des erreurs en comparant la prescription hospitalière initiale à la liste des médicaments pris à domicile par le patient ; cette liste ou ce bilan médicamenteux étant réalisé à partir du croisement de différentes sources. L’objectif de l’étude a été d’évaluer la gravité potentielle des erreurs interceptées par la CTM en unité d’hospitalisation de courte durée (UHCD).

Matériel et méthode : La gravité potentielle des erreurs interceptées a été évaluée à l’aide d’un algorithme clinique selon deux modalités : en considérant uniquement la période d’hospitalisation et sans considération de durée ; c’està- dire comme si l’erreur avait perduré au-delà de la sortie hospitalière du patient. Ces erreurs ont été positionnées selon cinq niveaux de gravité clinique potentielle : mineur, significatif, majeur, critique et catastrophique.

Résultats : La CTM réalisée auprès de 122 patients a permis d’identifier 461 erreurs. Les classes médicamenteuses majoritairement impliquées ont concerné les systèmes cardiovasculaire (n = 151, 32 %), nerveux (n = 103, 22 %) et digestif (n = 86, 18 %). Les principaux types d’erreurs ont été les omissions (n = 381, 83 %,) et les erreurs de dose (n = 57, 12 %). 1,1 % des erreurs auraient pu avoir des conséquences cliniques majeures pour les patients durant la période d’hospitalisation et 8,5 % d’entre elles des conséquences potentiellement majeures ou critiques en considérant un horizon temporel se prolongeant au-delà de l’hospitalisation.

Discussion : L’appréciation de la gravité potentielle des erreurs médicamenteuses traduit l’intérêt clinique de la CTM. Cette évaluation a permis de révéler en UHCD une sinistralité évitée jusque-là méconnue par les équipes médicales.

Assessment of the clinical relevance of pharmacists' interventions performed during medication review in a rheumatology ward

BACKGROUND

Pharmacists contribute to reduce the number of medication errors during medication review. Nevertheless, few French studies report the potential clinical impact of pharmacists' interventions performed after detecting drug-related problems. The objective was to evaluate the clinical relevance of pharmacists' interventions in a rheumatology ward from medical and pharmaceutical perspectives.

METHOD

The analysis was conducted on pharmacists' interventions performed between January 1 and December 31, 2015 in a French teaching hospital. Similar pharmacists' interventions were grouped in one item and they were analysed according to 11 drug categories. The clinical significance of pharmacists' interventions was considered independently by a pharmacist and a rheumatologist using a validated French scale that categorises drug-related problems from minor to catastrophic. The agreement between the two professionals was analysed using the weighted kappa coefficient.

RESULTS

Of 1313 prescriptions reviewed, 461 pharmacists' interventions (171 items) were formulated for drug-related problems with an acceptance rate of 67.2%. Of the 418 interventions selected for clinical significance analysis, 235 interventions (56.2%) for the physician and 400 interventions (95.7%) for the pharmacist were at least significant. The two professionals evaluated equally the clinical relevance of 90 items (50.6%). The categories with the most similarities were the analgesics/anti-inflammatory drugs (78.1%), the antidiabetics (75.0%) and the anticoagulants (71.4%). The agreement was estimated by a weighted kappa coefficient of 0.29.

CONCLUSION

This work highlights the positive clinical relevance of pharmacists' interventions in rheumatology and the importance of medico-pharmaceutical collaboration to prevent medication errors.

Drug-dispensing problems community pharmacists face when patients are discharged from hospitals: a study about 537 prescriptions in Alsace

Objectives

To identify both type and frequency of the challenges community pharmacists face when dispensing drugs from hospital discharge prescriptions, to describe the measures undertaken to resolve the issues at stake and to list their consequences.

Design

We carried out an observational study in the community pharmacies of the French region of Alsace and asked the community pharmacy staff to review 537 hospital discharge prescriptions in 2013 using anonymous data collection forms.

Setting and Participants

Nineteen community pharmacies.

Main outcome measures

Number of patients informed about their medication (at hospital and/or community pharmacy), type and frequency of issues encountered during drug dispensing, type and frequency of measures undertaken to resolve the issues, type and frequency of the consequences regarding drug dispensing.

Results

Community pharmacists faced 165 challenges from 145 hospital discharge prescriptions (i.e. 27.5% out of 528 analysed prescriptions), mostly correlated to the quality of the prescriptions (n = 100, 60.6%) or to logistical matters (n = 54, 32.7%). A mere 36.8% of the patients received information pertaining to their medication while being hospitalized. Of note, 40.5% of the prescriptions were delivered to pharmacies within 2 days following the patients' discharge. In order to resolve the different issues preventing drugs from being dispensed (n = 33/145 prescriptions), pharmacists sought information, mainly from patients, colleagues and hospital prescribers. The pharmacists were able to dispense all the drugs prescribed in 138 out of 145 cases (95.2%).

Conclusions

This study highlighted the challenges encountered by community pharmacists and their significant contribution to the continuity of care upon patients being discharged from hospitals.

The clinical impact of medication reconciliation on admission to a French hospital: a prospective observational study

OBJECTIVE

This study was designed to assess the clinical impact of medication reconciliation using two criteria: the number of inpatients who had experienced at least one medication error; the severity of the potential harm associated with these detected errors.

METHOD

The study was a prospective observational one. The eligible population included patients aged 65 and over subjected to medication reconciliation at admission. The potential severity of medication errors was evaluated independently by the physician in charge of the patient and by the pharmacist involved in the medication reconciliation process. Severity assessment took account of the drug(s) involved in the error, the type of medication error, and the patient's clinical and biological data.

RESULTS

From January 2011 to September 2012, 1799 medication errors were recorded among the 1670 patients subjected to medication reconciliation who were hospitalised from the emergency department. At least one medication error occurred for 744 (44.6%) of these patients. There were 87 medication errors associated with potentially major severity (5.6%). These concerned 67 patients (4.2%). The most prevalent error was omission. Cardiovascular and anticoagulant drugs were the drugs most frequently involved in these serious medication errors. Arrhythmia, haemorrhage, thrombosis, hyperglycaemia and hypoglycaemia were identified as the most likely harms that could have occurred.

CONCLUSIONS

The detection of cases of serious potential harm shows the clinical impact of medication reconciliation. It would be interesting to perform a multicentred assessment using indicators such as the number of inpatients experiencing at least one serious medication error. This could help to promote medication reconciliation as essential for patient safety.