The benefits of a hospital based community services liaison pharmacist

Impact of a Medication Reconciliation Improvement Package on Adherence to Medication Reconciliation Among Internal Medicine Physicians: A Quality Improvement Project in a Lower-Middle Income Country

Background: Medication reconciliation is one of the best measures to prevent medication-related errors at the time of admission and discharge of patients. We conducted a quasi-experimental study to evaluate the impact of a Medication reconciliation improvement package (intervention) on adherence to medication reconciliation at the time of admission in Department of Internal Medicine. The study included all adult patients admitted to internal medicine from August 2019 to December 2020. Pre-intervention data on adherence to medication reconciliation was less than 50%. The study involved creation of a quality improvement team to conduct a root-cause analysis which identified the need to target physician related issues and hence drafted a medication reconciliation improvement package which included meetings with physicians on the internal medicine floor, dedicated WhatsApp groups for repeated reminders, and appreciation messages for timely adherence. We used the Chi Square test to check the association between adherence to medication reconciliation and physicians and acuity level. Findings: We included 7914 records of patients, in which 4471 participants (56.4%) were from pre-intervention phase and 3443 (43.5%) were from intervention groups. The overall adherence to medication reconciliation was 54.3% (4297/7914). Adherence of medication reconciliation increased from 44.4% (1983/4471) in the pre-intervention phase to 67.2% (2314/3443) in the intervention phase (P < .001). Improvement was observed in adherence of medication reconciliation done by residents and in low acuity areas (P < .005). Conclusion: The Medical reconciliation improvement package is a simple low-cost intervention that resulted in improvement in adherence to medication reconciliation but needs further studies to assess its sustainability. However, it awaits to be seen if the same improvement can also be replicated to qualitative medication errors and clinical outcomes respectively.

[Medication reconciliation: Interests and limits]

Admission to hospital is a critical transition point for the continuity of care in medication management. Medication reconciliation can identify and resolve errors due to inaccurate medication histories. The practice of medication reconciliation is securing for the patient because of the medication errors detected with significant clinical impact. Its implementation must comply with the recommendations of the French National Authority for Health (HAS) and its deployment is now integrated into the contract for improving the quality and efficiency of care (CAQES). However, although it allows to intercept medication errors, its impact on the length of hospitalization, the rate of readmission and/or death following discharge seems limited. Given the limited human resources to carry out this time-consuming activity, patient prioritization should be considered. Studies on the fate of patients and on the medico-economic issues are also necessary in order to make this activity sustainable.

Medication Counselling in Older Patients Prior to Hospital Discharge: A Systematic Review

BACKGROUND

Older patients are regularly exposed to multiple medication changes during a hospital stay and are more likely to experience problems understanding these changes. Medication counselling is often proposed as an important component of seamless care to ensure appropriate medication use after hospital discharge.

OBJECTIVES

The purpose of this systematic review was to describe the components of medication counselling in older patients (aged ≥ 65 years) prior to hospital discharge and to review the effectiveness of such counselling on reported clinical outcomes.

METHODS

Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology (PROSPERO CRD42019116036), a systematic search of MEDLINE, EMBASE and CINAHL was conducted. The QualSyst Assessment Tool was used to assess bias. The impact of medication counselling on different outcomes was described and stratified by intervention content.

RESULTS

Twenty-nine studies were included. Fifteen different components of medication counselling were identified. Discussing the dose and dosage of patients' medications (19/29; 65.5%), providing a paper-based medication list (19/29; 65.5%) and explaining the indications of the prescribed medications (17/29; 58.6%) were the most frequently encountered components during the counselling session. Twelve different clinical outcomes were investigated in the 29 studies. A positive effect of medication counselling on medication adherence and medication knowledge was found more frequently, compared to its impact on hard outcomes such as hospital readmissions and mortality. Yet, evidence remains inconclusive regarding clinical benefit, owing to study design heterogeneity and different intervention components. Statistically significant results were more frequently observed when counselling was provided as part of a comprehensive intervention before discharge.

CONCLUSIONS

Substantial heterogeneity between the included studies was found for the components of medication counselling and the reported outcomes. Study findings suggest that medication counselling should be part of multifaceted interventions, but the evidence concerning clinical outcomes remains inconclusive.

A RCT evaluating a pragmatic in-hospital service to increase the quality of discharge prescriptions

OBJECTIVE

To improve discharge prescription quality and information transfer to improve post-hospital care with a pragmatic in-hospital service.

DESIGN

A single-centre, randomized controlled trial.

SETTING

Internal medicine wards in a Swiss teaching hospital.

PARTICIPANTS

Adult patients discharged to their homes, 76 each in the intervention and control group.

INTERVENTION

Medication reconciliation at discharge by a clinical pharmacist, a prescription check for formal flaws, interactions and missing therapy durations. Important information was annotated on the prescription.

MAIN OUTCOME MEASURES

At the time of medication dispensing, community pharmacy documented their pharmaceutical interventions when filling the prescription. A Poisson regression model was used to compare the number of interventions (primary outcome). The significance of the pharmaceutical interventions was categorized by the study team. Comparative analysis was used for the significance of interventions (secondary outcome).

RESULTS

The community pharmacy staff performed 183 interventions in the control group, and 169 in the intervention group. The regression model revealed a relative risk for an intervention of 0.78 (95% CI 0.62-0.99, p = 0.04) in the intervention group. The rate of clinically significant interventions was lower in the intervention group than in the control group (72 of 169 (42%) vs. 108 of 183 (59%), p < 0.01), but more economically significant interventions were performed (98, 58% vs. 80, 44%, p < 0.01).

CONCLUSIONS

The pragmatic in-hospital service increased the quality of prescriptions. The intervention group had a lower risk for the need for pharmaceutical interventions, and clinically significant interventions were less frequent. Overall, our pragmatic approach showed promising results to optimize post-discharge care.

The effect of a pharmaceutical transitional care program on rehospitalisations in internal medicine patients: an interrupted-time-series study

Background

Medication errors at transition of care can adversely affect patient safety. The objective of this study is to determine the effect of a transitional pharmaceutical care program on unplanned rehospitalisations.

Methods

An interrupted-time-series study was performed, including patients from the Internal Medicine department using at least one prescription drug. The program consisted of medication reconciliation, patient counselling at discharge, and communication to healthcare providers in primary care. The primary outcome was the proportion of patients with an unplanned rehospitalisation within six months post-discharge. Secondary outcomes were drug-related hospital visits, drug-related problems (DRPs), adherence, believes about medication, and patient satisfaction. Interrupted time series analysis was used for the primary outcome and descriptive statistics were performed for the secondary outcomes.

Results

In total 706 patients were included. At 6 months, the change in trend for unplanned rehospitalisations between usual care and the program group was non-significant (− 0.2, 95% CI -4.9;4.6). There was no significant difference for drug-related visits although visits due to medication reconciliation problems occurred less often (4 usual care versus 1 intervention). Interventions to prevent DRPs were present for all patients in the intervention group (mean: 10 interventions/patient). No effect was seen on adherence and beliefs about medication. Patients were significantly more satisfied with discharge counselling (68.9% usual care vs 87.1% program).

Conclusions

The transitional pharmaceutical care program showed no effect on unplanned rehospitalisations. This lack of effect is probably because the reason for rehospitalisations are multifactorial while the transitional care program focused on medication. There were less hospital visits due to medication reconciliation problems, but further large scale studies are needed due to the small number of drug-related visits. (Dutch trial register: NTR1519).

Hospitalization Drug Regimen Changes in Geriatric Patients and Adherence to Modifications by General Practitioners in Primary Care

OBJECTIVES

To evaluate the overall rate of adherence by general practitioners (GPs) to treatment modifications suggested at discharge from hospital and to assess the way communication between secondary and primary care could be improved.

DESIGN

Observational prospective cohort study.

SETTING

Patients hospitalized from the emergency department to the acute geriatric care unit of a university hospital.

PARTICIPANTS

206 subjects with a mean age of 85 years.

MEASUREMENTS

Changes in drug regimen undertaken during hospitalization were collected with the associated justifications. Adherence at one month by GPs to treatment modifications was assessed as well as modifications implemented in primary care with their rationale in case of non-adherence. Community pharmacists' and GPs' opinions about quality of communication and information transfer at hospital-general practice interface were investigated.

RESULTS

5.5 ± 2.8 drug regimen changes were done per patient during hospitalization. The rate of adherence by GPs to treatment modifications suggested at discharge from hospital was 83%. In most cases, non-adherence by GPs to treatment modifications done during hospitalization was due to dosage adjustments, symptoms resolution but also worsening of symptoms. The last of which was particularly true for psychotropic drugs. All GPs received their patients' discharge letters but the timely dissemination still needs to be improved. Only 6.6% of community pharmacists were informed of treatment modifications done during their patients' hospitalization.

CONCLUSION

Our findings showed a successful rate of adherence by GPs to treatment modifications suggested at discharge from hospital, due to the fact that optimization was done in a collaborative way between geriatricians and hospital pharmacists and that justifications for drug regimen changes were systematically provided in discharge letters. Communication processes at the interface between secondary and primary care, particularly with community pharmacists, must be strengthened to improve seamless care.

Hospital discharge: What are the problems, information needs and objectives of community pharmacists? A mixed method approach

BACKGROUND

After hospital discharge, community pharmacists are often the first health care professionals the discharged patient encounters. They reconcile and dispense prescribed medicines and provide pharmaceutical care. Compared to the roles of general practitioners, the pharmacists' needs to perform these tasks are not well known.

OBJECTIVE

This study aims to a) Identify community pharmacists' current problems and roles at hospital discharge, b) Assess their information needs, specifically the availability and usefulness of information, and c) Gain insight into pharmacists' objectives and ideas for discharge optimisation.

METHODS

A focus group was conducted with a sample of six community pharmacists from different Swiss regions. Based on these qualitative results, a nationwide online-questionnaire was sent to 1348 Swiss pharmacies.

RESULTS

The focus group participants were concerned about their extensive workload with discharge prescriptions and about gaps in therapy. They emphasised the importance of more extensive information transfer. This applied especially to medication changes, unclear prescriptions, and information about a patient's care. Participants identified treatment continuity as a main objective when it comes to discharge optimisation. There were 194 questionnaires returned (response rate 14.4%). The majority of respondents reported to fulfil their role as defined by the Joint-FIP/WHO Guideline on Good Pharmacy Practice (rather) badly. They reported many unavailable but useful information items, like therapy changes, allergies, specifications for "off-label" medication use or contact information. Information should be delivered in a structured way, but no clear preference for one particular transfer method was found. Pharmacists requested this information in order to improve treatment continuity and patient safety, and to be able to provide better pharmaceutical care services.

CONCLUSION

Surveyed Swiss community pharmacists rarely receive sufficient information along with discharge prescriptions, although it would be needed for medication reconciliation. According to the pharmacist's opinions, appropriate pharmaceutical care is therefore impeded.

Cost-effectiveness of a transitional pharmaceutical care program for patients discharged from the hospital

Background

To improve continuity of care at hospital admission and discharge and to decrease medication errors pharmaceutical care programs are developed. This study aims to determine the cost-effectiveness of the COACH program in comparison with usual care from a societal perspective.

Methods

A controlled clinical trial was performed at the Internal Medicine department of a general teaching hospital. All admitted patients using at least one prescription drug were included. The COACH program consisted of medication reconciliation, patient counselling at discharge, and communication to healthcare providers in primary care. The primary outcome was the proportion of patients with an unplanned rehospitalisation within three months after discharge. Also, the number of quality-adjusted life-years (QALYs) was assessed. Cost data were collected using cost diaries. Uncertainty surrounding cost differences and incremental cost-effectiveness ratios between the groups was estimated by bootstrapping.

Results

In the COACH program, 168 patients were included and in usual care 151 patients. There was no significant difference in the proportion of patients with unplanned rehospitalisations (mean difference 0.17%, 95% CI -8.85;8.51), and in QALYs (mean difference -0.0085, 95% CI -0.0170;0.0001). Total costs for the COACH program were non-significantly lower than usual care (-€1160, 95% CI -3168;847). Cost-effectiveness planes showed that the program was not cost-effective compared with usual care for unplanned rehospitalisations and QALYs gained.

Conclusion

The COACH program was not cost-effective in comparison with usual care. Future studies should focus on high risk patients and include other outcomes (e.g. adverse drug events) as this may increase the chances of a cost-effective intervention.

Dutch trial register NTR1519

Improving communication of medication changes using a pharmacist-prepared discharge medication management summary

Background Discontinuity of care between hospital and primary care is often due to poor information transfer. Medication information in medical discharge summaries (DS) is often incomplete or incorrect. The effectiveness and feasibility of hospital pharmacists communicating medication information, including changes made in the hospital, is not clearly defined. Objective To explore the impact of a pharmacist-prepared Discharge Medication Management Summary (DMMS) on the accuracy of information about medication changes provided to patients' general practitioners (GPs). Setting Two medical wards at a major metropolitan hospital in Australia. Method An intervention was developed in which ward pharmacists communicated medication change information to GPs using the DMMS. Retrospective audits were conducted at baseline and after implementation of the DMMS to compare the accuracy of information provided by doctors and pharmacists. GPs' satisfaction with the DMMS was assessed through a faxed survey. Main outcome measure Accuracy of medication change information communicated to GPs; GP satisfaction and feasibility of a pharmacist-prepared DMMS. Results At baseline, 263/573 (45.9%) medication changes were documented by doctors in the DS. In the post-intervention audit, more medication changes were documented in the pharmacist-prepared DMMS compared to the doctor-prepared DS (72.8% vs. 31.5%; p < 0.001). Most GPs (73.3%) were satisfied with the information provided and wanted to receive the DMMS in the future. Completing the DMMS took pharmacists an average of 11.7 minutes. Conclusion The accuracy of medication information transferred upon discharge can be improved by expanding the role of hospital pharmacists to include documenting medication changes.

Pharmacy led medicine reconciliation at hospital: A systematic review of effects and costs

BACKGROUND

Transition of patients care between settings presents an increased opportunity for errors and preventable morbidity. A number of studies outlined that pharmacy-led medicine reconciliation (MR) might facilitate safer information transfer and medication use. MR practice is not well standardized and often delivered in combination with other health care activities. The question regarding the effects and costs of pharmacy-led MR and the optimum MR practice is warranted of value.

OBJECTIVES

To review the evidence for the effects and costs/cost-effectiveness of complete pharmacy-led MR in hospital settings.

METHODS

A systematic review searching the following database was conducted up to the 13th December 2015; EMBASE & MEDLINE Ovid, CINAHL and the Cochrane library. Studies evaluating pharmacy-led MR performed fully from admission till discharges were included. Studies evaluated non-pharmacy-led MR at only one end of patient care or transfer was not included. Articles were screened and extracted independently by two investigators. Studies were divided into those in which: MR was the primary element of the intervention and labeled as "primarily MR" studies, or MR combined with non-MR care activities and labeled as "supplemented MR" studies. Quality assessment of studies was performed by independent reviewers using a pre-defined and validated tool.

RESULTS

The literature search identified 4065 citations, of which 13 implemented complete MR. The lack of evidence precluded addressing the effects and costs of MR.

CONCLUSIONS

The composite of optimum MR practice is not widely standardized and requires discussion among health professions and key organizations. Research focused on evaluating cost-effectiveness of pharmacy-led MR is lacking.

Custom and practice: a multi-center study of medicines reconciliation following admission in four acute hospitals in the UK

BACKGROUND

Many studies have highlighted the problems associated with different aspects of medicines reconciliation (MR). These have been followed by numerous recommendations of good practice shown in published studies to decrease error; however, there is little to suggest that practice has significantly changed. The study reported here was conducted to review local medicines reconciliation practice and compare it to data within previously published evidence.

OBJECTIVES

To determine current medicines reconciliation practice in four acute hospitals (A-D) in one region of the United Kingdom and compare it to published best practices.

METHOD

Quantitative data on key indicators were collected prospectively from medical wards in the four hospitals using a proforma compiled from existing literature and previous, validated audits. Data were collected on: i) time between admission and MR being undertaken; ii) time to conduct MR; iii) number and type of sources used to ascertain current medication; and iv) number, type and potential severity of unintended discrepancies. The potential severity of the discrepancies was retrospectively dually rated in 10% of the sample using a professional panel.

RESULTS

Of the 250 charts reviewed (54 Hospital A, 61 Hospital B, 69 Hospital C, 66 Hospital D), 37.6% (92/245) of patients experienced at least one discrepancy on their drug chart, with the majority of these being omissions (237/413, 57.1%). A total of 413 discrepancies were discovered, an overall mean of 1.69 (413/245) discrepancies per patient. The number of sources used to reconcile medicines varied with 36.8% (91/247) only using one source of information and the patient being used as a source in less than half of all medicines reconciliations (45.7%, 113/247). In three out of the four hospitals the discrepancies were most frequently categorized as potentially requiring increased monitoring or intervention.

CONCLUSION

This study shows higher rates of unintended discrepancies per patient than those in previous studies, with omission being the most frequently occurring type of discrepancy. None of the four centers adhered to current UK guidance on medicines reconciliation. All four centers demonstrated a strong reliance on General Practitioner (GP)-based sources. A minority of discrepancies had the potential to cause injury to patients and to increase utilization of health care resources. There is a need to review current practice and procedures at transitions in care to improve the accuracy of medication history-taking at admission by doctors and to encourage pharmacy staff to use an increased number of sources to validate the medication history. Although early research indicates that safety can be improved through patient involvement, this study found that patients were not involved in the majority of reconciliation encounters.

Drug related problems and pharmacist interventions in a geriatric unit employing electronic prescribing

BACKGROUND

Computerised physician order entry (CPOE) and the integration of a pharmacist in clinical wards have been shown to prevent drug related problems (DRPs).

OBJECTIVES

The primary objective was to make an inventory of the DRPs and resident pharmacist on-ward interventions (PIs) identified in a geriatric acute care unit using CPOE system. The secondary objective was to evaluate the physicians' acceptance of the proposed interventions.

SETTING

A 26-bed geriatric ward of a 1,300-bed teaching hospital.

METHOD

A 6-month descriptive study with prescription analysis and recommendations to physicians by a resident pharmacist during five half days a week.

MAIN OUTCOME MEASURES

Patients' characteristics, number of prescribed drugs per patient, nature and frequency of DRPs and PIs, physicians' acceptance and drugs questioned.

RESULTS

Resident pharmacist reviewed 311 patients and identified 241 DRPs. One hundred and fifty-two patients (49 %) had at least one DRP (mean ± SD age 87 ± 6 years, mean ± SD number of prescribed drugs 10.7 ± 3.4). Most frequent DRPs were: untreated indication (n = 58, 24.1 %), dose too high (n = 46, 19.1 %), improper administration (n = 31, 12.9 %) and drug interactions (n = 23, 9.5 %). The rate of physicians' acceptance was 90.0 % (7.5 % refusals, 2.5 % not assessable). DRPs related to CPOE system misuse (n = 35, 14.5 %) appeared as a worrying phenomenon (e.g., errors in selecting dosage or unit, or duplication of therapy).

CONCLUSION

A resident pharmacist detected various DRPs. Most PIs were accepted. DRPs related to the misuse of the CPOE system appeared potentially dangerous and need particular attention by healthcare professionals. The description of the DRPs is an essential step for implementation of targeted clinical pharmacy services in order to optimize pharmacists' job time.

Communicating medication changes to community pharmacy post-discharge: the good, the bad, and the improvements

BACKGROUND

Communication between hospital and community pharmacists when a patient is discharged from hospital can improve the accuracy of medication reconciliation, thus preventing unintentional changes and ensuring continuity of supply. It allows problems to be resolved before a patient requires a further supply of medication post-discharge. Despite evidence demonstrating the benefits of sharing information, community pharmacists' willingness to receive information and advances in information technology (particularly electronic discharge medication summaries), there is little published evidence to indicate whether communication has improved over the last 15 years. This study aimed to explore community pharmacists' experience of information sharing by and with their local hospital and GP practices.

OBJECTIVES

(1) To establish the extent to which community pharmacies currently receive discharge medication information, and for which patients.(2)To determine community pharmacy staff opinion on where and how current communication practice could be improved.

SETTING

Community Pharmacies in one Primary Care Organisation (PCO) in England.

METHOD

Semi-structured interviews conducted during visits to community pharmacies.

MAIN OUTCOME MEASURE

Reported receipt of discharge medication information from hospitals and general practices.

RESULTS

A total of 14 community pharmacies participated. Current provision of information to community pharmacies from hospitals regarding medication changes at discharge was reported to be inconsistent and lacking in quality. Where information was received it was predominantly for patients who receive their medicines in monitored dosage systems (MDS) rather than for the general population of patients. Some examples of "notable practice" were reported.

CONCLUSION

Community pharmacists received post-discharge information rarely and mainly for patients where the hospital perceived the patient's medication issues as "complex". Practice was inconsistent overall. These findings suggest that the potential of community pharmacists to improve patient safety after discharge from hospital is not being utilised.

Medication reviews by clinical pharmacists at hospitals lead to improved patient outcomes: a systematic review

Suboptimal medication use may lead to morbidity, mortality and increased costs. To reduce unnecessary patient harm, medicines management including medication reviews can be provided by clinical pharmacists. Some recent studies have indicated a positive effect of this service, but the quality and outcomes vary among studies. Hence, there is a need for compiling the evidence within this area. The aim of this systematic MiniReview was to identify, assess and summarize the literature investigating the effect of pharmacist-led medication reviews in hospitalized patients. Five databases (MEDLINE, EMBASE, CINAHL, Web of Science and the Cochrane Library) were searched from their inception to 2011 in addition to citation tracking and hand search. Only original research papers published in English describing pharmacist-led medication reviews in a hospital setting including minimum 100 patients or 100 interventions were included in the final assessment. A total of 836 research papers were identified, and 31 publications were included in the study: 21 descriptive studies and 10 controlled studies, of which 6 were randomized controlled trials. The pharmacist interventions were well implemented with acceptance rates from 39% to 100%. The 10 controlled studies generally show a positive effect on medication use and costs, satisfaction with the service and positive as well as insignificant effects on health service use. Several outcomes were statistically insignificant, but these were predominantly associated with low sample sizes or low acceptance rates. Therefore, future research within this area should be designed using rigorous design, large sample sizes and includes comparable outcome measures for patient health outcomes.

Reduce Readmissions with Pharmacy Programs; USP Updates Heparin Label; Insulin Concentration Rarely Needed on Orders

These medication errors have occurred in health care facilities at least once. They will happen again—perhaps where you work. Through education and alertness of personnel and procedural safeguards, they can be avoided. You should consider publishing accounts of errors in your newsletters and/or presenting them at your inservice training programs.

Your assistance is required to continue this feature. The reports described here were received through the Institute for Safe Medication Practices (ISMP) Medication Errors Reporting Program. Any reports published by ISMP will be anonymous. Comments are also invited; the writers’ names will be published if desired. ISMP may be contacted at the address shown below.

Errors, close calls, or hazardous conditions may be reported directly to ISMP through the ISMP Web site ( www.ismp.org ), by calling 800-FAIL-SAFE, or via e-mail at ismpinfo@ismp.org . ISMP guarantees the confidentiality and security of the information received and respects reporters’ wishes as to the level of detail included in publications.

[Assessment of a reconciliation and information programme for heart transplant patients]

INTRODUCTION

The objective is to assess a pharmaceutical care programme for heart transplant patients upon patient admission and discharge.

MATERIAL AND METHODS

Observational study of heart transplant patients, performed during the first quarter of 2007. Upon admission, the patient was interviewed regarding home treatments, adherence, allergies and adverse effects, and his/her prescriptions were compared with the last discharge report (drug reconciliation). At time of discharge, treatment was checked against the last hospital prescription (reconciliation) and an informative report was drawn up and personally delivered to the patient. Subsequently, a satisfaction questionnaire was carried out by telephone. Drug-related problems were recorded using Atefarm software.

RESULTS

The programme was applied to 24 patients upon admission and 23 upon discharge. No drug interactions were detected. Treatment adherence was higher than 90%. 37.5% of patients informed of an adverse reaction. Medication-related problems were identified in 16 patients (45.7%) for 6.6% of medications, most of which (38%) were for infection prophylaxis; medication omission was the most frequently-detected error. Positive evaluation of the information that was received was higher than 90%.

CONCLUSIONS

Pharmacotherapeutic follow-up upon admission and discharge resolves and prevents problems while improving patient information and satisfaction. Limitations on personnel prevent the population's requests from being met.

Informational needs of general practitioners regarding discharge medication: content, timing and pharmacotherapeutic advice

OBJECTIVE

To investigate the needs of Dutch general practitioners on discharge medication, both regarding content, timing and the appreciation of pharmacotherapeutic advice from clinical pharmacists.

SETTING

A general teaching hospital in Amsterdam, The Netherlands.

METHOD

A prospective observational study was performed. A questionnaire with regard to the content, optimal timing (including way of information transfer) and appreciation of pharmacotherapeutic advice was posted to 464 general practitioners. One reminder was sent.

MAIN OUTCOME MEASURE

Description of the needs of general practitioners was assessed. For each question and categories of comments frequency tables were made. The Fisher-exact test was used to study associations between the answers to the questions.

RESULTS

In total, 149 general practitioners (32%) responded. Most general practitioners (75%) experienced a delay in receiving discharge medication information and preferred to receive this on the day of discharge. GPs wished to receive this information mainly through e-mail (44%). There was a significant correlation (P = 0.002) between general practitioners who wanted to know whether and why medication had been stopped (87%) and changed (88%) during hospital admission. The general practitioners (88%) appreciated pharmacotherapeutic advice from clinical pharmacists.

CONCLUSION

This study indicates how information transfer on discharge medication to GPs can be optimised in the Netherlands. The information arrives late and GPs want to be informed on the day of discharge mainly by e-mail. GPs wish to know why medication is changed or discontinued and appreciate pharmacotherapeutic advice from clinical pharmacists.

Quality of medication use in primary care--mapping the problem, working to a solution: a systematic review of the literature

BACKGROUND

The UK, USA and the World Health Organization have identified improved patient safety in healthcare as a priority. Medication error has been identified as one of the most frequent forms of medical error and is associated with significant medical harm. Errors are the result of the systems that produce them. In industrial settings, a range of systematic techniques have been designed to reduce error and waste. The first stage of these processes is to map out the whole system and its reliability at each stage. However, to date, studies of medication error and solutions have concentrated on individual parts of the whole system. In this paper we wished to conduct a systematic review of the literature, in order to map out the medication system with its associated errors and failures in quality, to assess the strength of the evidence and to use approaches from quality management to identify ways in which the system could be made safer.

METHODS

We mapped out the medicines management system in primary care in the UK. We conducted a systematic literature review in order to refine our map of the system and to establish the quality of the research and reliability of the system.

RESULTS

The map demonstrated that the proportion of errors in the management system for medicines in primary care is very high. Several stages of the process had error rates of 50% or more: repeat prescribing reviews, interface prescribing and communication and patient adherence. When including the efficacy of the medicine in the system, the available evidence suggested that only between 4% and 21% of patients achieved the optimum benefit from their medication. Whilst there were some limitations in the evidence base, including the error rate measurement and the sampling strategies employed, there was sufficient information to indicate the ways in which the system could be improved, using management approaches. The first step to improving the overall quality would be routine monitoring of adherence, clinical effectiveness and hospital admissions.

CONCLUSION

By adopting the whole system approach from a management perspective we have found where failures in quality occur in medication use in primary care in the UK, and where weaknesses occur in the associated evidence base. Quality management approaches have allowed us to develop a coherent change and research agenda in order to tackle these, so far, fairly intractable problems.

Effect of medication reconciliation with and without patient counseling on the number of pharmaceutical interventions among patients discharged from the hospital

BACKGROUND

Hospital admissions are a risk factor for the occurrence of unintended medication discrepancies between drugs used before admission and after discharge. To diminish such discrepancies and improve quality of care, medication reconciliation has been developed. The exact contribution of patient counseling to the medication reconciliation process is unknown, especially not when compared with community pharmacy medication records, which are considered reliable in the Netherlands.

OBJECTIVE

To examine the effect of medication reconciliation with and without patient counseling among patients at the time of hospital discharge on the number and type of interventions aimed at preventing drug-related problems.

METHODS

A prospective observational study in a general teaching hospital was performed. Patients discharged from the pulmonology department were included. A pharmacy team assessed the interventions with and without patient counseling on discharge medications for each patient.

RESULTS

Two hundred sixty-two patients were included. Medication reconciliation without patient counseling was responsible for at least one intervention in 87% of patients (mean 2.7 interventions/patient). After patient counseling, at least one intervention (mean 5.3 interventions/patient) was performed in 97% of patients. After patient counseling, discharge prescriptions were frequently adjusted due to discrepancies in use or need of drug therapy. Most interventions led to the start of medication due to omission and dose changes due to incorrect dosages being prescribed. Patients also addressed their problems/concerns with use of the drug, which were discussed before discharge.

CONCLUSIONS

Significantly more interventions were identified after patient counseling. Therefore, patient information is essential in medication reconciliation.

Systematic review of the use of patients' own medications in acute care institutions

BACKGROUND

Patients' own medications (POM) are medications that patients have obtained in the community setting and bring to the hospital when admitted. The practice of using POMs has not been well studied.

OBJECTIVE

To identify benefits, risks and other impacts on the use of POM in hospitals.

METHODS

A systematic search of the literature and internet was conducted for articles in the English language dated from 1984 to 2004. PubMed, CINAHL, IPA, and Embase databases were searched with combinations of the following text words: patient, own, drug, medication, medicine. References of relevant articles and specific journals were hand-searched.

RESULTS

Nineteen primary studies that provided information on the benefits and risks of POMs were identified. Benefits included decreased wastage of POMs, improving the accuracy of admission orders, opportunities for patient counselling and continuity of care between acute and primary care. Hospitals must address liability and workload concerns but may benefit from savings to their drug budget.

DISCUSSION

Only a limited number of studies were found that addressed the benefits, risks and costs of using POMs in hospitals. These studies had small sample sizes with limitations in the quality of the study design. Nevertheless, the literature contained examples of benefits to the patient and hospital, as well as assistance with practical issues. Further research is needed to evaluate the benefits and risks of using POMs. Hospital policies should describe identification, storage and documentation procedures to address liability and risk concerns. Implementation of policies to use POMs should include an evaluation component, which could include a comprehensive economic analysis of drug costs and staff workload.

Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review

BACKGROUND

Over a quarter of hospital prescribing errors are attributable to incomplete medication histories being obtained at the time of admission. We undertook a systematic review of studies describing the frequency, type and clinical importance of medication history errors at hospital admission.

METHODS

We searched MEDLINE, EMBASE and CINAHL for articles published from 1966 through April 2005 and bibliographies of papers subsequently retrieved from the search. We reviewed all published studies with quantitative results that compared prescription medication histories obtained by physicians at the time of hospital admission with comprehensive medication histories. Three reviewers independently abstracted data on methodologic features and results.

RESULTS

We identified 22 studies involving a total of 3755 patients (range 33-1053, median 104). Errors in prescription medication histories occurred in up to 67% of cases: 10%- 61% had at least 1 omission error (deletion of a drug used before admission), and 13%- 22% had at least 1 commission error (addition of a drug not used before admission); 60%- 67% had at least 1 omission or commission error. Only 5 studies (n = 545 patients) explicitly distinguished between unintentional discrepancies and intentional therapeutic changes through discussions with ordering physicians. These studies found that 27%- 54% of patients had at least 1 medication history error and that 19%- 75% of the discrepancies were unintentional. In 6 of the studies (n = 588 patients), the investigators estimated that 11%-59% of the medication history errors were clinically important.

INTERPRETATION

Medication history errors at the time of hospital admission are common and potentially clinically important. Improved physician training, accessible community pharmacy databases and closer teamwork between patients, physicians and pharmacists could reduce the frequency of these errors.

Opportunities for Improving Post-Hospital Home Medication Management Among Older Adults

Effective post-hospital home medication management among older adults is a convoluted, error-prone process. Older adults, whose complex medication regimens are often changed at hospital discharge, are susceptible to medication-related problems (e.g. Adverse Drug Events or ADEs) as they resume responsibility for managing their medications at home. Human error theory frames the discussion of multi-faceted, interacting factors including care system functions, like discharge medication teaching that contribute to post-hospital ADEs. The taxonomy and causes of post-hospital ADEs and related risk factors are reviewed, as we describe in high-risk older adults a population that may benefit from targeted interventions. Potential solutions and future research possibilities highlight the importance of interdisciplinary teams, involvement of clinical pharmacists, use of transitional care models, and improved use of informational technologies.