Causes of discrepancies between medications listed in the national electronic prescribing system and patients' actual use of medications

[Concordance of medication prescription records in the hospitalised surgical patient]

INTRODUCTION

Electronic prescription is the prescription system that allows healthcare professionals to send medication prescriptions directly to community pharmacies and the outpatient unit of Hospital Pharmacy Services for dispensing. However, there is difficulty in obtaining a reliable pharmacotherapeutic history in chronic patients through electronic prescription upon hospital admission as a critical point for adequate treatment adaptation. Therefore, the pharmacist as a member of the multidisciplinary team must ensure, through medication conciliation, an adequate transition of care through the correct management of the treatment that the chronic patient requires during their hospitalization.

OBJECTIVES

To evaluate the quality of electronic prescription records for routine chronic treatment by analyzing the concordance of the electronic prescription.

MATERIAL AND METHODS

Observational, cross-sectional and retrospective study at the General University Hospital of Elche. Hospitalized patients in charge of the Orthopedic Surgery and Traumatology, Urology and Neurosurgery Services in which the responsible doctor requested medication reconciliation by the Pharmacy Service between January 2022 - December 2022 were included.

RESULTS

378 patients, 209 (55.3%) women and 169 (44.7%) men, with a mean age±standard deviation of 71.0±11.6 years and 69.0±11.8 years, respectively. The total percentage of patients with discrepancies in the electronic prescription with respect to the usual chronic treatment was 60.6%, reflecting that only 39.4% of the patients had non-discordant electronic prescriptions.

CONCLUSIONS

More than half of hospitalized surgical patients present discrepancies in the medications prescribed in the home electronic prescription, which justifies the importance of treatment reconciliation upon admission carried out by hospital pharmacists.

Discrepancies in Electronic Medical Prescriptions Found in a Hospital Emergency Department: A Prospective Observational Study

The medication in an electronic prescribing system (EPS) does not always match the patient's actual medication. This prospective study analyzes the discrepancies (any inconsistency) between medication prescribed using an EPS and the medication revised by the clinical pharmacist upon admission to the observation area of the emergency department (ED). Adult patients with multimorbidity and/or polypharmacy were included. The pharmacist used multiple sources to obtain the revised medication list, including patient/carer interviews. A total of 1654 discrepancies were identified among 1131 patients. Of these patients, 64.5% had ≥1 discrepancy. The most common types of discrepancy were differences in posology (43.6%), commission (34.7%), and omission (20.9%). Analgesics (11.1%), psycholeptics (10.0%), and diuretics (8.9%) were the most affected. Furthermore, 52.5% of discrepancies affected medication that was high-alert for patients with chronic illnesses and 42.0% of medication involved withdrawal syndromes. Discrepancies increased with the number of drugs (ρ = 0.44, p < 0.01) and there was a difference between non-polypharmacy patients, polypharmacy ones and those with extreme polypharmacy (p < 0.01). Those aged over 75 years had a higher number of prescribed medications and discrepancies occurred more frequently compared with younger patients. The number of discrepancies was larger in women than in men. The EPS medication record requires verification from additional sources, including patient and/or carer interviews.

Health professionals' experience and perceived obstacles with managing patients' medication information in Norway: cross-sectional survey

BACKGROUND

Access to correct and up to date medication information is crucial for effective patient treatment. However, persistent discrepancies exist. This study examines the experiences and challenges health professionals encounter while utilizing current digital solutions in the Norwegian healthcare system to manage patients' medication information.

METHODS

A cross-sectional descriptive analysis using quantitative survey data was conducted to investigate how health professionals managed patients' medication information. Content analysis was used to analyze free-text responses concerning challenges they encountered when transferring medication information and to identify factors deemed necessary for implementing the Shared Medication List in Norway.

RESULTS

A total of 262 doctors and 244 nurses responded to the survey. A higher percentage of doctors (72.2%) expressed concerns regarding obtaining accurate and updated medication lists than nurses (42.9%), particularly for patients with polypharmacy (35.3%) or transitioning between primary and specialist care services (27.6%). The patient's verbal information was the main source for hospital doctors (17%) to obtain an overview of the patient's medication usage, while general practitioners (19%) and nurses (working in both primary and specialist care services, 28% and 27% respectively) predominantly relied on electronic prescriptions. Doctors, in particular general practitioners, reported carrying excessive responsibilities in coordinating with other health actors (84.8%) and managing patients' medication information. The vast majority of both doctors (84.4%) and nurses (82.0%) were in favor of a Shared Medication List. However, about a third of doctors (36.3%) and nurses (29.8%) expressed the need for a more balanced responsibility in updating and managing patients' medication information, while ensuring compatibility with existing digital systems.

CONCLUSIONS

Fragmented resources for medication information and unclear responsibilities were prevalent concerns among both professional groups. Doctors voiced more concern than nurses about the accuracy of patients' medication list. While both groups are positive about a shared medication list, successful implementation requires proactive training initiatives and clearer role clarification.

Accuracy of an electronic prescribing system for standard treatments

BACKGROUND

The prescription system known as RELE is the electronic prescribing and dispensing system that has been used by the Balearic Islands Health Service (IB-SALUT, Spain) since April 2006. This repository contains patients' computerised medication profiles (CMPs). Data from studies conducted in other settings have shown the existence of discrepancies between the medications recorded in patients' CMPs and the medications actually taken by the patients.

METHODS

Chronic medications recorded in RELE CMPs were compared with those obtained through a structured clinical interview with patients or the persons responsible for the administration of the patients' medications. A descriptive analysis of each discrepancy was performed. Potentially associated factors were analysed using Pearson's χ2 test.

RESULTS

Of the 215 CMPs studied, 168 (78%) had discrepancies. The rate of discrepancies in the general population inferred from these results ranged from 72.57% to 83.71%, with a 95% confidence level. Polypharmacy was associated with the presence of discrepancies (χ2: 39.998, 1 df, p<0.0001) as well as patient age >65 years (χ2: 18.949, 2df, p<0.0001) and higher comorbidity (χ2: 12.548, 2 df, p=0.002). The association between the types of discrepancies and their causes showed that prescriber-generated dosage errors were the most common errors (n=116; 27%), followed by patient-generated commissions (n=79; 18%), patient-generated dosage errors (n=77; 18%) and prescriber-generated commissions (n=73; 17%).

CONCLUSION

The rate of discrepancies identified in this study shows that clinical interviews with patients during transitions of care continue to be essential.

Developing and piloting a cross-sectoral hospital pharmacist intervention for patients in transition between hospital and general practice

Background

Healthcare is challenged by a rapidly growing group of patients with multi-morbidity and polypharmacy. Increasing activity and specialization puts pressure on healthcare sectors. Medication errors in cross-sectoral transition of patients are often seen. The aim of the study was to explore drug-related problems (DRPs) in the transition of patients between sectors and to develop and pilot-test a cross-sectoral hospital pharmacist intervention to overcome some of these problems.

Methods

DRPs in cross-sectoral transitions were explored from four perspectives; the literature, the primary and secondary healthcare sector and the patients. An intervention was developed from the findings through co-creation between pharmacists, doctors and a nurse. The intervention was piloted and evaluated from data on the included patients and the activities performed.

Results

DRPs in transitions from general practice (GP) to hospital were caused by inadequate focus on updating the Shared Medication Record (SMR). For patients being discharged, DRPs were described with multiple facets; for example, missing information on medication changes, lacking patient involvement and problems with dose-dispensed medicine or electronic prescriptions. An intervention with a pharmacist in a shared employment between Hospital Pharmacy and GP was developed and piloted. The intervention included medication reconciliation and updating SMR for patients referred to hospital; and medication review, overview of medication changes and follow-up telephone calls for patients discharged from hospital. The intervention identified and solved several DRPs; in this way, medication errors were avoided. Access to health records in both sectors was important in the identification and resolution of DRPs.

Conclusion

DRPs in cross-sectoral transitions are multifaceted and the experiences depend on the point of view. The cross-sectoral hospital pharmacist intervention identified and solved several DRPs and medication errors were avoided. The intervention made sense to both healthcare sectors and patients. Shared employment and unique access to health records in both sectors showed to be of importance in the identification and resolution of DRPs.

Plain language summary

Development and pilot-test of a pharmacist intervention for patients in transition between hospital and general practice Background: Healthcare is challenged by a rapidly growing group of patients with multiple chronic diseases treated with several drugs at the same time. The aim of the study was to explore drug-related problems in the transition of patients between the hospital and patients' general practitioner and to develop and pilot-test a pharmacist intervention to overcome some of these problems.Methods: Drug-related problems in patient transitions were explored from the perspectives of the hospital, the general practitioner, the patients and the literature. An intervention was developed from the findings by pharmacists, doctors and a nurse. The intervention was pilot-tested and evaluated from the descriptions of the included patients and activities performed.Results: Drug-related problems in transitions from general practice to hospital were caused by inadequate focus on updating the Shared Medication Record.For patients being discharged, drug-related problems were related to for examplemissing information on medication changessparse involvement of the patient in their own treatmentproblems with medicine dispensed on a dose dispensing machine at the local pharmacy.An intervention with a pharmacist in a shared employment between Hospital Pharmacy and general practice was developed and piloted. The intervention includedtalking to the patient about their medication and updating the Shared Medication Record for patients referred to hospitalmedication review, overview of medication changes and follow-up telephone calls for patients discharged from hospital to general practice.The intervention identified and solved several drug-related problems. Access to health records in both the general practice and at the hospital was important in the identification of drug-related problems.Conclusions: Drug-related problems in cross-sectoral transitions are multifaceted. The pharmacist intervention identified and solved several drug-related problems. The intervention made sense to the general practitioner, hospital and patients. Shared employment and unique access to health records in both the general practice and at the hospital showed to be of importance in the identification of drug-related problems.

Healthcare professionals' perceptions of a web-based application for using the new National Medication List in Sweden

Objective

During the first stage of implementing the National Medication List in Sweden, a web-based application called Förskrivningskollen (FK) was launched. FK includes information about a patient's prescribed and dispensed medications, and it works as a backup system until the healthcare electronic health record (EHR) systems are fully integrated. The aim of this study was to examine the healthcare professionals' experiences and perceptions of FK.

Methods

The study applied a mixed methods approach, with statistics about the use of FK and a survey with open and closed questions. The respondents (n  =  288) were healthcare professionals who were users or potential users of FK.

Results

Overall there was little knowledge about FK and uncertainty regarding working routines and the regulations connected to the application. Lack of interoperability with the EHRs made FK time-consuming to use. Respondents said that the information in FK was not updated, and they were concerned that using FK could lead to a false sense of security about the accuracy of the list. Most clinical pharmacists thought FK added benefit to their clinical work, while as a group, physicians were more ambivalent about FK's benefit.

Conclusions

The concerns of healthcare professionals give important insights for future implementation of shared medication lists. Working routines and regulations linked to FK need to be clarified. In Sweden, the potential value of a national shared medication list will probably not be realized until it is fully integrated into the EHR in a way that supports healthcare professionals' desired ways of working.

Issues with the Swedish e-prescribing system - An analysis of health information technology-related incident reports using an existing classification system

Objective

To identify issues with the Swedish e-prescribing system and devise a set of recommendations to overcome the identified challenges.

Methods

A number of health information technology-related incidents were collected retrospectively from various sources using purposive and snowball sampling. A search term containing five keywords was used to identify the electronic prescription-related incidents. The identified incidents (n = 24) were subjected to an existing framework, i.e., the Health Information Technology Classification System. Special attention was paid to the software-related issues, which were analysed using thematic analysis.

Results

Several types of software-related issues (n = 22) were identified: system configuration, interface with other software systems or components, software functionality, data storage and backup, record migration, software not accessible, and network/server down or slow. Both human and technical factors contributed to these incidents, including prescriptions not cancelled actively, drug handling errors, software programming errors, and system updates/upgrades. These software problems led to various consequences, such as incidents affecting multiple patients’ care management, delays in patient care, and risks of serious deterioration of health. Several temporary initiatives or administrative adjustments, for instance, cover letters to patients and local strategies, were used to overcome some of these challenges.

Conclusions

This study provides insights into the challenges related to the e-prescribing system, contributing factors, consequences, and actions taken to mitigate those risks. Therefore, healthcare organisations using the e-prescribing system should adopt the provided recommendations to minimise the risks of design and developmental challenges, implementation and use-related issues, and the problems related to monitoring, evaluation, and optimisation.

Health care professionals' perspectives on medication safety among older migrants with cognitive impairment exposed to polypharmacy – A qualitative explorative study

Background

Older migrants with cognitive impairment exposed to polypharmacy constitute a vulnerable group of patients. To our knowledge, evidence on medication safety among this patient group with multiple risk factors is lacking.

Objectives

To explore the perspectives of health care professionals on medication safety among older migrants with cognitive impairment taking five or more medications daily.

Methods

A total of 34 health care professionals (general practitioners and hospital-, community pharmacy-, and home care staff) participated in the study, comprising nine focus groups and one semi-structured interview, and shared their perspectives on medication safety among older migrants with cognitive impairment exposed to polypharmacy. The analysis was inspired by Revsbæk and Tanggaard's “Analyzing in the Present” and was followed by systematic text condensation.

Results

Three main themes emerged: (i) the importance of relationships in medication safety, (ii) culture and finances as risk factors, and (iii) the health care system as a risk factor. Subthemes and codes were related within and across main themes and revealed a high level of complexity within the barriers to medication safety. Some of these barriers were closely related to characteristics of this specific patient group, while others were more general barriers that also affected other patient groups. Participants found that these more general problems were complicated further by language barriers and cognitive impairment when working with this patient group.

Conclusion

Health care professionals across various sectors and professions experienced several barriers that threatened medication safety among older migrants with cognitive impairment exposed to polypharmacy. Closer collaboration between health care professionals, patients, and relatives is required to improve medication safety.

Medicines Reconciliation in the Emergency Department: Important Prescribing Discrepancies between the Shared Medication Record and Patients’ Actual Use of Medication

Medication reconciliation is crucial to prevent medication errors. In Denmark, primary and secondary care physicians can prescribe medication in the same electronic prescribing system known as the Shared Medication Record (SMR). However, the SMR is not always updated by physicians, which can lead to discrepancies between the SMR and patients’ actual use of medication. These discrepancies may compromise patient safety upon admission to the emergency department (ED). Here, we investigated (a) the occurrence of discrepancies, (b) factors associated with discrepancies, and (c) the percentage of patients accessible to a clinical pharmacist during pharmacy working hours. The study included all patients age ≥ 18 years who were admitted to the Hvidovre Hospital ED on three consecutive days in June 2020. The clinical pharmacists performed medicines reconciliation to identify prescribing discrepancies. In total, 100 patients (52% male; median age 66.5 years) were included. The patients had a median of 10 [IQR 7–13] medications listed in the SMR and a median of two [IQR 1–3.25] discrepancies. Factors associated with increased rate of prescribing discrepancies were age < 65 years, time since last update of the SMR ≥ 115 days, and patients’ self-dispensing their medications. Eighty-four percent of patients were available for medicines reconciliations during the normal working hours of the clinical pharmacist. In conclusion, we found that discrepancies between the SMR and patients’ actual medication use upon admission to the ED are frequent, and we identified several risk factors associated with the increased rate of discrepancies.