1
|
Kulawiak J, Jacobson JL, Miller JA, Hovey SW. Evaluation of a Pharmacist-Driven Discharge Medication Reconciliation Service Pilot at a Children's Hospital. J Pediatr Pharmacol Ther 2024; 29:530-538. [PMID: 39411418 PMCID: PMC11472409 DOI: 10.5863/1551-6776-29.5.530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/17/2023] [Indexed: 10/19/2024]
Abstract
OBJECTIVE The purpose of this study was to evaluate the feasibility of a pharmacist-driven discharge medication reconciliation (DMR) service at our children's hospital by completing a 2-week pilot on a general pediatrics unit. METHODS This was a prospective study and included patients discharged during pilot hours whose DMR was completed by the pharmacist. The primary outcome was evaluation of time required for a pharmacist to complete the DMR. Secondary outcomes included classification of pharmacist interventions made and their associated cost-avoidance, medication-related problems reported within 14 days of discharge, hospital readmission due to medication problems within 30 days of discharge, and medical resident satisfaction assessed via prepilot and postpilot surveys. RESULTS A total of 67 patients had their DMR completed by a pharmacist during the pilot. The pharmacist spent an average of 30 minutes completing each DMR, although this was variable, as evidenced by an SD of 36.4 minutes. Pharmacists documented 89 total interventions during the study period. The most common intervention types were therapeutic optimization (32.6%) and modification of directions (29.2%). Total estimated cost-avoidance during the study pilot was $84,048.01. For the pilot population, 1 medication-related problem was identified within 14 days of discharge. There were no medication-related readmissions identified. Medical residents reported increased confidence that the DMR was completed accurately and satisfaction with the DMR process during the pilot compared with before the pilot. CONCLUSIONS Implementing a pharmacist discharge medication service requires consideration of -pharmacist time and salary, which may be offset by cost-avoidance.
Collapse
Affiliation(s)
- Jessica Kulawiak
- Department of Pharmacy (JK, JLJ, JAM), Rush University Medical Center, Chicago, IL
| | - Jessica L. Jacobson
- Department of Pharmacy (JK, JLJ, JAM), Rush University Medical Center, Chicago, IL
| | | | - Sara W. Hovey
- Department of Pharmacy Practice (SH), University of Illinois at Chicago, College of Pharmacy, Chicago, IL
| |
Collapse
|
2
|
Adducchio S, Grant ED, Fonseca LD, Omoloja A, Kumar G. Reducing Discharge Medication Reconciliation Errors at a Pediatric Neurology Inpatient Unit. Neurol Clin Pract 2024; 14:e200270. [PMID: 38524835 PMCID: PMC10955335 DOI: 10.1212/cpj.0000000000200270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/08/2024] [Indexed: 03/26/2024]
Abstract
Background and Objectives Medication reconciliation errors are a common problem in health care, particularly during transitions of care. Discharge medication reconciliation (DMR) errors in a pediatric setting can range from 26% to 42.2%. We conducted a quality improvement project to decrease DMR error rate at Dayton Children's Hospital in Dayton, Ohio. Methods We conducted 2 interventions, each with 3 Plan-Do-Study-Act cycles from September 2021 through February 2023. The first intervention focused on using current specialty neurology nurses as scribes and creating a template note to include the plan of care and review of DMR before discharge. Our second intervention consisted of standardizing the seizure rescue medication order by creating an order panel within our electronic medical record system for all the rescue medications presently available. Medication errors were documented by the specialty neurology nurse during a phone conversation on the next business day post discharge. DMR error rates were calculated for each week using a control chart. Medication errors and patient harm were classified according to the National Coordinating Council for Medication Error Reporting and Prevention Index. Results One hundred six errors were noted. Of these, 98 (92%) occurred in patients with seizure and 64 (60%) were related to prescription of seizure rescue medication specifically. The baseline error rate was calculated at 15.7% or 7 errors per month (January 2021 through June 2021). The average error rate dropped from 15.7% to 5.3% (2 errors per month) after initiation of our first intervention (September 2021). Twelve weeks after initiation of the second intervention, a 2.9% (1 error per month) was noted. Afterward, there was a ten-week period of 0% errors. Discussion Sustainable reduction of DMR errors in pediatric patients with epilepsy was achieved by using specialty neurology nurses to scribe the care plan and creating order panels to facilitate accuracy of discharge medication orders without additional cost to the hospital.
Collapse
Affiliation(s)
- Sara Adducchio
- Department of Neurology (SA, LDF, GK), Dayton Children's Hospital; Department of Pediatrics (EDG, GK), Wright State University Boonshoft School of Medicine, Dayton; and Department of Nephrology (AO), Dayton Children's Hospital, OH
| | - Ethan D Grant
- Department of Neurology (SA, LDF, GK), Dayton Children's Hospital; Department of Pediatrics (EDG, GK), Wright State University Boonshoft School of Medicine, Dayton; and Department of Nephrology (AO), Dayton Children's Hospital, OH
| | - Laura D Fonseca
- Department of Neurology (SA, LDF, GK), Dayton Children's Hospital; Department of Pediatrics (EDG, GK), Wright State University Boonshoft School of Medicine, Dayton; and Department of Nephrology (AO), Dayton Children's Hospital, OH
| | - Abiodun Omoloja
- Department of Neurology (SA, LDF, GK), Dayton Children's Hospital; Department of Pediatrics (EDG, GK), Wright State University Boonshoft School of Medicine, Dayton; and Department of Nephrology (AO), Dayton Children's Hospital, OH
| | - Gogi Kumar
- Department of Neurology (SA, LDF, GK), Dayton Children's Hospital; Department of Pediatrics (EDG, GK), Wright State University Boonshoft School of Medicine, Dayton; and Department of Nephrology (AO), Dayton Children's Hospital, OH
| |
Collapse
|
3
|
Gunkelman SM, Jamerino-Thrush J, Genet K, Blackford M, Jones K, Bigham MT. Improving Accuracy of Medication Reconciliation for Hospitalized Children: A Quality Project. Hosp Pediatr 2024; 14:300-307. [PMID: 38529561 DOI: 10.1542/hpeds.2023-007396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND AND OBJECTIVES Medication reconciliation is a complex, but necessary, process to prevent patient harm from medication discrepancies. Locally, the steps of medication reconciliation are completed consistently; however, medication errors still occur, which suggest process inaccuracies. We focused on removal of unnecessary medications as a proxy for accuracy. The primary aim was to increase the percentage of patients admitted to the pediatric hospital medicine service with at least 1 medication removed from the home medication list by 10% during the hospital stay by June of 2022. METHODS Using the Model for Improvement, a multidisciplinary team was formed at a children's hospital, a survey was completed, and multiple Plan-Do-Study-Act cycles were done focusing on: 1. simplifying electronic health record processes by making it easier to remove medications; 2. continuous resident education about the electronic health record processes to improve efficiency and address knowledge gaps; and 3. auditing charts and real-time feedback. Data were monitored with statistical process control charts. RESULTS The project exceeded the goal, improving from 35% to 48% of patients having at least 1 medication removed from their home medication list. Improvement has sustained for 12 months. CONCLUSIONS The combination of interventions including simplifying workflow, improving education, and enhancing accountability resulted in more patients with medications removed from their home medication list.
Collapse
Affiliation(s)
- Samantha M Gunkelman
- Divisions of Pediatric Hospital Medicine
- Departments of Quality Services
- Department of Pediatrics, Northeast Ohio Medical University, Rootstown, Ohio
| | | | - Katherine Genet
- Emergency Medicine
- Medical Education
- Department of Pediatrics, Northeast Ohio Medical University, Rootstown, Ohio
| | - Martha Blackford
- Clinical Pharmacology and Toxicology
- Department of Pediatrics, Northeast Ohio Medical University, Rootstown, Ohio
| | - Kerwyn Jones
- Orthopedic Surgery, Akron Children's Hospital, Akron, Ohio
| | - Michael T Bigham
- Critical Care Medicine
- Departments of Quality Services
- Department of Pediatrics, Northeast Ohio Medical University, Rootstown, Ohio
| |
Collapse
|
4
|
Ring LM, Cinotti J, Hom LA, Mullenholz M, Mangum J, Ahmed-Winston S, Cheng JJ, Randolph E, Harahsheh AS. A Quality Improvement Initiative to Improve Pediatric Discharge Medication Safety and Efficiency. Pediatr Qual Saf 2023; 8:e671. [PMID: 37434598 PMCID: PMC10332828 DOI: 10.1097/pq9.0000000000000671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 06/13/2023] [Indexed: 07/13/2023] Open
Abstract
Medication errors are a leading safety concern, especially for families with limited English proficiency and health literacy, and patients discharged on multiple medications with complex schedules. Integration of a multilanguage electronic discharge medication platform may help decrease medication errors. This quality improvement (QI) project's primary aim (process measure) was to increase utilization in the electronic health record (EHR) of the integrated MedActionPlanPro (MAP) for cardiovascular surgery and blood and marrow transplant patients at hospital discharge and for the first clinic follow-up visit to 80% by July 2021. Methods This QI project occurred between August 2020 and July 2021 on 2 subspecialty pediatric acute care inpatient units and respective outpatient clinics. An interdisciplinary team developed and implemented interventions, including integration of MAP within EHR; the team tracked and analyzed outcomes for discharge medication matching, and efficacy and safety MAP integration occurred with a go-live date of February 1, 2021. Statistical process control charts tracked progress. Results Following the implementation of the QI interventions, there was an increase from 0% to 73% in the utilization of the integrated MAP in the EHR across the acute care cardiology unit-cardiovascular surgery/blood and marrow transplant units. The average user hours per patient (outcome measure) decreased 70% from the centerline of 0.89 hours during the baseline period to 0.27 hours. In addition, the medication matching between Cerner inpatient and MAP inpatient increased significantly from baseline to postintervention by 25.6% (P < 0.001). Conclusion MAP integration into the EHR was associated with improved inpatient discharge medication reconciliation safety and provider efficiency.
Collapse
Affiliation(s)
- Lisa M. Ring
- Children’s National Heart Institute, Children’s National Hospital, Washington, D.C
- Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, D.C
- Department of Advanced Practice Providers, Children’s National Hospital, Washington, D.C
| | - Jamie Cinotti
- Global Services, Children’s National Hospital, Washington, D.C
| | - Lisa A. Hom
- Children’s National Heart Institute, Children’s National Hospital, Washington, D.C
- Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, D.C
| | - Mary Mullenholz
- Children’s National Heart Institute, Children’s National Hospital, Washington, D.C
| | - Jordan Mangum
- Children’s National Heart Institute, Children’s National Hospital, Washington, D.C
| | | | - Jenhao Jacob Cheng
- Children’s National Heart Institute, Children’s National Hospital, Washington, D.C
| | - Ellie Randolph
- Global Services, Children’s National Hospital, Washington, D.C
| | - Ashraf S. Harahsheh
- Children’s National Heart Institute, Children’s National Hospital, Washington, D.C
- Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, D.C
| |
Collapse
|
5
|
Rabbani N, Ho M, Dash D, Calway T, Morse K, Chadwick W. Pseudorandomized Testing of a Discharge Medication Alert to Reduce Free-Text Prescribing. Appl Clin Inform 2023; 14:470-477. [PMID: 37015344 PMCID: PMC10266904 DOI: 10.1055/a-2068-6940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 04/03/2023] [Indexed: 04/06/2023] Open
Abstract
BACKGROUND Pseudorandomized testing can be applied to perform rigorous yet practical evaluations of clinical decision support tools. We apply this methodology to an interruptive alert aimed at reducing free-text prescriptions. Using free-text instead of structured computerized provider order entry elements can cause medication errors and inequity in care by bypassing medication-based clinical decision support tools and hindering automated translation of prescription instructions. OBJECTIVE The objective of this study is to evaluate the effectiveness of an interruptive alert at reducing free-text prescriptions via pseudorandomized testing using native electronic health records (EHR) functionality. METHODS Two versions of an EHR alert triggered when a provider attempted to sign a discharge free-text prescription. The visible version displayed an interruptive alert to the user, and a silent version triggered in the background, serving as a control. Providers were assigned to the visible and silent arms based on even/odd EHR provider IDs. The proportion of encounters with a free-text prescription was calculated across the groups. Alert trigger rates were compared in process control charts. Free-text prescriptions were analyzed to identify prescribing patterns. RESULTS Over the 28-week study period, 143 providers triggered 695 alerts (345 visible and 350 silent). The proportions of encounters with free-text prescriptions were 83% (266/320) and 90% (273/303) in the intervention and control groups, respectively (p = 0.01). For the active alert, median time to action was 31 seconds. Alert trigger rates between groups were similar over time. Ibuprofen, oxycodone, steroid tapers, and oncology-related prescriptions accounted for most free-text prescriptions. A majority of these prescriptions originated from user preference lists. CONCLUSION An interruptive alert was associated with a modest reduction in free-text prescriptions. Furthermore, the majority of these prescriptions could have been reproduced using structured order entry fields. Targeting user preference lists shows promise for future intervention.
Collapse
Affiliation(s)
- Naveed Rabbani
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States
| | - Milan Ho
- Department of Pediatrics, University of Texas Southwestern Medical School, Dallas, Texas, United States
| | - Debadutta Dash
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California, United States
| | - Tyler Calway
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States
| | - Keith Morse
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States
- Division of Hospital Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States
| | - Whitney Chadwick
- Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States
- Division of Hospital Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, United States
| |
Collapse
|
6
|
OUP accepted manuscript. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2022; 30:420-426. [DOI: 10.1093/ijpp/riac037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 04/01/2022] [Indexed: 11/12/2022]
|