Prescription and transcription errors in multidose-dispensed medications on discharge from hospital: an observational and interventional study

Integrating medication risk management interventions into regular automated dose dispensing service of older home care clients - a systems approach

BACKGROUND

Automated dose dispensing (ADD) services have been implemented in many health care systems internationally. However, the ADD service itself is a logistic process that requires integration with medication risk management interventions to ensure safe and appropriate medication use. National policies and regulations guiding ADD in Finland have recommended medication reconciliation, review, and follow-up for suitable risk management interventions. This implementation study aimed to develop a medication management process integrating these recommended risk management interventions into a regular ADD service for older home care clients.

METHODS

This study applied an action research method and was carried out in a home care setting, part of primary care in the City of Lahti, Finland. The systems-approach to risk management was applied as a theoretical framework.

RESULTS

The outcome of the systems-based development process was a comprehensive medication management procedure. The medication risk management interventions of medication reconciliation, review and follow-up were integrated into the medication management process while implementing the ADD service. The tasks and responsibilities of each health care professional involved in the care team became more explicitly defined, and available resources were utilized more effectively. In particular, the hospital pharmacists became members of the care team where collaboration between physicians, pharmacists, and nurses shifted from parallel working towards close collaboration. More efforts are needed to integrate community pharmacists into the care team.

CONCLUSION

The transition to the ADD service allows implementation of the effective medication risk management interventions within regular home care practice. These systemic defenses should be considered when national ADD guidelines are implemented locally. The same applies to situations in which public home care organizations responsible for services e.g., municipalities, purchase ADD services from private service providers.

Assessment of requests for medication-related follow-up after hospital discharge, and the relation to unplanned hospital revisits, in older patients: a multicentre retrospective chart review

BACKGROUND

The discharge of older hospitalised patients is critical in terms of patient safety. Inadequate transfer of information about medications to the next healthcare provider is a known problem, but there is a lack of understanding of this problem in settings where shared electronic health records are used. The aims of this study were to evaluate the prevalence of patients for whom hospitals sent adequate requests for medication-related follow-up at discharge, the proportion of patients with unplanned hospital revisits because of inadequate follow-up requests, and the association between medication reviews performed during hospitalisation and adequate or inadequate follow-up requests.

METHODS

We conducted a retrospective chart review. The study population was randomly selected from a cluster-randomised crossover trial which included patients 65 years or older who had been admitted to three hospitals in Sweden with shared electronic health records between hospital and primary care. Each patient was assessed with respect to the adequacy of the request for follow-up. For patients where the hospitals sent inadequate requests, data about any unplanned hospital revisits were collected, and we assessed whether the inadequate requests had contributed to the revisits. The association between medication reviews and adequate or inadequate requests was analysed with a Chi-square test.

RESULTS

A total of 699 patients were included. The patients' mean age was 80 years; an average of 10 medications each were prescribed on hospital admission. The hospitals sent an adequate request for 418 (60%) patients. Thirty-eight patients (14%) had a hospital revisit within six months of discharge which was related to an inadequate request. The proportion of adequate or inadequate requests did not differ between patients who had received a medication review during hospitalisation and those who had not (p = 0.83).

CONCLUSIONS

The prevalence of patients for whom the hospitals sent adequate follow-up requests on discharge was low. More than one in every ten who had an inadequate request revisited hospital within six months of discharge for reasons related to the request. Medication reviews conducted during hospitalisation did not affect the proportion of adequate or inadequate requests sent. A communication gap still exists despite the usage of a shared electronic health record between primary and secondary care levels.

'I've got a little list'-the scourge of a surgical junior. A quality improvement project to change the surgical patient list in a district general hospital

BACKGROUND

Junior doctors at the Royal Devon and Exeter Hospital spend hours every day creating and updating patient lists for all surgical specialties on Microsoft Excel spreadsheets. This not only consumes time that should be spent on clinical tasks, it allows for human errors, system errors and patient safety concerns. Our aim was to reduce time spent on the list and reduce the chance for error.

METHODS

We measured the time junior doctors spent creating and updating the surgical lists for one specialty, and on-call shifts. Our first Plan-Do-Study-Act (PDSA) cycle was to introduce clinical secretaries; this reduced the time spent by ward teams on the list but had no effect on the on-call team. We then worked with the hospital application developer to adapt software currently used to suit all surgical teams. Once completed, this software was rolled out alongside the existing spreadsheet method with a view to a switch after a transition period.

RESULTS

The introduction of clinical secretaries reduced the time spent on the colorectal surgery list from 99.22 min a day to 43.38 min. The on-call team however did not benefit from this intervention. Following the introduction of the new software, the day on-call team time spent on the list changed from 121 min a day to 4.66 min. The night on-call team time changed from 91 min to 7.38 min.

CONCLUSION

Reducing the time juniors spend compiling surgical lists has clear benefits to patients with extra time for junior doctors to clerk patients. The use of an automated system removes the chance of error in transcription of blood results. Due to the success of this project, colorectal, upper gastrointestinal, urology, vascular and on-call teams have adopted the new list permanently.

Analysis of medication errors at a large tertiary care hospital in Saudi Arabia: a retrospective analysis

Background Medication errors (MEs) are common in health care settings and pose a threat for the hospitalized population. Therefore, aspects of MEs were explored in a tertiary setting serving a diverse population. Objective To examine the occurrence, severity and reporting of MEs in hospitalized patients. Methods This retrospective analysis included 10,683 ME report forms that were received by the Medication Safety Unit of King Saud Medical City (KSMC) in 2015. ME outcomes were determined according to the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) Index for categorizing MEs algorithm. Results A total of 13,677 MEs in 912,500 prescriptions were reported. The incidence rate of MEs was 1.5% (13,677/912,500). The highest percentage (42.2%) of MEs occurred during the transcription stage, and 70.0% of MEs were reported as near misses. Wrong frequency and wrong concentration accounted for nearly half of the MEs. Conclusion We found 1.5 MEs per 100 prescriptions; more than two-thirds of the MEs were preventable and were intercepted before reaching the patients. Most MEs reported by pharmacists occurred at the transcription stage while wrong frequency was the most common error type encountered. Further studies should explore the clinical consequences of MEs at a healthcare institution.

The medication reconciliation process and classification of discrepancies: a systematic review

AIMS

Medication reconciliation is a part of the medication management process and facilitates improved patient safety during care transitions. The aims of the study were to evaluate how medication reconciliation has been conducted and how medication discrepancies have been classified.

METHODS

We searched MEDLINE, EMBASE, CINAHL, PubMed, International Pharmaceutical Abstracts (IPA), and Web of Science (WOS), in accordance with the PRISMA statement up to April 2016. Studies were eligible for inclusion if they evaluated the types of medication discrepancy found through the medication reconciliation process and contained a classification system for discrepancies. Data were extracted by one author based on a predefined table, and 10% of included studies were verified by two authors.

RESULTS

Ninety-five studies met the inclusion criteria. Approximately one-third of included studies (n = 35, 36.8%) utilized a 'gold' standard medication list. The majority of studies (n = 57, 60%) used an empirical classification system and the number of classification terms ranged from 2 to 50 terms. Whilst we identified three taxonomies, only eight studies utilized these tools to categorize discrepancies, and 11.6% of included studies used different patient safety related terms rather than discrepancy to describe the disagreement between the medication lists.

CONCLUSIONS

We suggest that clear and consistent information on prevalence, types, causes and contributory factors of medication discrepancy are required to develop suitable strategies to reduce the risk of adverse consequences on patient safety. Therefore, to obtain that information, we need a well-designed taxonomy to be able to accurately measure, report and classify medication discrepancies in clinical practice.

The effects of pharmacist intervention on emergency department visits in patients 80 years and older: subgroup analyses by number of prescribed drugs and appropriate prescribing

Background

Clinical pharmacist interventions have been shown to have positive effect on occurrence of drug-related issues as well as on clinical outcomes. However, evidence about which patients benefiting most from the interventions is limited. We aimed to explore whether pharmacist intervention is equally effective in preventing emergency department (ED) visits in patients with few or many prescribed drugs and in those with different levels of inappropriate prescribing.

Methods

Patient and outcome data from a randomized controlled trial exploring the clinical effects of a ward-based pharmacist intervention in patients, 80 years and older, were used. The patients were divided into subgroups according to the number of prescribed drugs (<5 or ≥5 drugs) and the level of inappropriate prescribing [using the Screening Tool Of Older People's potentially inappropriate Prescriptions (STOPP) and the Screening Tool to Alert doctors to Right Treatment (START) with a score of ≥2 (STOPP) and ≥1 (START) as cutoff points]. The effect of the intervention on the number of times the different subgroups visited the ED was analyzed.

Results

The pharmacist intervention was more effective with respect to the number of subsequent ED visits in patients taking <5 drugs on admission than in those taking ≥5 drugs. The rate ratio (RR) for a subsequent ED visit was 0.22 [95% confidence interval (CI) 0.09–0.52] for <5 drugs and 0.70 (95% CI 0.47–1.04) for ≥5 drugs (p = 0.02 for the interaction). The effect of intervention did not differ between patients with high or low STOPP or START scores.

Conclusion

In this exploratory study, the pharmacist intervention appeared to be more effective in preventing visits to the ED for patients who were taking fewer drugs before the intervention. Our analysis of STOPP and START scores indicated that the level of inappropriate prescribing on admission had no effect on the outcomes of intervention with respect to ED visits.

Prevalence of suboptimal drug treatment in patients with and without multidose drug dispensing--a cross-sectional study

PURPOSE

The aim of this study was to compare the prevalence of suboptimal drug treatment in older patients with and without multidose drug dispensing (MDD).

METHODS

In 200 hip fracture patients (≥65 years of age), originally recruited to a randomized controlled study in Sahlgrenska University Hospital in 2009, quality of drug treatment at study entry was compared between patients with and without MDD. Two specialist physicians independently assessed and then agreed on the quality of the drug treatment of each patient. Suboptimal drug treatment was defined as ≥1 STOPP (Screening Tool of Older Persons' potentially inappropriate Prescriptions) or ≥1 START (Screening Tool to Alert to Right Treatment) outcome assessed as clinically relevant after individual considerations had been made, i.e. over- or undertreatment (≥1 inappropriate and ≥1 missing drug, respectively).

RESULTS

Patients with MDD (n=100) differed from patients without MDD (n=100) in several ways, for example by being older (87.6 vs. 81.5 years) and using more drugs (8.4 vs. 5.9 drugs). The total number (±standard deviation) of inappropriate and/or missing drugs per person was greater in MDD patients compared with patients without MDD (1.92±1.52 vs. 1.06±1.29, P<0.0001); MDD patients had an additional 0.77 inappropriate drugs and an additional 0.09 missing drugs per person. The prevalence of suboptimal drug treatment was greater in patients with MDD than in those without MDD (86 vs. 55%, P<0.0001). Logistic regression revealed that suboptimal drug treatment was 8.0 times as common in MDD patients, after adjustments for age, sex, number of drugs, cognition, and residence (95% confidence interval 2.4; 26.9). Corresponding figures for over- and undertreatment were 2.9 (1.1; 7.4) and 1.8 (0.8; 4.3), respectively.

CONCLUSIONS

Suboptimal drug treatment, including over- and undertreatment, is more common in MDD patients than in patients who receive their drugs via ordinary prescriptions. The findings confirm safety concerns regarding quality of drug treatment in MDD patients.

Characterizing medication discrepancies among older adults during transitions of care: a systematic review focusing on discrepancy synonyms, data sources and classification terms

Medication reconciliation is a Joint Commission National Patient Safety Goal prioritized at transitions of care. Medication discrepancies are the reason for, and result of, medication reconciliation. However, their characterization in the literature has not been systematically studied. Older adults are at particularly high risk for medication discrepancies given the prevalence of polypharmacy in this population. The aim was to determine how medication discrepancies among older adults are defined during transitions of care by analyzing synonyms, medication data sources and classification terms. A systematic search of PubMed and EMBASE for primary literature involving medication discrepancies among adults aged ≥50 years during hospital care transitions was carried out. Reviewers consolidated data into like categories and used descriptive statistics to summarize findings. Out of 746 records retrieved, 35 studies were included in this review. In total, 19 studies (54%) were exclusive to adults over 65 years of age. Study settings included hospital discharge (n = 16; 46%), admission (n = 13; 37%) and mixed or multiple transitions (n = 6; 17%). Synonyms for discrepancies included inconsistencies, incongruences, inaccuracies and disagreements, among others. Common data sources included inpatient medication records and medication histories. A comprehensive, best possible medication history utilizing all available medication data sources was recorded in 51% of studies (n = 18), most consistently at admission. Most studies (n = 32; 91%) classified discrepancies; common classification terms included drug dose (n = 28; 88%), omission (n = 26; 80%) and commission (n = 16; 50%). In this first systematic review of medication discrepancy definitions, we found inconsistency across studies. Standardization and common discrepancy nomenclature is necessary for medication reconciliation outcomes to be compared, and to identify best practices to enhance safety. Safety implications are most salient in older adults given the number of medications and transitions of care to which they are exposed, as well as their sensitivity to adverse consequences of medication discrepancies.

Drug treatment in older people before and after the transition to a multi-dose drug dispensing system--a longitudinal analysis

Background

An association has been found between multi-dose drug dispensing (MDD) and use of many drugs. The aim of this study was to investigate the nature of this association, by performing a longitudinal analysis of the drug treatment before and after the transition to MDD.

Methods

Inclusion critera in this register-based study were inhabitants in Region Västra Götaland, Sweden, who, at ≥65 years of age and between 1^st July 2006 and 30^th June 2010, filled their first MDD prescription. For each individual, prescribed drugs were estimated at three month intervals before and after (maximum 3 years, respectively) the first date of filling an MDD prescription (index date).

Results

A total of 30,922 individuals matched the inclusion criteria (mean age: 83.2 years; 59.9% female). There was a temporal association between the transition to MDD and an increased number of drugs: 5.4±3.9 and 7.5±3.8 unique drugs three months before and after the index date, respectively, as well as worse outcomes on several indicators of prescribing quality. When either data before or after the index date were used, a multi-level regression analysis predicted the number of drugs at the index date at 5.76 (95% confidence limits: 5.71; 5.80) and 7.15 (7.10; 7.19), respectively, for an average female individual (83.2 years, 10.8 unique diagnoses, 2.4 healthcare contacts/three months). The predicted change in the number of drugs, from three months before the index date to the index date, was greater when data before this date was used as compared with data after this date: 0.12 (0.09; 0.14) versus 0.02 (−0.01; 0.05).

Conclusions

After the patients entered the MDD system, they had an increased number of drugs, more often potentially harmful drug treatment, and fewer changes in drug treatment. These findings support a causal relationship between such a system and safety concerns as regards prescribing practices.