Accuracy of Electronic Medical Record Medication Reconciliation in Emergency Department Patients

Effectiveness of Microinvasive Glaucoma Surgery in the United States: Intelligent Research in Sight Registry Analysis 2013-2019

PURPOSE

To evaluate the effectiveness of microinvasive glaucoma surgery (MIGS) with and without concurrent phacoemulsification.

DESIGN

Multicenter, retrospective cohort study.

PARTICIPANTS

Patients in the Intelligent Research in Sight (IRIS®) Registry who underwent Xen gel stent (ab interno) implantation, endoscopic cyclophotocoagulation (ECP), or goniotomy or canaloplasty from 2013 through 2019.

METHODS

Kaplan-Meier survival analysis was used to assess reoperation rates. We defined reoperation as any subsequent glaucoma surgery occurring 1 month to 3 years after the initial procedure. Multivariable Cox proportional hazard models were used to determine factors predictive of reoperation.

MAIN OUTCOME MEASURES

Reoperation rate, mean intraocular pressure (IOP) and visual acuity (VA), postoperative complications, predictors of reoperation, and reoperation procedure type.

RESULTS

A total of 79 363 eyes from 57 561 patients were included, with 15 118 eyes (19%) receiving stand-alone MIGS and 64 245 eyes (81%) receiving MIGS concurrent with phacoemulsification. Overall, patients who underwent MIGS concurrently with phacoemulsification showed lower reoperation rates compared with stand-alone MIGS, most pronounced in ECP and goniotomy or canaloplasty. At postoperative year 2, the cumulative reoperation rate for stand-alone procedures was 15% for ECP, 24% for Xen implantation, and 24% for goniotomy or canaloplasty compared with 3% for ECP, 19% for Xen implantation, and 6% for goniotomy or canaloplasty concurrent with phacoemulsification (P < 0.001 for each stand-alone MIGS vs. MIGS with phacoemulsification). Black race, older age, moderate and severe glaucoma, higher baseline IOP, and glaucoma subtype were associated with higher reoperation risk. Although IOP decreased in all groups, stand-alone MIGS showed a more substantial decrease in mean IOP. Complication rates from MIGS were low overall: 1% for ECP, 1% for Xen implantation, and 2% for goniotomy or canaloplasty.

CONCLUSIONS

In current United States clinical practice, MIGS has substantially lower reoperation rates when performed with phacoemulsification, especially for ECP and goniotomy or canaloplasty. Approximately one-sixth of patients undergoing stand-alone ECP and one-quarter of patients undergoing stand-alone Xen implantation or goniotomy or canaloplasty require reoperation by 2 years. Black race, diagnosis coding of moderate to severe glaucoma, and higher baseline IOP were associated with higher risk of reoperation after MIGS procedures.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found after the references.

Medication history-wide association studies for pharmacovigilance of pregnant patients

Background

Systematic exclusion of pregnant people from interventional clinical trials has created a public health emergency for millions of patients through a dearth of robust safety data for common drugs.

Methods

We harnessed an enterprise collection of 2.8 M electronic health records (EHRs) from routine care, leveraging data linkages between mothers and their babies to detect drug safety signals in this population at full scale. Our mixed-methods signal detection approach stimulates new hypotheses for post-marketing surveillance agnostically of both drugs and diseases-by identifying 1,054 drugs historically prescribed to pregnant patients; developing a quantitative, medication history-wide association study; and integrating a qualitative evidence synthesis platform using expert clinician review for integration of biomedical specificity-to test the effects of maternal exposure to diverse drugs on the incidence of neurodevelopmental defects in their children.

Results

We replicated known teratogenic risks and existing knowledge on drug structure-related teratogenicity; we also highlight 5 common drug classes for which we believe this work warrants updated assessment of their safety.

Conclusion

Here, we present roots of an agile framework to guide enhanced medication regulations, as well as the ontological and analytical limitations that currently restrict the integration of real-world data into drug safety management during pregnancy. This research is not a replacement for inclusion of pregnant people in prospective clinical studies, but it presents a tractable team science approach to evaluating the utility of EHRs for new regulatory review programs-towards improving the delicate equipoise of accuracy and ethics in assessing drug safety in pregnancy.

The Accuracy of In-State Prescription Monitoring Program Database and Electronic Medical Records Compared to Urine Toxicology Screening in Total Joint Arthroplasty Preoperative Evaluation

Preoperative narcotic use is associated with poor postoperative pain management and worse outcomes after total joint arthroplasty (TJA). Therefore, identifying controlled substance use preoperatively is necessary. Electronic medical records (EMRs), prescription monitoring programs (PMP), or urine toxicology screening (UTS) are most commonly used. This study aims to compare the accuracy of EMR and PMP versus UTS to determine whether UTS should be implemented as standard of care in TJA preoperative assessment. Preoperative UTS was performed for primary or revision TJA from November 1, 2018, to March 31, 2019. Patient demographics, medical history, prescription history, and UTS results were retrospectively recorded. Prescription monitoring program and EMR were queried for prescription history in the past 2 years. The accuracy of EMR and PMP compared with UTS was calculated. Multivariable logistic regression analysis was performed to identify patient predictors associated with UTS+. Thirty of 148 patients had UTS+. Positive urine toxicology screening was more common in patients younger than 58 years, White race, and undergoing revision surgery. Electronic medical record and PMP documentation had the highest sensitivity (73.3%), specificity (92.4%), positive predictive value (71.0%), and negative predictive value (93.2%). Patients with higher odds of UTS+ include current/former smokers, those with a history of alcohol abuse, drug abuse, hepatitis C diagnosis, and mental illness. For patients without any risk factors for having a UTS+, the use of EMR and PMP may be sufficient to evaluate for controlled substance use; however, UTS should be considered in patients who present with one of the risk factors for UTS+.

Patient Characteristics Associated With Missed Appointments in Pediatric Subspecialty Clinics

OBJECTIVES

Missed appointments negatively affect patients, providers, and health systems. This study aimed to (1) quantify the percentage of missed appointments across 14 pediatric subspecialties in a tertiary-care children's hospital and (2) identify patient characteristics associated with missed appointments in those subspecialties.

METHODS

We extracted patient characteristics from 267,151 outpatient appointments, between January 1, 2013, and December 31, 2018, across 14 subspecialty clinics. Medical complexity was categorized using the Pediatric Medical Complexity Algorithm. The primary outcome was appointment nonattendance. Cancellations, imaging/laboratory visits, patients older than 18 years, and duplicate visits were excluded. Characteristics associated with nonattendance were analyzed with chi-square tests and included in the multivariable model if p < .1. Missing data were addressed using random forest imputation, and assuming data were "missing at random." Variables were considered statistically significant if p < .05.

RESULTS

Of the 128,117 scheduled appointments analyzed, 23,204 (18.1%) were missed. In the multivariable model, clinical nutrition had the greatest subspecialty odds of missed appointments, whereas cardiology had the lowest. Patient characteristics most strongly associated with missed appointments were public insurance, history of >2 missed appointments, appointment lead time, lesser medical complexity, Black race/ethnicity, and fewer medications.

CONCLUSIONS

Clinical characteristics including lesser medical complexity and fewer medications are associated with missed appointments in pediatric subspecialties.

Impact of integrated medication management program on medication errors in a medical center: an interrupted time series study

Background

Medication errors (MEs) are harmful to patients during hospitalization, especially elderly patients. To reduce MEs, an integrated medication management (IMM) model was developed in a 2500-bed medical center, allowing a clinical pharmacist to participate in the daily ward round and perform medication reconciliation and medication reviews. This study aimed to evaluate the impact of the IMM model on MEs and medication utilization using a quasi-experimental design.

Methods

We conducted an interrupted time-series study using the aggregated data of monthly admissions from two wards of a medical center, where one ward served as the intervention and the other served as the external control. The pre- and post-intervention phases comprised of 40 and 12 monthly observational units, respectively. The primary outcome was the mean number of ME reports, which were further investigated for different ME types. The mean number of daily inpatient prescriptions, mean number of daily self-prepared medications, and median daily medication costs were measured. All outcomes were measured per admission episode. Segmented regression was used to evaluate the level and slope changes in the outcomes after IMM model implementation, and subgroup analyses were performed to examine the effects on different groups.

Results

After IMM model implementation, the mean number of ME reports increased (level change: 1.02, 95% confidence interval [CI]: 0.68 to 1.35, P < 0.001). The number of reports has shown a dramatic increase in omissions or medication discrepancies, inappropriate drug choices, and inappropriate routes or formulations. Furthermore, the mean number of daily inpatient prescriptions was reduced for patients aged ≥75 years (level change: −1.78, 95% CI: −3.06 to −0.50, P = 0.009). No significant level or slope change was observed in the control ward during the post-intervention phase.

Conclusions

The IMM model improved patient safety and optimized medication utilization by increasing the reporting of MEs and decreasing the number of medications used.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08178-w.

Perfil das Discrepâncias Obtidas por meio da Conciliação Medicamentosa em Pacientes Oncológicos: Revisão Integrativa da Literatura

Introdução: O cuidado ao paciente oncológico demanda ações de uma equipe multiprofissional em virtude da complexidade do seu tratamento. Um dos serviços oferecidos pelo farmacêutico, visando a contribuir para segurança do paciente, é a conciliação medicamentosa capaz de detectar discrepâncias nas prescrições e prevenir erros de medicação. Objetivo: Traçar o perfil das principais discrepâncias encontradas na literatura em pacientes oncológicos durante a prática da conciliação medicamentosa realizada por farmacêuticos. Adicionalmente, visa-se a uma abordagem descritiva sobre as intervenções farmacêuticas realizadas nos estudos. Método: Revisão integrativa da literatura. Foram utilizados os descritores: “Medication Reconciliation”, “Neoplasms”, “Pharmacists”, “Medication Errors” para as estratégias de busca. As bases de dados selecionadas foram: PubMed, Web of Science, Embase e Scopus. Resultados: Inicialmente, identificaram-se 141 artigos. Destes, foram selecionados 11 trabalhos para serem discutidos. A conciliação medicamentosa foi realizada em pacientes na admissão hospitalar (27,3%), alta hospitalar (18,2%), e acompanhamento ambulatorial (54,5%). A maior parte era de estudos observacionais (72,7%) seguidos dos estudos de intervenção (27,3%). A principal discrepância relatada foi a de omissão/necessidade de adição de um medicamento (81,5%). As intervenções farmacêuticas estavam descritas mais detalhadamente em 36,4% das publicações. Conclusão: O estudo demonstrou a necessidade de mais trabalhos que correlacionem a prática da conciliação medicamentosa com a detecção de discrepâncias e intervenções farmacêuticas em Oncologia. Os farmacêuticos, objetivando a segurança do paciente, devem estruturar essa prática na vivência clínica dos pacientes oncológicos.

Patient Perspectives on the Development of a Novel Mobile Health (mHealth) Application for Dietary Supplement Tracking and Reconciliation – A Qualitative Focus Group Study

Background: More than 170 million adults use dietary supplements (DS) in the United States, which can have both benefit and harm to patient health. DS use is often poorly documented in the medical record and can pose health risks if not properly communicated with providers. Reasons for poor DS documentation include low disclosure rates, time constraints of clinical encounters, and providers’ failure to inquire about DS use. This study was conducted to assess patients’ views on the facilitators and barriers to using a mobile health (mHealth) application (app) to collect and share DS information with their healthcare providers. Methods: Utilizing a theory-based conceptual model, we conducted seven patient focus groups (FGs) to assess opinions on DS safety, provider communication, comfort with technology use, and our proposed mHealth app. Participants were recruited from the general public and through patient advisory groups. Patient views will inform the creation of an mHealth app to improve DS patient-provider communication and tracking and reconciliation in the electronic medical record (EMR). Results: Overall, participants believe their DS information is inaccurately represented in the EMR leading to safety concerns and negatively impacting overall quality-of-care. Participants desired an app designed with: 1) Health Insurance Portability and Accountability Act (HIPAA)-compliance; 2) ease of use for a variety of technical efficacy levels; 3) access to reliable DS information, including a DS-drug interaction checker; 4) integration with the EMR. Conclusion: An app to simplify and improve DS entry and reconciliation was of interest to patients, as long as it maintained health autonomy and privacy and possessed key valuable features.

Personal Electronic Records of Medications (PERMs) for medication reconciliation at care transitions: a rapid realist review

Background

Medication reconciliation (MedRec), a process to reduce medication error at care transitions, is labour- and resource-intensive and time-consuming. Use of Personal Electronic Records of Medications (PERMs) in health information systems to support MedRec have proven challenging. Relatively little is known about the design, use or implementation of PERMs at care transitions that impacts on MedRec in the ‘real world’. To respond to this gap in knowledge we undertook a rapid realist review (RRR). The aim was to develop theories to explain how, why, when, where and for whom PERMs are designed, implemented or used in practice at care transitions that impacts on MedRec.

Methodology

We used realist methodology and undertook the RRR between August 2020 and February 2021. We collaborated with experts in the field to identify key themes. Articles were sourced from four databases (Pubmed, Embase, CINAHL Complete and OpenGrey) to contribute to the theory development. Quality assessment, screening and data extraction using NVivo was completed. Contexts, mechanisms and outcomes configurations were identified and synthesised. The experts considered these theories for relevance and practicality and suggested refinements.

Results

Ten provisional theories were identified from 19 articles. Some theories relate to the design (T2 Inclusive design, T3 PERMs complement existing good processes, T7 Interoperability), some relate to the implementation (T5 Tailored training, T9 Positive impact of legislation or governance), some relate to use (T6 Support and on-demand training) and others relate iteratively to all stages of the process (T1 Engage stakeholders, T4 Build trust, T8 Resource investment, T10 Patients as users of PERMs).

Conclusions

This RRR has allowed additional valuable data to be extracted from existing primary research, with minimal resources, that may impact positively on future developments in this area. The theories are interdependent to a greater or lesser extent; several or all of the theories may need to be in play to collectively impact on the design, implementation or use of PERMs for MedRec at care transitions. These theories should now be incorporated into an intervention and evaluated to further test their validity.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01659-8.

Fidelity of Electronic Documentation for Reactions Prompting Premedication to Iodinated Contrast Media

PURPOSE

The aims of this study were to assess the fidelity of electronic health record documentation prompting premedication to iodinated contrast media and to determine the appropriateness of administered premedication on the basis of that documentation.

METHODS

In this retrospective quality assurance cohort study, medication adverse events recorded in electronic health records between January 1, 2018, and August 31, 2019, to "iodine," "iodine-containing products," and "iodinated contrast media" were identified (N = 4,309); entries missing documentation (n = 1,651) and breakthrough reactions (n = 22) were excluded. Reaction description, severity, and free-text comments were used to categorize each entry as concordant (documentation matches recorded severity per the ACR Manual on Contrast Media version 10.3), discordant (description-severity mismatch, agent unrelated to iodinated contrast media, not a hypersensitivity reaction), or unclear. A subset of patients undergoing premedication was identified, and premedication was categorized as appropriate, inappropriate, or unsure on the basis of the index reaction using the aforementioned framework. Descriptive statistics were calculated.

RESULTS

There were 2,636 adverse event entries in 2,441 patients: 59.9% (1,578 of 2,636) were classified as concordant, 30.2% (797 of 2,636) as discordant (n = 377 not a hypersensitivity reaction, n = 317 description-severity mismatch, and n = 103 unrelated agent), and 9.9% (n = 261) as unclear documentation. For the premedicated subset, concordance classification was feasible for 202 unique patients premedicated 335 times. Premedication was appropriate in 72% (240 of 335) and inappropriate in 22% (73 of 335); 17% of premedication events (56 of 335) were inappropriately administered for a prior physiologic reaction.

CONCLUSIONS

Premedication prompts in the electronic health record are often erroneous because of inaccurate coding, incomplete data, and reaction misclassification. These errors result in inappropriate premedication for a substantial minority of patients.

How does preoperative opioid use impact postoperative health-related quality of life scores for patients undergoing lumbar microdiscectomy?

BACKGROUND CONTEXT

Narcotic use amongst patients suffering from lumbar radiculopathy is common, but the clinical benefit of narcotics for lumbar radiculopathy is likely minimal. It is unknown what the impact of preoperative use of narcotics has on outcomes related to lumbar microdiscectomy.

PURPOSE

Determine the impact that preoperative opioid use has on postoperative outcomes after lumbar microdisectomy.

STUDY DESIGN

Retrospective analysis of a prospectively collected database.

PATIENT SAMPLE

One hundred and twenty-six patients undergoing a microdiscectomy for a lumbar disc herniation.

OUTCOME MEASURES

Patient-reported outcomes measurement information system mental health scores (PROMIS MHS), patient-reported outcomes measurement information system physical health scores (PROMIS PHS) and oswestry disability index (ODI).

METHODS

We analyzed a prospectively collected database of patients undergoing a lumbar microdiscectomy for preoperative opioid use. We measured the severity of lumbar pathology on MRI based on degree of facet/disc degeneration and cross-sectional area of the dural tube at the disc herniation. We tracked PROMIS MHS, PROMIS PHS and ODI for patients both preoperatively and postoperatively. A Mann-Whitney test was used to compare HRQOL scores and time to MCID for the opioid using cohort (OC) and the nonopioid using cohort (non-OC). We performed a linear regression analysis to determine correlation between preoperative opioid use and postoperative HRQOLs.

RESULTS

There were 44 of 126 microdiscectomy patients in the OC (32.5%). There was no difference in the dural cross-sectional area (p=.91), degree of facet degeneration (p=.38), or disc degeneration (p=.5) between OC and non-OC. There were no differences in PROMIS PHS, PROMIS MHS or ODI between the OC and non-OC at the preoperative visit and all postoperative time points. There were no differences in time to reach MCID between the OC and non-OC for ODI (p=.9), PROMIS PHS (p=.64) or PROMIS MHS (p=.90). At three months out from surgery there was a statistically significant correlation between pre-op opioid use and ODI (p=.02), PROMIS MHS (p=.02) and PROMIS PHS (p=.049).

CONCLUSIONS

Our results demonstrate that patients that use opioids prior to lumbar microdiscectomy have equivalent postoperative outcomes as those that do not use opioids. Use of higher doses of opioids is associated with worse short-term outcomes.

Electronic Medical Record Inaccuracies: Multicenter Analysis of Challenges with Modified Lung Cancer Screening Criteria

The National Comprehensive Cancer Network expanded their lung cancer screening (LCS) criteria to comprise one additional clinical risk factor, including chronic obstructive pulmonary disease (COPD). The electronic medical record (EMR) is a source of clinical information that could identify high-risk populations for LCS, including a diagnosis of COPD; however, an unsubstantiated COPD diagnosis in the EMR may lead to inappropriate LCS referrals. We aimed to detect the prevalence of unsubstantiated COPD diagnosis in the EMR for LCS referrals, to determine the efficacy of utilizing the EMR as an accurate population-based eligibility screening "trigger" using modified clinical criteria. We performed a multicenter review of all individuals referred to three LCS programs from 2012 to 2015. Each individual's EMR was searched for COPD diagnostic terms and the presence of a diagnostic pulmonary functionality test (PFT). An unsubstantiated COPD diagnosis was defined by an individual's EMR containing a COPD term with no PFTs present, or the presence of PFTs without evidence of obstruction. A total of 2834 referred individuals were identified, of which 30% (840/2834) had a COPD term present in their EMR. Of these, 68% (571/840) were considered unsubstantiated diagnoses: 86% (489/571) due to absent PFTs and 14% (82/571) due to PFTs demonstrating no evidence of postbronchodilation obstruction. A large proportion of individuals referred for LCS may have an unsubstantiated COPD diagnosis within their EMR. Thus, utilizing the EMR as a population-based eligibility screening tool, employing expanded criteria, may lead to individuals being referred, potentially, inappropriately for LCS.

Effect of pharmacy-led medication reconciliation in emergency departments: A systematic review and meta-analysis

WHAT IS KNOWN AND OBJECTIVE

Medication reconciliation is recommended to be performed at every transition of medical care to prevent medication errors or adverse drug events. This study investigated the impact of pharmacy-led medication reconciliation on medication discrepancies and potential adverse drug events in the ED to assess the benefits of pharmacy services.

METHODS

The systematic review and meta-analysis was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. The PubMed, Ovid Embase and Cochrane library databases were searched up from inception to 1 July 2018. Studies comparing the effectiveness of the medication reconciliation service performed by pharmacy personnel to usual care (nurses or physicians) in the ED were included. Duplicated studies, non-clinical studies, studies with ineligible comparators or study designs were excluded.

RESULTS AND DISCUSSION

Eleven studies were eligible for qualitative analysis, and 8 studies were included in meta-analysis. Pharmacy-led medication reconciliation substantially reduced medication discrepancies in the ED. The most common medication discrepancies included medication omission and incorrect/omitted dose or frequency. Unlike usual care, pharmacy-led medication reconciliation significantly reduced the proportion of patients with medication discrepancies by 68% (response rate 0.32; 95% confidence interval (CI): 0.19-0.53, P < .0001) and the number of medication discrepancy events by 88% (response rate 0.12; 95% CI 0.06-0.26, P < .00001). Intervention decreased the number of discrepancies per patient by 3.08 (mean difference -3.08; 95% CI: -4.76 to -1.39, P = .0003). Subgroup analysis revealed no differences between pharmacists and pharmacy technicians in medication reconciliation performance pertaining to medication discrepancies. The patients with several comorbidities or those administered numerous medications received marked benefits related to reduced medication discrepancies from pharmacy-led medication reconciliation. Moreover, a randomized controlled trial revealed decreased risk of potential adverse drug events by pharmacy-led medication reconciliation in patients receiving care in the ED.

WHAT IS NEW AND CONCLUSION

Pharmacy-led medication reconciliation significantly decreased the number of medication discrepancies. However, only one study investigated potential adverse drug events in patients receiving care in the ED. Therefore, further studies investigating the direct clinical impact of decreased medication discrepancies are required.

Use of a tablet computer application to engage patients in updating their medication list

Purpose

Failure to obtain an accurate medication history can adversely affect patient care in the emergency department (ED) and propagate errors into the inpatient and outpatient settings. Obtaining an accurate medication history in the ED is challenging, however, due to limited time, a suboptimal environment for patient interaction, and inadequate information in the electronic health record (EHR). This article describes the development and initial evaluation of the PictureRx Medication History Application, a tablet computer-based program that queries patients' prescription fill data from the Surescripts Medication History service and renders it graphically for review and editing at the point of care.

Methods

A quasi-experimental trial of PictureRx was performed in a large academic ED. Adult patients taking at least 1 prescription medication were prospectively eligible for the intervention. Usual care control patients were retrospectively matched 1:1. The main outcomes were updates to the patients' existing pre-visit medication list in the EHR and patient perceptions of the application.

Results

The medication list was updated for 101/244 (41.4%) of the intervention group and for 43/244 (17.6%) of the control group (difference 23.8%, 95% confidence interval, 16.0-31.6%). Similar differences were observed for medication additions, removals, and corrections in dose. Approximately 80% of intervention patients "strongly agreed" that the application was easy to use, aided medication list accuracy, and the graphical features assisted with recall.

Conclusion

A novel tablet computer-based medication history application was feasible to implement in a busy academic ED. Use of the tool was associated with more updates to patients' EHR medication list.

Identification de facteurs de risque d’erreur de prescription médicamenteuse aux urgences : optimisation d’une activité de conciliation médicamenteuse à l’UHCD

Introduction : Les patients hospitalisés au décours d’un passage aux urgences sont à risque d’erreur médicamenteuse. Le déploiement de l’activité de conciliation médicamenteuse à l’admission en unité d’hospitalisation de courte durée (UHCD) permet d’identifier les divergences non intentionnelles (DNI) de prescription médicamenteuse hospitalière en comparaison avec le traitement pris à domicile, puis de les corriger. L’objectif de l’étude était d’identifier les facteurs prédictifs d’erreurs de prescription médicamenteuse aux urgences, afin de mieux prioriser la conciliation médicamenteuse pour les patients admis à l’UHCD.

Méthode : Nous avons mené une étude rétrospective, monocentrique et observationnelle incluant tous les patients ayant bénéficié d’une conciliation médicamenteuse à l’admission à l’UHCD pendant six mois. L’association entre les caractéristiques des patients et la survenue d’au moins une DNI a été étudiée à l’aide d’une régression logistique en ajustant sur les facteurs de confusion (analyse multivariée).

Résultats : Parmi 200 patients inclus, 111 étaient concernés par la survenue d’au moins une DNI (56 %) avec une médiane de deux par patient. Les erreurs étaient principalement des omissions, en majorité pour des traitements à visée cardiovasculaire et du système nerveux central. La majorité des patients étaient exposés à un potentiel événement indésirable lié aux soins (n = 70, 63 %), mais aucun à un événement indésirable de gravité potentielle catastrophique. Dans l’analyse multivariée, la présence d’au moins cinq lignes de traitement dans l’observation médicale de l’urgentiste était très prédictive de la survenue d’au moins une DNI (OR : 1,30 ; IC 95 % : [1,15–1,26] ; p < 0,01). Cette variable concernait principalement un groupe de patients distincts d’âge supérieur ou égal à 75 ans et connus pour au moins deux comorbidités dont la majorité a été concernée par au moins une DNI (69 %). Les facteurs organisationnels propres à l’hospitalisation en situation urgente n’étaient pas prédictifs de la survenue de DNI.

Conclusion : Pour le pharmacien de l’UHCD, la présence d’au moins cinq lignes de traitement dans l’observation médicale d’un patient doit être considérée comme une alerte et déclencher l’activité de conciliation médicamenteuse, en priorisant les patients âgés de plus de 75 ans et polypathologiques.

Medications and patient safety in the trauma setting: a systematic review

Background

Medication errors account for the most common adverse events and a significant cause of mortality in the USA. The Joint Commission has required medication reconciliation since 2006. We aimed to survey the literature and determine the challenges and effectiveness of medication reconciliation in the trauma patient population.

Materials and methods

We conducted a systematic review of the literature to determine the effectiveness of medication reconciliation in trauma patients. English language articles were retrieved from PubMed/Medline, CINAHL, and Cochrane Review databases with search terms "trauma OR injury, AND medication reconciliation OR med rec OR med rek, AND effectiveness OR errors OR intervention OR improvements."

Results

The search resulted in 82 articles. After screening for relevance and duplicates, the 43 remaining were further reviewed, and only four articles, which presented results on medication reconciliation in 3041 trauma patients, were included. Two were retrospective and two were prospective. Two showed only 4% accuracy at time of admission with 48% of medication reconciliations having at least one medication discrepancy. There were major differences across the studies prohibiting comparative statistical analysis.

Conclusions

Trauma medication reconciliation is important because of the potential for adverse outcomes given the emergent nature of the illness. The few articles published at this time on medication reconciliation in trauma suggest poor accuracy. Numerous strategies have been implemented in general medicine to improve its accuracy, but these have not yet been studied in trauma. This topic is an important but unrecognized area of research in this field.

Clinical Utility of Definitive Drug⁻Drug Interaction Testing in Primary Care

Drug–drug interactions (DDIs) are a leading cause of morbidity and mortality. New tools are needed to improve identification and treatment of DDIs. We conducted a randomized controlled trial to assess the clinical utility of a new test to identify DDIs and improve their management. Primary care physicians (PCPs) cared for simulated patients presenting with DDI symptoms from commonly prescribed medications and other ingestants. All physicians, in either control or one of two intervention groups, cared for six patients over two rounds of assessment. Intervention physicians were educated on the DDI test and given access to these test reports when caring for their patients in the second round. At baseline, we saw no significant differences in making the DDI diagnosis (p = 0.071) or DDI-related treatment (p = 0.640) between control and intervention arms. By round two, providers who accessed the DDI test performed significantly better in making the DDI diagnosis (+41.6%) and performing DDI-specific treatment (+12.2%) than in the previous round, and were 9.8 and 20.4 times more likely to diagnose and identify the DDI (p < 0.001 for all). The introduction of a definitive DDI test significantly increased identification, appropriate management, and counseling of DDIs among PCPs, which has the potential to improve clinical care.

Rethinking the outpatient medication list: increasing patient activation and education while architecting for centralization and improved medication reconciliation

Objective

Identify barriers impacting the time consuming and error fraught process of medication reconciliation. Design and implement an electronic medication management system where patient and trusted healthcare proxies can participate in establishing and maintaining an inclusive and up-to-date list of medications.

Methods

A patient-facing electronic medication manager was deployed within an existing research project focused on elder care management funded by the AHRQ, InfoSAGE, allowing patients and patients' proxies the ability to build and maintain an accurate and up-to-date medication list. Free and open-source tools available from the U.S. government were used to embed the tenets of centralization, interoperability, data federation, and patient activation into the design.

Results

Using patient-centered design and free, open-source tools, we implemented a web and mobile enabled patient-facing medication manager for complex medication management.

Conclusions

Patient and caregiver participation are essential to improve medication safety. Our medication manager is an early step towards a patient-facing medication manager that has been designed with data federation and interoperability in mind.

Usage and accuracy of medication data from nationwide health information exchange in Quebec, Canada

Objective

(1) To describe the usage of medication data from the Health Information Exchange (HIE) at the health care system level in the province of Quebec; (2) To assess the accuracy of the medication list obtained from the HIE.

Methods

A descriptive study was conducted utilizing usage data obtained from the Ministry of Health at the individual provider level from January 1 to December 31, 2015. Usage patterns by role, type of site, and tool used to access the HIE were investigated. The list of medications of 111 high risk patients arriving at the emergency department of an academic healthcare center was obtained from the HIE and compared with the list obtained through the medication reconciliation process.

Results

There were 31 022 distinct users accessing the HIE 11 085 653 times in 2015. The vast majority of pharmacists and general practitioners accessed it, compared to a minority of specialists and nurses. The top 1% of users was responsible of 19% of access. Also, 63% of the access was made using the Viewer application, while using a certified electronic medical record application seemed to facilitate usage. Among 111 patients, 71 (64%) had at least one discrepancy between the medication list obtained from the HIE and the reference list.

Conclusions

Early adopters were mostly in primary care settings, and were accessing it more frequently when using a certified electronic medical record. Further work is needed to investigate how to resolve accuracy issues with the medication list and how certain tools provide different features.

OPQRST(U): Integrating substance use disorders or "Use" into the medical history

Substance use disorders (SUDs) are pervasive in the United States, with 20.1 million cases in 2016, of which only 19% receive treatment. SUDs permeate all medical specialties and should be considered in the differential diagnosis of every chief complaint. Acknowledging the salience of SUDs provides a unique opportunity for early identification and intervention. Thus, SUDs should be reflected prominently in the history of the present illness rather than in the social history. To this effect, we propose the inclusion of Use (U) in the history of present illness and incorporating "U" into the pedagogical mnemonic of OPQRST that is commonly used in medical training. Obtaining this history will help determine if and which abused substances may be contributing to the chief complaint. We also suggest the incorporation of an additional acronym, SORTED, to account for the various domains of Use, including Street (illicit drugs), OTCs (over-the-counter medications), Rx (prescriptions, including nonmedicinal use of pharmaceutical drugs), Tobacco (including e-cigarettes), EtOH (alcohol), and Dietary (caffeine, vitamins, and herbal supplements) agents. We discuss how utilizing OPQRSTU will help reshape the way medical students think about SUDs and will facilitate detection and diagnosis of all domains of SUDs.

Medication discrepancies across multiple care transitions: A retrospective longitudinal cohort study in Italy

PURPOSE

Medication discrepancies are defined as unexplained differences among regimens across different sites of care. The problem of medication discrepancies that occur during the entire care pathway from hospital admission to a local care setting discharge (namely all types of settings dedicated to formal care other than hospitals) has received little attention in the medical literature. The present study aims to (1) determine the prevalence of medication discrepancies that occur during the entire care pathway from hospital admission to local care setting discharge, (2) describe the discrepancy and medication type, and (3) identify potential risk factors for experiencing medication discrepancies in patient care transitions. Evidence from an integrated health care system, such as the Italian one, may explain results from other studies in different healthcare systems.

METHODS

A retrospective longitudinal cohort study of patients admitted from July 2015 to July 2016 to the Giovanni Bosco Hospital serving Turin, Italy and its surrounding territory was performed. Discrepancies were recorded at the following four care transitions: T1: Hospital admission; T2: Hospital discharge; T3: Admission into local care settings; T4: Discharge from local care settings. All evaluations were based on documented regimens and were performed by a team (doctor, nurse and pharmacists).

RESULTS

Of 366 included patients, 25.68% had at least one discrepancy. The most frequent type of discrepancy was from medication omission (N = 74; 71.15%). Only discharge from a long-stay care setting (T4) was significantly associated with the onset of discrepancies (p = 0.045). When considering a lack of adequate documentation, not as missing data but as a discrepancy, 43.72% of patients had at least one discrepancy.

CONCLUSIONS

This study suggests that an integrated health care system, such as Italian system, may influence the prevalence of discrepancies, thus highlighting the need for structured multidisciplinary and, if possible, computerized medication reconciliation to prevent medication discrepancies and improve the quality of medical documentation.

Opioid and opioid substitution therapy in liver transplant candidates: A survey of center policies and practices

This national survey sought to determine the practices and policies pertaining to opioid and opioid substitution therapy (OST) use in the selection of liver transplant (LT) candidates. Of 114 centers, 61 (53.5%) responded to the survey, representing 49.2% of the LT volume in 2016. Only two programs considered chronic opioid (1 [1.6%]) or OST use (1 [1.6%]) absolute contraindications to transplant, while 63.9% and 37.7% considered either one a relative contraindication, respectively. The majority of programs did not have a written policy regarding chronic opioid use (73.8%) or OST use (78.7%) in LT candidates. Nearly half (45.9%) of centers agreed that there should be a national consensus policy addressing opioid and OST use. The majority of responding LT centers did not consider opioid or OST use in LT candidates to be absolute contraindications to LT, but there was significant variability in center practices. These surveys also demonstrated a lack of written policies in the assessment of the candidacy of such patients. The results of our survey identify an opportunity to develop a national consensus statement regarding opioid and OST use in LT candidates to bring greater uniformity and equity into the selection of LT candidates.

Epidemiology and outcomes of missing admission medication history in severe trauma: A retrospective study

OBJECTIVE

Anticoagulant and antiplatelet (ACAP) drugs are associated with increased mortality in trauma patients, therefore medication history on admission is important. Whether these medications are recorded on trauma admission has not been investigated, nor if absence of a medication history is associated with worse patient outcomes.

METHODS

We conducted a retrospective database review combining demographic and outcome data from the St George Hospital (Sydney) trauma registry with admission medication history in the electronic record. To contrast medications with a known increased risk (ACAP) to patients with unknown risk, patients were divided into three groups: those on ACAPs, no-ACAP if medication history was present and no-ACAP documented, or no-Hx if no medication history recorded. Inclusion criteria were aged >16 and Injury Severity Score (ISS) >12. Admission demographic data and outcome data were compared between all three groups.

RESULTS

Of 533 consecutive patients, 21% comprised the no-Hx group, while 22% were on an ACAP and 57% not on an ACAP. No-Hx patients had more severe head injuries and a younger median age compared to ACAP patients (42 vs 82 years old, P < 0.001). Mortality was higher for ACAP (24%; 95% CI 17-33%) compared to no-ACAP (11%; 95% CI 8-16%) or no-Hx patients (12%; 95% CI 7-20%) (P = 0.04).

CONCLUSIONS

While a large number of severe trauma patients were admitted without a medication history, no-Hx patients did not appear at increased risk of adverse outcomes. ACAP patients had a higher mortality compared to no-ACAP highlighting the vulnerability of this group.