Medication Reconciliation in Continuum of Care Transitions: A Moving Target

Medication Discrepancies among Older Hospitalized Adults Discharged from Post-Acute Care Facilities to Home

OBJECTIVES

The epidemiology of medication discrepancies during transitions from post-acute care (PAC) to home is poorly described. We sought to describe the frequency and types of medication discrepancies among hospitalized older adults transitioning from PAC to home.

DESIGN

A nested cohort analysis.

SETTING AND PARTICIPANTS

Included participants enrolled in a patient-centered deprescribing trial, for patients (aged ≥50 years and taking at least 5 medications) transitioning from one of 22 PACs to home.

METHODS

We assessed demographic and medication measures at the initial hospitalization. The primary outcome measure was medication discrepancies, with the PAC discharge list serving as reference for comparison to the participant's self-reported medication list at 7 days following PAC discharge. Discrepancies were categorized as additions, omissions, and dose discrepancies and were organized by common medication classes and risk of harm (eg, 2015 Beers Criteria). Ordinal logistic regression assessed for patient risk factors for PAC discharge discrepancy count.

RESULTS

A total of 184 participants had 7-day PAC discharge medication data. Participants were predominately female (67%) and Caucasian (83%) with a median of 16 prehospital medications [interquartile range (IQR) 11, 20]. At the 7-day follow-up, 98% of participants had at least 1 medication discrepancy, with a median number of 7 medication discrepancies (IQR 4, 10) per person, 4 (IQR 2, 6) of which were potentially inappropriate medications as defined by the Beers Criteria. Higher medication discrepancies at index hospital admission and receipt of caregiver assistance with medications were 2 key predictors of medication discrepancies in the week after PAC discharge to home.

CONCLUSIONS AND IMPLICATIONS

Older patients transitioning home from a PAC facility are at high risk for medication discrepancies. This study underscores the need for interventions targeted at this overlooked transition period, especially as patients resume responsibility for managing their own medications after both a hospital and PAC stay.

Pharmacists' Impact on Older Adults Transitioning To and From Patient Care Centers: A Scoping Review

Objective: Expand upon previous reviews conducted on transitions of care (TOC) services with a focus on pharmacist interventions for older adults specifically transitioning to and from long-term care, acute rehabilitation, residential care facilities, care homes, skilled nursing, or assisted living facilities, collectively termed patient care centers (PCC). Data Sources: A PubMed and Ovid MEDLINE search was conducted including citations between 1974 and July 14, 2022. Bibliographies were also reviewed for additional citations. Methods: Articles included described pharmacist interventions during TOC for patients transitioning to and from PCC, were written in English, and reported outcomes pertaining to TOC services. Of 873 citations reviewed, 22 articles met the inclusion criteria. Results: Most studies were prospective in design with small sample sizes, of limited duration, and with varying interventions and reported outcomes. Most explored the transition from hospital to PCC and included a pharmacist intervention involving the identification of medication errors and discrepancies during the TOC. Few studies reported cost savings or 30- and 60-day reductions in readmission rates or mortality. Conclusions: This scoping review revealed a lack of robust clinical trials to assess the effectiveness of specific interventions performed by pharmacists for patients transitioning to and from PCC. Of the available data, pharmacist involvement within an interprofessional team can be an effective intervention to resolve medication discrepancies, reduce readmissions, and medication-related adverse events. An opportunity exists for future studies to explore ways to improve outcomes during TOC within PCC.

Obtaining the Best Possible Medication History at Hospital Admission: Description of a Pharmacy Technician-Driven Program to Identify Medication Discrepancies

PURPOSE

Describe the process of obtaining the best possible medication history (BPMH) by Certified Pharmacy Technicians (CPhTs) on hospital admission to identify medication discrepancies.

METHODS

Cross-sectional, descriptive study conducted between December 2016 and June 2017 at a quaternary center in New York, including all patients 18 years and older admitted to the medicine service through the Emergency Department (ED) and seen by a CPhT. CPhTs obtained the BPMH using a systematic approach involving a standardized interview, checking medications with secondary sources and updating the electronic health record (EHR). Medication discrepancies were identified and categorized by type and risk. Summary statistics were provided as average and standard deviation (SD) for continuous variables, and as frequencies and percentages for categorical variables. Multivariable regression was used to test for associations between patient factors and presence of a medication discrepancy.

RESULTS

Of the 3,087 patient visits, the average age was 69 (SD 17.8), 54% were female (n = 1652) and 65% white (n = 2017); comorbidity score breakdown was: 0 (25%, n = 757), 1-2 (33%, n = 1023), 3-4 (23%, n = 699), > 4 (20%, n = 608). The average number of home and discharge medications were 10 (SD 6.1) and 10 (SD 5.4), respectively. The average time spent obtaining the BPMH was 30.6 minutes (SD 12.9). 69% of patients (n = 2130) had at least 1 discrepancy with an average of 4.2 (SD 4.6), of which 43% (n = 920) included high-risk medications. Having a medication discrepancy was associated with a higher number of home medications (p < 0.0001) comorbidities (p < 0.0001), and source of information (p < 0.04).

CONCLUSION

Obtaining the BPMH by CPhTs on hospital admission frequently identifies medication discrepancies. Further studies are needed to evaluate the association between obtaining the BPMH and clinical outcomes.

Care Fragmentation After Hospitalization for Acute Myocardial Infarction

Care fragmentation (CF), or readmission at a nonindex hospital, has been linked to inferior clinical and financial outcomes for patients. However, its impact on patients with acute myocardial infarction (AMI) is unclear. This study investigated the prevalence and impact of CF on the outcomes of patients with AMI. All US adult (≥18 years) hospitalizations for AMI from January 2010 to November 2019 were identified using the Nationwide Readmissions Database. Patients were stratified by readmission at an index or nonindex center. Multivariable models were developed to evaluate factors associated with CF, and independent associations with mortality, complications, and resource utilization. A total of 413,819 patients with AMI requiring nonelective readmission within 30 days of discharge were included for analysis. Of these, 25.4% (n = 104,966) experienced CF. The incidence of CF increased from 2010 to 2019 (nptrend <0.001). After adjustment, patients insured by Medicaid faced higher odds of nonindex readmission. CF was associated with in-hospital mortality (adjusted odds ratio [AOR] 1.09, 95% confidence interval [CI] 1.01 to 1.18), and cardiac (AOR 1.12, 95% CI 1.03 to 1.22), respiratory (AOR 1.14, 95% CI 1.12 to 1.26), and infectious complications (AOR 1.14, 95% CI 1.07 to 1.22). Further, CF was linked to increased odds of nonhome discharge (AOR 1.18, 95% CI 1.11 to 1.24) and an additional ∼$5,000 in per-patient hospitalization costs (95% CI 4,260 to 5,100). Approximately 25% of AMI patients experienced CF, which was independently associated with excess mortality, complications, and expenditures. Given the growing national burden of cardiovascular disease, new efforts are needed to mitigate the significant clinical and financial implications of nonindex readmissions and improve value-based healthcare.

An analysis of a novel Canadian pilot health information exchange to improve transitions between hospital and long-term care/skilled nursing facility

Purpose

The purpose of the article is to assess the effectiveness, compliance, adoption and lessons learnt from the pilot implementation of a data integration solution between an acute care hospital information system (HIS) and a long-term care (LTC) home electronic medical record through a case report.

Design/methodology/approach

Utilization statistics of the data integration solution were captured at one-month post implementation and again one year later for both the emergency department (ED) and LTC home. Clinician feedback from surveys and structured interviews was obtained from ED physicians and a multidisciplinary LTC group.

Findings

The authors successfully exchanged health information between a HIS and the electronic medical record (EMR) of an LTC facility in Canada. Perceived time savings were acknowledged by ED physicians, and actual time savings as high as 45 min were reported by LTC staff when completing medication reconciliation. Barriers to adoption included awareness, training efficacy and delivery models, workflow integration within existing practice and the limited number of facilities participating in the pilot. Future direction includes broader staff involvement, expanding the number of sites and re-evaluating impacts.

Practical implications

A data integration solution to exchange clinical information can make patient transfers more efficient, reduce data transcription errors, and improve the visibility of essential patient information across the continuum of care.

Originality/value

Although there has been a large effort to integrate health data across care levels in the United States and internationally, the groundwork for such integrations between interoperable systems has only just begun in Canada. The implementation of the integration between an enterprise LTC electronic medical record system and an HIS described herein is the first of its kind in Canada. Benefits and lessons learnt from this pilot will be useful for further hospital-to-LTC home interoperability work.

Standardized assessment of medication reconciliation in post-acute care

BACKGROUND

Medication reconciliation (MR) facilitates safety during transitions of care, which occur frequently across post-acute care (PAC) settings. Under the intent of the IMPACT Act of 2014, the Centers for Medicare & Medicaid Services contracted with the RAND Corporation to develop and test standardized assessment data elements (SADEs) that assess the MR process.

METHODS

We employed an iterative process that incorporated stakeholder input and three rounds of testing to identify, refine, and evaluate MR SADEs. Testing took place in 186 PAC sites (57 home health agencies, 28 inpatient rehabilitation facilities, 28 long-term care hospitals, and 73 skilled nursing facilities). There were 2951 patients in the final test. Novel MR SADEs, based on the Joint Commission's framework, were refined. The final SADEs assessed whether: patient was taking high-risk medications; an indication was noted for each medication class; discrepancies were identified; patient or family/caregiver was involved in addressing discrepancies; discrepancies were communicated to physician (or designee) within 24 h; recommended physician actions regarding discrepancies were implemented within 24 h after physician response; and the reconciled list was communicated to patient, prescriber, and/or pharmacy. Two assessors per facility collected data for each patient. Analyses described completion time, data missingness, and interrater reliability, as well as feedback on assessor burden.

RESULTS

Time to complete the MR SADEs was 3.2 min. Missing data were <5%. Interrater reliability was moderate to high (κ: 0.42 [whether a reconciled list was communicated to prescribers] to 0.89 [identifying patients taking hypoglycemics]). For identifying high-risk medication classes, interrater reliability was high (κ: 0.72-0.89). There were minimal differences by setting.

CONCLUSIONS

This is the first set of MR SADEs that have been assessed across the PAC settings. Results demonstrate feasibility, based on missing data and completion time, and moderate to strong reliability, based on interrater comparisons, of assessing MR.

Implementation assessment of a patient personalized clinical pharmacy programme (5P project) into orthogeriatric care pathway

WHAT IS KNOWN AND OBJECTIVE

The orthogeriatric path (hip-fractured elderly patients) is composed of several transition points (emergency surgery, orthopaedic, geriatric and rehabilitation units). The intervention of clinical pharmacists can ensure the continuity of patients' drug management during their hospital stay. The aim of the study was to assess the implementation of clinical pharmacy activities in an orthogeriatric pathway, regarding its impact on medication error prevention, the healthcare professionals' and patients' satisfaction, and the estimated associated pharmaceutical workload.

METHODS

Participants were aged 75 or older and managed for proximal femoral fracture. Their admission prescription was reviewed. If they were evaluated at high risk of adverse event (AE), medication reconciliation (MedRec) and pharmaceutical interviews (admission, discharge, and targeted on oral anticoagulant) were added at different steps of their care pathway. The achievement and duration of each clinical pharmacy activity were recorded. The number of pharmaceutical interventions (PI) made during prescription review, and unintentional discrepancies (UID) identified during MedRec were collected. A satisfaction questionnaire was sent to patients and healthcare professionals.

RESULTS AND DISCUSSION

Among 455 included patients, 284 patients were considered at high risk of AE. Clinical pharmacy activity achievement rates varied between 12% and 98%. A total of 622 PI and 333 UID were identified. The overall patients' and healthcare professionals' satisfaction was rated from 63% to 100%. The total workload was estimated at 376 h: on average 16 min per prescription review, 43 min per admission MedRec, 26 min per discharge MedRec and 17 to 25 minutes per interview.

CONCLUSION

The implementation of the programme showed a high potential of drug management securing. To sustain it, additional pharmaceutical human resources and high-performance computing tools are needed.

Prescription of Potentially Inappropriate Medication in Older Inpatients of an Internal Medicine Ward: Concordance and Overlap Among the EU(7)-PIM List and Beers and STOPP Criteria

Background: Age-related comorbidities prone older adults to polypharmacy and to an increased risk of potentially inappropriate medication (PIM) use. This work aims to analyze the concordance and overlap among the EU(7)-PIM list, 2019 Beers criteria, and Screening Tool of Older Person’s Prescriptions (STOPP) version 2 criteria and also to analyze the prevalence of PIM.

Methods: A retrospective cohort study was conducted on older inpatients of an internal medicine ward. Demographic, clinical, and pharmacological data were collected, during March 2020. After PIM identification by the EU(7)-PIM list, Beers criteria, and STOPP v2 criteria, the concordance and overlap between criteria were analyzed. A descriptive analysis was performed, and all the results with a p-value lower than 0.05 were considered statistically significant.

Results: A total of 616 older patients were included in the study whose median age was 85 (Q1–Q3) (78–89) years. Most of the older patients were male (51.6%), and the median (Q1–Q3) number of days of hospitalization was 17 (13–22) days. According to the EU(7)-PIM list, Beers criteria, and STOPP criteria, 79.7, 92.0, and 76.5% of older adults, respectively, used at least one PIM. A poor concordance (<63.4%) among criteria was observed. An association between PIM and the number of prescribed medicines was found in all applied criteria. Moreover, an association between the number of PIMs and diagnoses of endocrine, nutritional, and metabolic diseases, mental, behavioral, and neurodevelopmental disorders, and circulatory system diseases and days of hospitalization was observed according to Beers criteria, and that with diseases of the circulatory system and musculoskeletal system and connective tissue was observed according to STOPP criteria.

Conclusion: Despite the poor concordance between the EU(7)-PIM list, 2019 Beers, and STOPP v2 criteria, this work highlights the need for more studies in inpatients to develop strategies to facilitate the identification of PIM to decrease the high prevalence of PIM in hospitalized patients. The poor concordance among criteria also highlights the need to develop new tools adapting the existing criteria to medical ward inpatients.

Interprofessional and Intraprofessional Communication about Older People's Medications across Transitions of Care

Communication breakdowns contribute to medication incidents involving older people across transitions of care. The purpose of this paper is to examine how interprofessional and intraprofessional communication occurs in managing older patients' medications across transitions of care in acute and geriatric rehabilitation settings. An ethnographic design was used with semi-structured interviews, observations and focus groups undertaken in an acute tertiary referral hospital and a geriatric rehabilitation facility. Communication to manage medications was influenced by the clinical context comprising the transferring setting (preparing for transfer), receiving setting (setting after transfer) and 'real-time' (simultaneous communication). Three themes reflected these clinical contexts: dissemination of medication information, safe continuation of medications and barriers to collaborative communication. In transferring settings, nurses and pharmacists anticipated communication breakdowns and initiated additional communication activities to ensure safe information transfer. In receiving settings, all health professionals contributed to facilitating safe continuation of medications. Although health professionals of different disciplines sometimes communicated with each other, communication mostly occurred between health professionals of the same discipline. Lack of communication with pharmacists occurred despite all health professionals acknowledging their important role. Greater levels of proactive preparation by health professionals prior to transfers would reduce opportunities for errors relating to continuation of medications.

Evaluation of the medication reconciliation process and classification of discrepancies at hospital admission and discharge in Italy

Background Medication errors at different transitions of care are common and potentially harmful. Medication reconciliation process should be evaluated to reduce the unintentional discrepancies. Objective This study aims to identify and classify unintentional medication discrepancies at hospital admission and discharge and associated risk factors. Setting Two general internal medicine and a pulmonology wards of an Italian non-academic hospital. Method A retrospective observational study was conducted among adult patients admitted to the wards. In order to evaluate the current medication reconciliation process of these wards, the frequency and type of unintentional chronic medication discrepancies between the physician assessment of home medication and hospital admission and discharge prescriptions were studied. Patients' characteristic associated with the presence of at least one unintentional discrepancy were evaluated. Main outcome measure Frequencies of unintentional medication discrepancies upon admission and discharge and associated patients' characteristics. Results Among the 144 patients enrolled in the study, 53 and 64 unintentional medication discrepancies were identified at hospital admission and at discharge, respectively. Both at admission and discharge a quarter of patients had at least one unintentional discrepancy. 'Medication omission' was the most frequent type of discrepancy identified and respiratory system and nervous system were the classes of medication with the highest rate of unintentional discrepancies. Unintentional discrepancies were more likely to occur in patients receiving more medicine pre-admission, longer hospitalization stays and coming from or discharged to a nursing home. Conclusion Transitions of care are critical moments for patient safety in terms of unintentional medication discrepancies and a more structured medication reconciliation process is needed. The medication reconciliation process should be considered in terms of a multidisciplinary approach involving all health professionals as well as patients and caregivers directly.

Improving patient safety through a pharmacist-led medication reconciliation programme in nursing homes for the elderly in Spain

Background Medication errors frequently occur during transitions of care and may have damaging consequences, especially amongst the elderly. Some studies show that quality improvement initiatives with a focus on medication reconciliation have resulted in better health outcomes and a reduced number of readmissions. Objective The primary objective of this study was to quantify and classify medication reconciliation errors detected by a pharmacist and taking place during transitions of care between nursing homes and the health system. Secondary objectives were to assess the relation between error frequency and polypharmacy or between error frequency and the transition type and to describe the medication concerned by this error. Setting Five elderly nursing homes of the health care area in Ferrol (Spain) between January 2013 and December 2017 Method A prospective descriptive study on medication discrepancies found during pharmacist's medication reconciliation. This was performed at first admission and after every transition of care upon the patient's return to the nursing home. Interventions were categorized according to the consensus terminology. Main outcome measure Number and type of medication errors, percentage of transitions of care and percentage of patients who suffered at least one reconciliation error were measured. Results At least one medication error was found in 16% of the 2123 studied care transitions, summing up 417 reconciliation errors in 273/981 patients (28%). Wrong dosing (48%) and medication omissions (31%) were the most frequently detected errors. High-risk medication was involved in 40% of the cases. A positive association between polypharmacy (≥ 5 chronic medications) and the frequency of reconciliation errors was found. On the other hand, different transition types did not show a difference in error frequency. Conclusion Reconciliation errors were found in almost 30% of our patients. Unlike other studies, visits to outpatient specialist clinics were included as another type of healthcare transition, encompassing an important percentage of reconciliation errors. The pharmacist helped to reduce these errors in a particularly fragile population such as institutionalized patients.

Errors in antibiotic transitions between hospital and nursing home: How often do they occur?

We performed systematic review on 40 paired hospital and nursing home charts from a clinical trial to evaluate the fidelity of transitions of care among those discharged on antibiotics. We found that 30% of transitions included an inappropriate change to the patient's antibiotic plan of care.

A Framework for Supporting Post-acute Care Transitions of Older Patients With Hip Fracture

OBJECTIVE

Improving care transitions is of critical importance for older patients, especially those with complex care needs. Our study examined the "Transitions of Care" (ToC) of complex, post-acute older adults at multiple time points. The objective of this article is to identify domains relevant to health care transitions of post-acute older patients with hip fracture so as to inform future ToC interventions.

DESIGN

Here we conducted a framework-based synthesis of the 12 peer-reviewed manuscripts that were published from our multisite, ethnographic study.

SETTING AND PARTICIPANTS

All 12 manuscripts were based on 1 study, described here. Data were collected in multiple regions, in acute and sub-acute care wards, rehabilitation programs, home care agencies, long-term care and assisted living facilities, and patients' private homes. We completed 51 interviews with 23 postoperative hip fracture patients aged ≥65 years, 24 interviews with 19 family caregivers, and 96 interviews with 92 health care providers. Interviews with patients, family caregivers, and health care providers were conducted at each transition point for a total of 171 individual interviews.

RESULTS

Taken together, our framework analysis of the 12 manuscripts identified 8 themes related to ToC. Two themes, patient complexity and system constraints, are contextual factors that tend to impede ToC and may be less amenable to change. The remaining 6 themes, patient involvement and choice, family caregiver roles, strong relationships, coordination of roles, documentation, and information sharing, have the potential to support and improve ToC.

CONCLUSIONS AND IMPLICATIONS

With comprehensive data from a range of stakeholders, collected at multiple transition points along the health care continuum, in our final 6 themes we identify potential points of intervention for clinicians and teams seeking to improve ToC for older complex patients.

Lost in Transition: a Qualitative Study of Patients Discharged from Hospital to Skilled Nursing Facility

OBJECTIVE

This research aimed to understand the experiences of patients transitioning from hospitals to skilled nursing facilities (SNFs) by eliciting views from patients and hospital and skilled nursing facility staff.

DESIGN

We conducted semi-structured interviews with hospital and skilled nursing facility staff and skilled nursing facility patients and their family members in an attempt to understand transitions between hospital and SNF. These interviews focused on all aspects of the discharge planning and nursing facility placement processes including who is involved, how decisions are made, patients' experiences, hospital-SNF communication, and the presence of programs to improve the transition process.

PARTICIPANTS

Participants were 138 staff in 16 hospitals and 25 SNFs in 8 markets across the country, and 98 newly admitted, previously community-dwelling SNF patients and/or their family members in five of those markets.

APPROACH

Interviews were qualitatively analyzed to identify overarching themes.

KEY RESULTS

Patients reported they felt rushed in making their SNF decisions, did not feel they were appropriately prepared for the hospital-SNF transition or educated about their post-acute needs, and experienced transitions that felt chaotic, with complications they associated with timing and medications. Hospital and SNF staff expressed similar opinions, stating that transitions were rushed, there were problems with the timing of the discharge, with information transfer and medication reconciliation, and that patients were not appropriately prepared for the transition. Staff at some facilities reported programs designed to address these problems, but the efficacy of these programs is unknown.

CONCLUSIONS

Results indicate problematic transitions stemming from insufficient care coordination and failure to appropriately prepare patients and their family members. Previous research suggests that problematic or hurried transitions from hospital to SNF are associated with medication errors and unnecessary rehospitalizations. Interventions to improve transitions from hospital to SNF that include a focus on patients and families are needed.

Measuring the Impact of Medication-Related Interventions on 30-Day Readmission Rates in a Skilled Nursing Facility

BACKGROUND

There is a lack of published literature that measures the impact of transitional care pharmacist (TCP) medication-related interventions within the skilled nursing facility (SNF) setting.

OBJECTIVES

To evaluate the impact of TCP medication-related interventions on 30-day hospital readmissions among SNF patients compared to current standard of care.

METHODS

This was a retrospective pilot study. All patients included in the study were discharged from an inpatient facility to a SNF. The control group received transitional services from a care team with no pharmacist. The intervention group received transitional services from a care team plus a pharmacist.

RESULTS

The 30-day readmission rates in the intervention group were 14 (12%)/116 compared to the control group, 19 (16%)/116; however, the difference was not statistically significant (P = .35). The median time to readmission was statistically significantly longer in the intervention group, 17.5 days, compared to the control group, 10 days (P = .02). One hundred seventy-four medication-related interventions were performed in the intervention group during the study period.

CONCLUSION

This study demonstrates that TCP interventions in an SNF are associated with a significant delay in readmission. A continuation of the pilot program may show a role in reducing all-cause 30-day readmission and ED visit rates.

Magnitude and factors associated with medication discrepancies identified through medication reconciliation at care transitions of a tertiary hospital in eastern Ethiopia

Objective

The aim of this study is to determine the magnitude of medication discrepancies and its associated factors at transitions in care of a Specialized University Hospital in eastern Ethiopia.

Results

This study enrolled 411 patients having at least one prescription medication. For each of the patient enrolled, a medication reconciliation process was accomplished between medication use history before transition and medication orders at the transition. A total of 1027 medications were reconciled and 298 of them showed discrepancies. From such medication discrepancies, 96 (32.2%) of them were unintended discrepancies. Patients admitted to surgical ward (adjusted odds ratio {AOR} 0.27 [95% confidence interval 0.10–0.74]) and on malnutrition therapy (AOR 0.13 [0.03–0.52]) had reduced likelihoods of medication discrepancies. However, patients on cardiovascular drug therapy (AOR 5.69 [2.4–13.62]) and who were hospitalized for more than 5 days (AOR 5.69 [2.97–10.9] {5–10 days}) had significantly increased likelihoods of discrepancies. Accordingly, one-third of the medication discrepancies identified were unintentional and these discrepancies were more likely to occur with cardiovascular drugs, in medical or pediatric wards and patients hospitalized for prolonged time. Therefore, this pharmacist-led medication reconciliation indicates the potential of pharmacists in reducing drug-related adverse health outcomes that arise from medication discrepancy.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3668-z) contains supplementary material, which is available to authorized users.

Potential drug-drug interactions and polypharmacy in institutionalized elderly patients in a public hospital in Brazil

WHAT IS KNOWN ON THE SUBJECT?: Older individuals constitute an increasing proportion of the population, and therefore, are the major consumers of drugs. The elderly, especially those with mental disabilities, frequently develop chronic diseases and start using numerous drugs. Drug-drug interactions (DDIs) are a major clinical problem in the elderly population, and previous studies have focused only on antidepressants and others types of drugs used to treat mental health conditions. WHAT THIS ARTICLE ADDS TO EXISTING KNOWLEDGE?: This study shows that in hospitalized elderly patients with mental disorders (aged 60-69 years), polypharmacy (≥5 drugs) and the use of drugs that act on the cardiovascular, respiratory and nervous systems can lead to potential drug-drug interactions. Moreover, it was reported that the prevalence of drug-drug interactions in elderly patients with mental disorders was high during their hospitalization in a public hospital in Brazil. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nurses should know the factors associated with drug-drug interactions in hospitalized elderly patients with mental disorders to choose appropriate strategies for avoiding treatment failure and adverse events in patients.

ABSTRACT

Introduction Despite the impact on patient safety and the fact that prevalence is higher in older patients, previous research did not analyse drug-drug interactions (DDIs) in view of nursing care of elderly psychiatric patients. Aim To identify potential drug-drug interactions and polypharmacy in prescriptions of aged inpatients with psychiatric disorders and analyse associated factors. Methods In this retrospective cross-sectional study, we analysed the medical records of institutionalized patients diagnosed with psychiatric disorders (n = 94), aged >60 years, and prescribed multiple medications. Drug prescriptions were checked at admission, midway through and the last prescription. Factors associated with DDI occurrence were assessed using multivariable logistic regression analysis. Results A DDI prevalence potential of 67.0%, 74.5% and 80.8% occurred in patients at admission, midway through hospitalization and the last prescription, respectively. Most of the prescribed drugs were nervous system agents. A high percentage of serious and contraindicated potential DDIs occurred. Age between 60 and 69 years, use of cardiovascular and respiratory system drugs, and the number of medications contributed significantly to DDI. Implications for mental health nursing Knowledge on the factors associated with DDIs in patients with mental disorders can contribute to the improvement of effectiveness and safety of nursing care.

Determinants of Potentially Inappropriate Medication Use in Long-Term and Acute Care Settings: A Systematic Review

BACKGROUND

Potentially inappropriate medications (PIMs) are widely used in institutionalized older adults, yet the key determinants that drive their use are incompletely characterized.

METHODS

We systematically searched published literature within MEDLINE and Embase from January 1998 to March 2017. We searched for studies conducted in the United States that described determinants of PIM use in adults ≥60 years of age in a nursing home or residential care facility, in the emergency department (ED), or in the hospital. Paired reviewers independently screened abstracts and full-text articles, assessed quality, and extracted data.

RESULTS

Among 30 included articles, 12 examined PIM use in the nursing home or residential care settings, 4 in the ED, 12 in acute care hospitals, and 2 across settings. The Beers criteria were most frequently used to identify PIM use, which ranged from 3.6% to 92.0%. Across all settings, the most common determinants of PIM use were medication burden and geographic region. In the nursing home, the most common additional determinants were younger age, and diagnoses of depression or diabetes. In both the ED and hospital, patients receiving care in the West, Midwest, and South, relative to the Northeast, were at greater risk of receiving a PIM. Very few studies examined clinician determinants of PIM use; geriatricians used fewer PIMs in the hospital than other clinicians.

CONCLUSIONS

Among older adults, those who are on many medications are at increased risk for PIM use across multiple settings. We propose that careful testing of interventions that target modifiable determinants are indicated to assess their impact on PIM use.

Medication Management and e-Care Planning: What are the Opportunities for the Future?

Effective communication and coordination of care is a priority strategy to improve health care quality in the United States. To address this strategy, care coordinators are being integrated into clinical practice settings and tasked with developing patient-centered care plans. One component of the care plan is the development of a medication list. This care plan medication list facilitates many medication management functions performed by pharmacists, such as identifying and resolving medication-related problems. Health information technology enables access to data to assist developing the medication list for the care plan and also provides routes to communicate the care plan with other health care providers, patients, and caregivers. The current article reviews the current landscape for promoting effective medication-related communication and care plan information.

Post-acute care reform: Implications and opportunities for hospitalists

Nearly all practicing hospitalists have firsthand experience discharging patients to post-acute care (PAC), which is provided by inpatient rehabilitation facilities, skilled nursing facilities, or home healthcare providers. Many may not know that PAC is poised to undergo transformative change, spurred by recent legislation resulting in a range of reforms. These reforms have the potential to fundamentally reshape the relationship between hospitals and PAC providers. They have important implications for hospitalists and will open up opportunities for hospitalists to improve healthcare value. In this article, the authors explore the reasons for PAC reform and the scope of the reforms. Then they describe the implications for hospitalists and hospitalists' opportunities to Choose Wisely and improve healthcare value for the rapidly growing number of vulnerable older adults transitioning to PAC after hospital discharge.

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.

Interprofessional Collaboration to Improve Discharge from Skilled Nursing Facility to Home: Preliminary Data on Postdischarge Hospitalizations and Emergency Department Visits

An interprofessional collaborative practice model was established at Hennepin County Medical Center to improve discharge management from the transitional care unit of the skilled nursing facility (SNF) to home. The practice model involves a geriatrician, nurse practitioner, and pharmacist who care for individuals at a community-based SNF. Before SNF discharge, the pharmacist conducts a chart and in-person medication review and collaborates with the nurse practitioner to determine the discharge medication regimen. The pharmacist's review focuses on assessing the indication, safety, effectiveness, and convenience of medications. The pharmacist provides follow-up in-home or over the telephone 1 week after SNF discharge, focusing on reviewing medications and assessing adherence. Hospitalizations and emergency department (ED) visits 30 days after SNF discharge of individuals who received care from this model was compared with those of individuals who received usual care from a nurse practitioner and geriatrician. From October 2012 through December 2013, the intervention was delivered to 87 individuals, with 189 individuals serving as the control group. After adjusting for age, sex, race, and payor, those receiving the intervention had a lower risk of ED visits (odds ratio (OR) = 0.46, 95% confidence interval (CI) = 0.22-0.97), although there was no significant difference in hospitalizations (OR = 0.47, 95% CI = 0.21-1.08). The study suggests that an interprofessional approach involving a pharmacist may be beneficial in reducing ED visits 30 days after SNF discharge.

Medication regimens of frail older adults after discharge from home healthcare

The purpose of this study was to examine the number and types of discrepancy errors present after discharge from home healthcare in older adults at risk for medication management problems following an episode of home healthcare. More than half of the 414 participants had at least one medication discrepancy error (53.2%, n = 219) with the participant's omission of a prescribed medication (n = 118, 30.17%) occurring most frequently. The results of this study support the need for home healthcare clinicians to perform frequent assessments of medication regimens to ensure that the older adults are aware of the regimen they are prescribed, and have systems in place to support them in managing their medications.

Appropriate prescribing and important drug interactions in older adults

Polypharmacy, specifically the overuse and misuse of medications, is associated with adverse health events, increased disability, hospitalizations, and mortality. Mechanisms through which polypharmacy may increase adverse health outcomes include decreased adherence, increased drug side effects, higher use of potentially inappropriate medications, and more frequent drug-drug interactions. This article reviews clinical problems associated with polypharmacy and presents a framework to optimize prescribing for older adults.

Medication reconciliation in patients hospitalized in a cardiology unit

OBJECTIVES

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

METHOD

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

RESULTS

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

CONCLUSION

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