Implementation of a medication reconciliation process in an ambulatory internal medicine clinic

Clinical pharmacist interventions in the transition of care in a mental health hospital: case reports focused on the medication reconciliation process

The transition of care represents a key point in the hospital admission and discharge process. A comprehensive transition could lead to fewer medication-related problems. The hospital clinical pharmacist could help in the transition of care process with a comprehensive medication reconciliation process, which has been poorly described in mental health hospitals. This study presents two clinical cases in which hospital clinical pharmacists identified omitted medications and other medication-related issues, including medication errors, during the transition of care in a mental health hospital. These positive experiences may encourage other countries to establish similar collaborations with hospital clinical pharmacists in mental health hospitals.

Participatory research to improve medication reconciliation for older adults in the community

INTRODUCTION

Medication reconciliation, a technique that assists in aligning a care team's understanding of an individual's true medication regimen, is vital to optimize medication use and prevent medication errors. Historically, most medication reconciliation research has focused on institutional settings and transitional care, with comparatively little attention given to medication reconciliation in community settings. To optimize medication reconciliation for community-dwelling older adults, healthcare professionals and older adults must be engaged in co-designing processes that create sustainable approaches.

METHODS

Academic researchers, older adults, and community- and health system-based healthcare professionals engaged in a participatory process to better understand medication reconciliation barriers and co-design solutions. The initiative consisted of two participatory research approaches: (1) Sparks Innovation Studios, which synthesized professional expertise and opinions, and (2) a Community Consultation Studio with older adults. Input from both groups informed a list of possible solutions and these were ranked based on evaluative criteria of feasibility, person-centeredness, equity, and sustainability.

RESULTS

Sparks Innovation Studios identified a lack of ownership, fragmented healthcare systems, and time constraints as the leading barriers to medication reconciliation. The Community Consultation Studio revealed that older adults often feel dismissed in medical encounters and perceive poor communication with and among providers. The Community Consultation Studio and Sparks Innovation Studios resulted in four highly-ranked solutions to improve medication reconciliation: (1) support for older adults to improve health literacy and ownership; (2) ensuring medication indications are included on prescription labels; (3) trainings and incentives for front-line staff in clinic settings to become champions for medication reconciliation; and (4) electronic health record improvements that simplify active medication lists.

CONCLUSION

Engaging community representatives with academic partners in the research process enhanced understanding of community priorities and provided a practical roadmap for innovations that have the potential to improve the well-being of community-dwelling older adults.

The effect of medication reconciliation on generating an accurate medication list in a pharmacogenomics practice

Background

Medication reconciliation is recognized as a critically important medication safety element and a key initiative by multiple organizations. Within our precision medicine program, accurate medication lists are essential to our ability to make specific medication recommendations based on pharmacogenetic results. Our study aimed to identify discrepancies within the patient's medication list to improve medication management via genetic factors through a pharmacy team-based approach.

Methods

A dedicated team of pharmacists and trained student pharmacists conducted telephone interviews to complete medication reconciliation for individuals enrolled in our precision medicine preemptive screening program. Medication list discrepancies were tracked as well as if pharmacogenetic consults were altered by findings during the telephone interviews.

Results

Medication reconciliation was completed on 465 participants who had recently received or were awaiting pharmacogenetic testing. We found similar results to previously described rates of medication list discrepancies with an average of 4.9 medication discrepancies per patient as well as greater than 90% of individuals having at least one medication discrepancy. Pharmacogenetic recommendations for 20 individuals (4.3%) required adjustment following medication reconciliation.

Conclusions

This pilot program supports the value of a dedicated team for medication reconciliation and the importance of accurate medication lists to optimize precision medicine programs.

A mixed methods evaluation of medication reconciliation in the primary care setting

OBJECTIVES

To understand the extent to which behaviors consistent with high quality medication reconciliation occurred in primary care settings and explore barriers to high quality medication reconciliation.

DESIGN

Fully mixed sequential equal status design including ethnographic observations, semi-structured interviews, and surveys.

SETTING

Primary care practices within an integrated healthcare delivery system in the United States.

PARTICIPANTS

We conducted 170 observations of patient encounters across 15 primary care clinics, 48 semi-structured interviews with staff, and 10 semi-structured interviews with patients. We also sent out surveys to 2,541 eligible staff with 616 responses (24% response rate) and to 5,132 eligible patients with 577 responses (11% response rate).

RESULTS

Inconsistency emerged as a major barrier to effective medication reconciliation. This inconsistency was present across a variety of factors such as the lack of standardized workflows for conducting medication reconciliation, a lack of knowledge about medication and the process of medication reconciliation, varying levels of importance ascribed to medication reconciliation, and inadequate integration of medication reconciliation into clinical workflows. Findings were generally consistent across all data collection methods.

CONCLUSION

We have identified several barriers which impact the process of medication reconciliation in primary care settings. Our key finding is that the process of medication reconciliation is plagued by inconsistencies which contribute to inaccurate medication lists. These inconsistencies can be broken down into several categories (standardization, knowledge, importance, and inadequate integration) which can be targets for future studies and interventions.

An Analysis of Two Sources of Cardiology Patient Data to Measure Medication Agreement

Errors and incompleteness in electronic health record (EHR) medication lists can result in medical errors. To reduce errors in these medication lists, clinicians use patient self-reported data to reconcile EHR data. We assessed the agreement between patient self-reported medications and medications recorded in the EHR for six medication classes related to cardiovascular care and used logistic regression models to determine which patient-related factors were associated with the disagreement between these two information sources. From our 297 patients, we found self-reported medications had an overall above-average agreement with the EHR (? = .727). We observed the highest agreement level for statins (? = .831) and the lowest for other antihypertensives (? = .465). Agreement was less likely for Hispanic and male patients. We also performed an in-depth error analysis of different types of disagreement beyond medication names, which revealed that the most frequent type of disagreement was mismatched dosages.

Patient Harm Resulting From Medication Reconciliation Process Failures: A Study of Serious Events Reported by Pennsylvania Hospitals

Medication reconciliation broadly defined includes both formal and informal processes that involve the comprehensive evaluation of a patient’s medications during each transition of care and change in therapy. The medication reconciliation process is complex, and studies have shown that up to 91% of medication reconciliation errors are clinically significant and 1–2% are serious or potentially life-threatening. We queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) and identified 93 serious events related to the medication reconciliation process reported between January 2015 and August 2020. Serious events related to medication reconciliation were most common among patients 65 years or older (55.9%; 52 of 93). The majority of events (58.1%; 54 of 93) contributed to or resulted in temporary harm and required treatment or intervention. Permanent harm or death occurred as a result of 3.3% (3 of 93) of the events. Admission/triage was the most frequent transition of care associated with events (69.9%; 65 of 93). The most common stage of the medication reconciliation process at which failures most directly contributed to patient harm was order entry/transcription (41.9%; 39 of 93) and resulted most frequently in wrong dose (n=21) or dose omission (n=13). Most events were discovered after the patient had a change in condition (76.3%; 71 of 93), and patients most often required readmission, hospitalization, emergency care, intensive care, or transfer to a higher level of care (58.0%; 54 of 93). Among 128 medications identified across all events, neurologic or psychiatric medications were the most common (39.1%; 50 of 128), and anticonvulsants were the most common pharmacologic class among neurologic or psychiatric medications (42.0%; 21 of 50). Based on our findings, risk reduction strategies that may improve patient safety related to the medication reconciliation process include defined clinician roles for medication reconciliation, listing the indication for each medication prescribed, and for facilities to consider adding anticonvulsants to their processes for medications with a high risk for harm.

Benefits of medication charts provided at transitions of care: a narrative systematic review

OBJECTIVES

Particularly at transitions of care points information concerning current medication tends to be incomplete. A medication chart that contains all essential information on current therapy is likely to be a helpful tool for patients and healthcare providers. We aimed to investigate any type of benefits associated with medication charts provided at transition points.

METHODS

A systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed. Two databases, two online journals and two association websites dedicated to biomedicine and pharmacy issues were consulted to identify studies for the review using the search term 'medication chart' and synonyms. We run our search from database inception up to March 2019. Studies of any study design, intervention and population which examined the effect of paper-based medication charts were included. We extracted study results narratively and coded and classified them by themes and categories inductively by using the 'framework method' with content analysis. The methodological quality of the studies was assessed using the Effective Public Health Practice Project (EPHPP) tool.

RESULTS

From the 846 retrieved articles, 30 studies met the inclusion criteria, mostly from Germany (18 studies) and the USA (5 studies). Thirteen studies reported a statistically significant result. In the 'patient theme', the most obvious benefits were an increase in medication knowledge, a reduction of medication errors and higher medication adherence. In the 'interdisciplinary theme', a medication chart represented a helpful tool to increase communication and inter-sectoral cooperation between healthcare providers. In the 'theme of terms and conditions', accuracy and currency of data are prerequisites for any positive effect. The quality of the studies was classified predominantly weak mainly due to unmet good quality criteria (no randomised controlled trials study design, no reported dropouts).

CONCLUSION

Overall, the reviewed studies suggested some benefits when using medication charts. Healthcare providers could consider using medication charts in their counselling practice. However, it is unknown whether the reported benefits lead to measurable improvement in clinical outcomes. PROSPERO REGISTRATION NUMBER.

Using medication containers during pharmacist transitional care visits and impact on medication discrepancies identified and hospital readmission risk

OBJECTIVE

To evaluate the impact of having patients present to a pharmacist-clinician collaborative (PCC) visit after hospital discharge with their medication containers on risk of 30-day readmission.

METHODS

This is a retrospective cohort study from July 1, 2013 to June 18, 2018 at 5 primary care clinic sites. We included adult patients on at least 10 total medications at hospital discharge who did and did not present to the PCC visit with medication containers. Patients in both groups met with a pharmacist for 30 minutes, immediately followed by a clinician visit. Thirty-day risk of readmission was assessed using Cox proportional hazards regression.

RESULTS

A total of 724 qualifying patients presented for a PCC visit with their medication containers within 30 days of hospital discharge, whereas 636 did not. After adjusting for significant differences in baseline characteristics, there was no statistically significant difference in hospital readmission risk between the groups at 30 days after the visit (hazard ratio 0.94 [95% CI 0.68-1.29], P = 0.69). When patients brought their medication containers, pharmacists identified more medication discrepancies (mean ± SD, 2.2 ± 2.1 vs. 1.5 ± 1.7, P < 0.001) and made more medication therapy recommendations (1.8 ± 1.3 vs. 1.5 ± 1.2, P < 0.001) to the clinician.

CONCLUSION

The presence of medication containers did not affect the risk of hospital readmission, although, it did allow pharmacists to identify more medication discrepancies and medication problems. These findings support instructing patients to bring their medication containers to transitional care visits to resolve medication-related issues.

Team-based approach to improving medication reconciliation rates in family medicine residency clinics

OBJECTIVE

The objective of this quality improvement project was to design and implement a systematic team-based care approach to medication reconciliation, with a goal of physician-documented medication reconciliation at 70% of all patient office visits.

SETTING

Ambulatory clinics located in urban, underserved communities in Minneapolis and St. Paul, MN.

PRACTICE DESCRIPTION

Four family medicine residency clinics, with pharmacists integrated at each site. All clinics use the Epic electronic medical record (Epic Systems Corporation).

PRACTICE INNOVATION

A team-based care approach to medication reconciliation was designed and implemented involving medical assistants (MAs), physicians, and pharmacists. The MAs did an initial review with patients, the physicians addressed discrepancies, and difficult situations were escalated to the pharmacist for a detailed assessment.

EVALUATION

The percentage of visits with physician-documented medication reconciliation was measured preintervention and then for 18 months postintervention in 6-month intervals involving more than 118,000 patient visits. Satisfaction surveys of team members were done pre- and postintervention.

RESULTS

The percentage of visits with physician-documented medication reconciliation improved significantly from 6.5% preintervention to 58.7% (P < 0.001) postintervention, and was sustained and further improved to 70.3% (P < 0.001) 1 year later. The team members had a statistically significant improvement in their ability to articulate the medication reconciliation process. Satisfaction improved significantly for physicians, but MAs did not experience a statistically significant change.

CONCLUSION

A team-based care approach to medication reconciliation was successfully implemented and sustained at 4 family medicine clinics. There was significant improvement in physician-documented medication reconciliation. Future studies need to address whether this process improves medication-list discrepancies, completeness, and accuracy.

Evaluation of the medication reconciliation process and classification of discrepancies at hospital admission and discharge in Italy

Background Medication errors at different transitions of care are common and potentially harmful. Medication reconciliation process should be evaluated to reduce the unintentional discrepancies. Objective This study aims to identify and classify unintentional medication discrepancies at hospital admission and discharge and associated risk factors. Setting Two general internal medicine and a pulmonology wards of an Italian non-academic hospital. Method A retrospective observational study was conducted among adult patients admitted to the wards. In order to evaluate the current medication reconciliation process of these wards, the frequency and type of unintentional chronic medication discrepancies between the physician assessment of home medication and hospital admission and discharge prescriptions were studied. Patients' characteristic associated with the presence of at least one unintentional discrepancy were evaluated. Main outcome measure Frequencies of unintentional medication discrepancies upon admission and discharge and associated patients' characteristics. Results Among the 144 patients enrolled in the study, 53 and 64 unintentional medication discrepancies were identified at hospital admission and at discharge, respectively. Both at admission and discharge a quarter of patients had at least one unintentional discrepancy. 'Medication omission' was the most frequent type of discrepancy identified and respiratory system and nervous system were the classes of medication with the highest rate of unintentional discrepancies. Unintentional discrepancies were more likely to occur in patients receiving more medicine pre-admission, longer hospitalization stays and coming from or discharged to a nursing home. Conclusion Transitions of care are critical moments for patient safety in terms of unintentional medication discrepancies and a more structured medication reconciliation process is needed. The medication reconciliation process should be considered in terms of a multidisciplinary approach involving all health professionals as well as patients and caregivers directly.

Development of the prototype concise safe systems checklist tool for general practice

BACKGROUND

In the course of producing a patient safety toolkit for primary care, we identified the need for a concise safe-systems checklist designed to address areas of patient safety which are under-represented in mandatory requirements and existing tools. This paper describes the development of a prototype checklist designed to be used in busy general practice environments to provide an overview of key patient safety related processes and prompt practice wide-discussion.

METHODS

An extensive narrative review and a survey of world-wide general practice organisations were used to identify existing primary care patient safety issues and tools. A RAND panel of international experts rated the results, summarising the findings for importance and relevance. The checklist was created to include areas that are not part of established patient safety tools or mandatory and legal requirements. Four main themes were identified: information flow, practice safety information, prescribing, and use of IT systems from which a 13 item checklist was trialled in 16 practices resulting in a nine item prototype checklist, which was tested in eight practices. Qualitative data on the utility and usability of the prototype was collected through a series of semi-structured interviews.

RESULTS

In testing the prototype four of nine items on the checklist were achieved by all eight practices. Three items were achieved by seven of eight practices and two items by six of eight practices. Participants welcomed the brevity and ease of use of the prototype, that it might be used within time scales at their discretion and its ability to engage a range of practice staff in relevant discussions on the safety of existing processes. The items relating to prescribing safety were considered particularly useful.

CONCLUSIONS

As a result of this work the concise patient safety checklist tool, specifically designed for general practice, has now been made available as part of an online Patient Safety Toolkit hosted by the Royal College of General Practitioners. Senior practice staff such as practice managers and GP partners should find it a useful tool to understand the safety of less explored yet important safety processes within the practice.

MedManage: The development of a tool to assist medication reconciliation in a rural primary care clinic

BACKGROUND

Medication reconciliation is a critical step in the health care process to prevent hospital readmission, adverse drug events, and fall prevention. The purpose of the study was to pilot test a medication reconciliation process, MedManage, informed by the Medications at Transitions and Clinical Handoffs (MATCH) toolkit with nursing staff in a rural primary care clinic.

METHODS

The research team conducted 38 chart audits of high-risk patients, and preintervention and postintervention were conducted to assess changes in medications reported by patients. The intervention included a chart audit tool and medication reconciliation tool created by the interdisciplinary team, MedManage, were pilot tested in the clinic.

CONCLUSIONS

The Use of MedManage resulted in improvements in patient reporting of over-the-counter (82% of patients reported previously unrecorded OTCs), PRN medications (3% unreported), and herbal supplements/vitamins (28% reported previously unrecorded vitamins).

IMPLICATIONS FOR PRACTICE

MedManage may be an effective tool to assist clinical nursing staff to attain a more complete and accurate medication list from patients and should be assessed more broadly across rural primary care clinics.

Associations Between Health Literacy and Medication Self-Management Among Community Health Center Patients with Uncontrolled Hypertension

PURPOSE

Examine associations between health literacy and several medication self-management constructs among a population of adults with uncontrolled hypertension.

PATIENTS AND METHODS

Cross-sectional study of health center patients from the Chicago area with uncontrolled hypertension enrolled between April 2012 and February 2015. Medication self-management constructs-applied to hypertension medications, chronic condition medications and all medications-included: 1) medication reconciliation, 2) knowledge of drug indications, 3) understanding instructions and dosing, and 4) self-reported adherence over 4 days (no missed doses). We determined associations between health literacy and self-management outcomes using multivariable generalized linear regression.

RESULTS

There were 1460 patients who completed screening interviews; 62.9% enrolled and had complete baseline data collected, and were included in the analysis. Of 919 participants, 47.4% had likely limited (low), 33.2% possibly limited, and 19.4% likely adequate health literacy. Compared to participants with likely adequate health literacy, participants with low health literacy were less likely to have chronic medications reconciled (18.0% versus 29.6%, p=0.007), know indications for chronic medications (64.1% versus 83.1%, p<0.001), and demonstrate understanding of instructions and dosing (68.1% versus 82.9%, p=0.001). Self-reported adherence to hypertension medications was higher among the low health literacy group (65.6% versus 56.0%, p=0.010). In multivariable models, health literacy was strongly associated with knowledge of drug indications, and understanding of instructions and dosing.

CONCLUSION

Low health literacy was associated with worse medication self-management in several domains. However, non-adherence was greatest in the most health literate in unadjusted analysis. Among a population of patients with uncontrolled hypertension, the drivers of poor control may vary by health literacy.

Dietitians can improve accuracy of prescribing by interacting with electronic prescribing systems

Background

Dietitians increasingly interact with electronic health records (EHRs) and use them to alert prescribers to medication inaccuracies.

Objective

To understand renal dietitians’ use of electronic prescribing systems and influence on medication accuracy in inpatients. In outpatients to determine whether renal dietitians’ use of the electronic medication recording might improve accuracy.

Methods

In inpatients we studied the impact of dietetic advice on medical prescribing before and after moving from paper recommendations to ePrescribing. In outpatients, when dietitians recommended changes in dialysis units, we assessed the time to patients receiving the new medications. We trained dietitians to use the ePrescribing system and assessed accuracy of medication lists at the start and end of the study period.

Results

Inpatients: before the use of EHRs, 25% of proposals were carried out and took an average of 20 days. This rose to 38% using an EHR and took an average of 4 days.

Outpatients: in dialysis units dietitians recommend initiating and stopping medications and advise on repeat medications. Most recommendations were during multidisciplinary team (MDT) meetings; the average time to receive medications was 10 days. Drug histories updated by dietitians increased after the start of the study and accuracy of medication lists improved from 2.4 discrepancies/patient to 0.4.

Conclusion

Dietitians can make medication suggestions directly using EHR, delivering more timely change to patient care and improving accuracy of patients’ medication lists. Allowing the whole of the MDT to contribute to the EHR improves data completeness and therefore patient care is likely to be enhanced.

Increasing the use of home medication lists in an outpatient neurorehabilitation clinic

Medication reconciliation in ambulatory care settings helps prevent adverse drug events. Patient involvement in the process is crucial, as clinicians must verify the reported medication history with other sources such as home medication lists or brown-bagged home medications provided by patients. However, only 47.8% of brain injury and stroke adult outpatients at Toronto Rehabilitation Institute, an academic rehabilitation hospital, bring their medications/medication lists to clinic visits. In turn, missing medication information impacts the clinic by causing delays in treatment and interrupted clinic flow. This project aimed to increase the percentage of patients who bring their medications/medication lists to 80% and decrease the impact on clinic visits caused by missing medication information to 10%. This was a controlled before-after study, with the outpatient rehabilitation assessment (OPRA) clinic as the intervention and the spasticity clinic as the control. The model for improvement was used as the project framework. Process mapping, Ishikawa diagrams, driver diagrams and patient surveys generated the change ideas. Verbal reminders during confirmation phone calls, written reminders and medication list templates were implemented. Data were collected on a biweekly basis and analysed using statistical control charts. After six Plan-Do-Study-Act cycles conducted over 49 weeks, both project aims were achieved. The percentage of OPRA clinic patients who brought medications/medication lists was 81.8% and the impact on clinic visits caused by missing medication information was 9.1% of clinic visits. Special cause variation was detected on the statistical control charts. Conversely, there was no special cause variation for the spasticity clinic (the control) for either aim. Lessons learnt include the importance of prolonged data collection when implementing interventions with long lag time, and that verbal reminders may not be effective for patients with cognitive impairments. Future efforts may focus on implementing the bundle of project interventions for the spasticity clinic.

Post-discharge Medication Reconciliation: Reduction in Readmissions in a Geriatric Primary Care Clinic

Objectives: This study aimed to evaluate hospital utilization and characterize interventions of pharmacist-led telephonic post-discharge medication reconciliation. Method: A retrospective analysis was conducted, including 833 index events in 586 geriatric patients receiving the intervention. Medicare claims were used to capture 30-day hospital utilization (admission to the emergency department, observation unit, or inpatient hospitalization) following discharge from any of these locations. Medication-related interventions were described. Results: Hospital utilization within 30 days after discharge from any location was greater for patients receiving usual care compared with the intervention (32.5% vs. 22.2%; odds ratio [OR] = 1.69, 95% confidence interval [CI] = [1.06, 2.68]). Inpatient admission within 30 days after discharge from any location was greater for those receiving usual care (14.7% vs. 6.4%; OR = 2.54, 95% CI = [1.18, 5.44]). At least one medication-related problem was identified and addressed in 89.8% of patients receiving the intervention. Discussion: A telephonic post-discharge medication reconciliation program can lead to reduction in hospital utilization in a geriatric population.

Effect of Electronic Health Record-Based Medication Support and Nurse-Led Medication Therapy Management on Hypertension and Medication Self-management: A Randomized Clinical Trial

Importance

Complex medication regimens pose self-management challenges, particularly among populations with low levels of health literacy.

Objective

To test medication management tools delivered through a commercial electronic health record (EHR) with and without a nurse-led education intervention.

Design, Setting, and Participants

This 3-group cluster randomized clinical trial was performed in community health centers in Chicago, Illinois. Participants included 794 patients with hypertension who self-reported using 3 or more medications concurrently (for any purpose). Data were collected from April 30, 2012, through February 29, 2016, and analyzed by intention to treat.

Interventions

Clinics were randomly assigned to to groups: electronic health record-based medication management tools (medication review sheets at visit check-in, lay medication information sheets printed after visits; EHR-alone group), EHR-based tools plus nurse-led medication management support (EHR plus education group), or usual care.

Main Outcomes and Measures

Outcomes at 12 months included systolic blood pressure (primary outcome), medication reconciliation, knowledge of drug indications, understanding of medication instructions and dosing, and self-reported medication adherence. Medication outcomes were assessed for all hypertension prescriptions, all prescriptions to treat chronic disease, and all medications.

Results

Among the 794 participants (68.6% women; mean [SD] age, 52.7 [9.6] years), systolic blood pressure at 12 months was greater in the EHR-alone group compared with the usual care group by 3.6 mm Hg (95% CI, 0.3 to 6.9 mm Hg). Systolic blood pressure in the EHR plus education group was not significantly lower compared with the usual care group (difference, -2.0 mm Hg; 95% CI, -5.2 to 1.3 mm Hg) but was lower compared with the EHR-alone group (-5.6 mm Hg; 95% CI, -8.8 to -2.4 mm Hg). At 12 months, hypertension medication reconciliation was improved in the EHR-alone group (adjusted odds ratio [OR], 1.8; 95% CI, 1.1 to 2.9) and the EHR plus education group (adjusted odds ratio [OR], 2.0; 95% CI, 1.3 to 3.3) compared with usual care. Understanding of medication instructions and dosing was greater in the EHR plus education group than the usual care group for hypertension medications (OR, 2.3; 95% CI, 1.1 to 4.8) and all medications combined (OR, 1.7; 95% CI, 1.0 to 2.8). Compared with usual care, the EHR tools alone and EHR plus education interventions did not improve hypertension medication adherence (OR, 0.9; 95% CI, 0.6-1.4 for both) or knowledge of chronic drug indications (OR for EHR tools alone, 1.0 [95% CI, 0.6 to 1.5] and OR for EHR plus education, 1.1 [95% CI, 0.7-1.7]).

Conclusions and Relevance

The study found that EHR tools in isolation improved medication reconciliation but worsened blood pressure. Combining these tools with nurse-led support suggested improved understanding of medication instructions and dosing but did not lower blood pressure compared with usual care.

Trial Registration

ClinicalTrials.gov identifier: NCT01578577.

Ambulatory Medication Reconciliation and Frequency of Hospitalizations and Emergency Department Visits in Patients With Diabetes

OBJECTIVE

To investigate the association between ambulatory medication reconciliation and health care utilization in patients with diabetes.

RESEARCH DESIGN AND METHODS

In this retrospective cohort analysis, we studied adults taking at least one diabetes medication treated in primary care practices affiliated with two academic medical centers between 2000 and 2014. We assessed the relationship between the fraction of outpatient diabetes medications reconciled over a 6-month period and the composite primary outcome of combined frequency of emergency department (ED) visits and hospitalizations over the subsequent 6 months.

RESULTS

Among 261,765 reconciliation assessment periods contributed by 31,689 patients, 176,274 (67.3%), 27,775 (10.6%), and 57,716 (22.1%) had all, some, or none of the diabetes medications reconciled, respectively. Patients with all, some, or no diabetes medications reconciled had 0.354, 0.377, and 0.384 primary outcome events per 6 months, respectively (P < 0.0001). In a multivariable analysis adjusted for demographics and comorbidities, having some or all versus no diabetes medications reconciled was associated with a lower risk of the primary outcome (rate ratio 0.94 [95% CI 0.90-0.98; P = 0.0046] vs. 0.92 [0.89-0.95; P < 0.0001], respectively). Introduction of feedback to individual providers was associated with a significant increase in the odds of all diabetes medications being reconciled (2.634 [2.524-2.749]; P < 0.0001).

CONCLUSIONS

A higher fraction of reconciled outpatient diabetes medications was associated with a lower frequency of ED visits and hospitalizations. Individual performance feedback could help to achieve more comprehensive medication reconciliation.

Evaluation of Multimedia Medication Reconciliation Software: A Randomized Controlled, Single-Blind Trial to Measure Diagnostic Accuracy for Discrepancy Detection

BACKGROUND

The Veterans Affairs Portland Healthcare System developed a medication history collection software that displays prescription names and medication images.

OBJECTIVE

This article measures the frequency of medication discrepancy reporting using the medication history collection software and compares with the frequency of reporting using a paper-based process. This article also determines the accuracy of each method by comparing both strategies to a best possible medication history.

STUDY DESIGN

Randomized, controlled, single-blind trial.

SETTING

Three community-based primary care clinics associated with the Veterans Affairs Portland Healthcare System: a 300-bed teaching facility and ambulatory care network serving Veteran soldiers in the Pacific Northwest United States.

PARTICIPANTS

Of 212 patients with primary care appointments, 209 patients fulfilled the study requirements.

INTERVENTION

Patients randomized to a software-directed medication history or a paper-based medication history. Randomization and allocation to treatment groups were performed using a computer-based random number generator. Assignments were placed in a sealed envelope and opened after participant consent. The research coordinator did not know or have access to the treatment assignment until the time of presentation.

MAIN OUTCOME MEASURES

The primary analysis compared the discrepancy detection rates between groups with respect to the health record and a best possible medication history.

RESULTS

Of 3,500 medications reviewed, we detected 1,435 discrepancies. Forty-six percent of those discrepancies were potentially high risk for causing an adverse drug event. There was no difference in detection rates between treatment arms. Software sensitivity was 83% and specificity was 91%; paper sensitivity was 81% and specificity was 94%. No participants were lost to follow-up.

CONCLUSION

The medication history collection software is an efficient and scalable method for gathering a medication history and detecting high-risk discrepancies. Although it included medication images, the technology did not improve accuracy over a paper list when compared with a best possible medication history.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02135731.

Implementation of a Medication Reconciliation Assistive Technology: A Qualitative Analysis

Objective: To aid the implementation of a medication reconciliation process within a hybrid primary-specialty care setting by using qualitative techniques to describe the climate of implementation and provide guidance for future projects. Methods: Guided by McMullen et al's Rapid Assessment Process¹, we performed semi-structured interviews prior to and iteratively throughout the implementation. Interviews were coded and analyzed using grounded theory² and cross-examined for validity. Results: We identified five barriers and five facilitators that impacted the implementation. Facilitators identified were process alignment with user values, and motivation and clinical champions fostered by the implementation team rather than the administration. Barriers included a perceived limited capacity for change, diverging priorities, and inconsistencies in process standards and role definitions. Discussion: A more complete, qualitative understanding of existing barriers and facilitators helps to guide critical decisions on the design and implementation of a successful medication reconciliation process.

Implementation of a Medication Reconciliation Process in an Internal Medicine Clinic at an Academic Medical Center

Discrepancies in medication orders at transitions of care have been shown to affect patient outcomes in a negative way. The Joint Commission recognizes the importance of medication reconciliation through their National Patient Safety Goals, with an emphasis placed on maintaining accurate medication information for each patient. The primary objective of this study was to assess the effectiveness of implementing a medication reconciliation process in an internal medicine clinic at an academic medical center. A retrospective chart review of patients seen at an Internal Medicine Clinic within and Academic Medical Center, a continuity and teaching clinic for Internal Medicine residents and faculty practice clinic, was conducted. Nursing staff were educated by PharmDs to perform a standardized medication history during the triage process. Medication reconciliation data was analyzed for 3263 patients from 1 August 2014 to 27 February 2015. A total of 4479 discrepancies were found through this process, with the majority (71%) of discrepancies being medications on the list that patient was no longer taking. This project illustrated to our nursing and physician staff the need for regular thorough review of the patient medication list.

Systemic anticancer therapy (SACT) for lung cancer and its potential for interactions with other medicines

Background

Systemic anticancer therapy, comprising chemotherapy agents alongside targeted therapies and immunotherapy, is clinically indicated for late-stage lung cancer. It is delivered in regimens often containing multiple anticancer agents as well as supportive care medicines to reduce side effects, raising potential for polypharmacy and therefore the possibility of drug–drug interactions with medicines taken for comorbidities. A pharmacy-led process commonly performed to assist safe prescribing in secondary care is medicines reconciliation; its benefit in minimising interactions involving systemic anticancer therapy medicines has not been assessed previously.

Objectives

The objectives were to characterise the potential drug–drug interactions between systemic anticancer therapy medicines for lung cancer and other medicines and to evaluate the rate of medicines reconciliation being performed and the extent of documentation of potential interactions (clinical audit).

Methodology

This retrospective case series study involved recording the medicines being taken by lung cancer patients undergoing systemic anticancer therapy elicited in consultations at Chelsea and Westminster Hospital, United Kingdom. Potential interactions were identified and characterised in terms of severity using the British National Formulary and other sources. Patient consultation records were also searched for documentation of medicines reconciliation and acknowledgement of potential drug–drug interactions.

Results

Twenty-three patients were included in this study. Eighty-eight potential drug–drug interactions were identified across 21 patients, 39% (34/88) of which involved the supportive care medicine dexamethasone. 3.0% of consultations included a documented medicines reconciliation, and 15.9% of potential interactions were documented in the notes, with no correlation between the two. Potentially serious interactions were significantly more likely to be documented (p < 0.05).

Conclusions

Many potential drug–drug interactions involving anticancer agents and supportive care medicines exist; particular attention should be paid to dexamethasone. Documentation of interactions and medicines reconciliation occur much less often than expected, suggesting there is scope for implementing methods of safe prescribing to prevent adverse drug effects.

Measuring to Improve Medication Reconciliation in a Large Subspecialty Outpatient Practice

BACKGROUND

To assess performance in medication reconciliation (med rec)-the process of comparing and reconciling patients' medication lists at clinical transition points-and demonstrate improvement in an outpatient setting, sustainable and valid measures are needed.

METHODS

An interdisciplinary team at National Jewish Health (Denver) attempted to improve med rec in an ambulatory practice serving patients with respiratory and related diseases. Interventions, which were aimed at physicians, nurses (RNs), and medical assistants, involved changes in practice and changes in documentation in the electronic health record (EHR). New measures designed to assess med rec performance, and to validate the measures, were derived from EHR data.

RESULTS

Across 18 months, electronic attestation that med rec was completed at clinic visits increased from 9.8% to 91.3% (p <0.0001). Consistent with this improvement, patients with medication lists missing dose/frequency for at least one prescription-type medication decreased from 18.1% to 15.8% (p <0.0001). Patients with duplicate albuterol inhalers on their list decreased from 4.0% to 2.6% (p <0.0001). Percentages of patients increased for printing of the medication list at the visit (18.7% to 94.0%; p <0.0001) and receipt of the printed medication list at the visit (52.3% to 67.0%; p = 0.0074). Documentation that patient education handouts were offered increased initially then declined to an overall poor performance of 32.4% of clinic visits. Investigation of this result revealed poor buy-in and a highly redundant process.

CONCLUSION

Deriving measures reflecting performance and quality of med rec from EHR data is feasible and sustainable over the time periods necessary to demonstrate change. Concurrent, complementary measures may be used to support the validity of summary measures.

Patient, Physician, Medical Assistant, and Office Visit Factors Associated With Medication List Agreement

OBJECTIVES

Despite its importance for patient safety, there have been few studies of medication reconciliation in primary care. Our goal was to identify potential patient, physician, medical assistant (MA), and office visit factors associated with accurate medication lists in Cleveland Clinic primary care practices.

METHODS

Physician and MA medication reconciliation activities were directly observed during office visits. The primary outcome was agreement between the electronic medical record medication list at the conclusion of the office visit and what the patients said they were actually taking, assessed by structured telephone interview within 2 weeks of the office visit. Medication list agreement was defined as the absence of any discrepancies in name, dose, frequency, route, and as-needed status. Associations between patient, physician, MA, and office visit factors and medication list accuracy were assessed using χ2 tests and logistic regression.

RESULTS

Twenty-four physicians and 33 MAs were observed during 231 patient encounters. Nineteen patients (8%) could not be contacted for the telephone interview and were excluded from the analysis. Thirty-two patients (15%) had perfect medication list agreement for prescription and nonprescription medications, and 66 patients (31%) had medication list agreement for prescription medications only. Of the 14 patient, physician, and MA medication reconciliation behaviors examined, only 1, in which the MA begins the medication review with an open-ended question, was significantly associated with a medication list in agreement (odds ratio, 2.96; confidence interval, 1.43-6.09) for prescription and nonprescription medications. This association was not significant when only prescription medications were included (odds ratio, 0.90; confidence interval, 0.43-1.91). No behaviors we observed significantly influenced prescription medication list agreement.

CONCLUSIONS

Having MAs begin their medication review with an open-ended question may be a simple, inexpensive, and easily implemented process to increase accuracy of medication lists for prescription and nonprescription medications.

Introducing a structured prescription form improves the quality of handwritten prescriptions in limited resource setting of developing countries

INTRODUCTION

Incomplete or illegible prescriptions can lead to serious errors in administration of the prescribed medication, which can become hazardous.

OBJECTIVE

Our aim is to determine if a structured prescription form can improve the quality of handwritten prescription in terms of completeness and legibility.

METHODS

We conducted a prospective, non-randomized, time series study of quality of written prescriptions of general practitioners at a tertiary teaching hospital in Peshawar, Pakistan. The study involved an intervention, composed of the introduction of a pre-printed structured prescription form. The data were collected within 4 weeks including a 2-week pre-intervention phase and 2-week post-intervention phase. Completeness, quality of prescriptions and legibility were compared before and after the intervention of the pre-printed structured prescription form.

RESULTS

A total of 463 prescriptions were obtained (260 in the pre-intervention phase and 203 in the post-intervention phase). Between pre-intervention phase and post-intervention phase, the Pakistan Medical and Dental Council registration number presence in prescriptions improved from 73.1% to 100% (P < 0.0005). The presence of prescriber's signature improved from 92.7% to 99% (P = 0.001). Drug duration was not missing in 99.5% in post-intervention phase as compared with 90.4% in pre-intervention phase (P < 0.0005). Prescriptions with no legibility problems improved from 76.2% to 94.1% (P < 0.0005). Although not statistically significant, prescriptions in which drug dosage was not missing improved from 85% to 90.6% (P = 0.07).

LIMITATIONS

We have a limited single-center study. A larger study in multiple settings is needed to develop adequate evidence for such interventions. Subjective nature of prescription legibility can also be considered as a limitation.

CONCLUSION

Structuring a prescription form alone may improve certain aspects of quality of written prescription in terms of completeness and legibility.

Identifying opportunities to improve medication management in transitions of care

PURPOSE

The types and causes of medication discrepancies during the transition from inpatient to ambulatory care were investigated.

METHODS

A descriptive study was conducted at an academic outpatient group practice affiliated with a private nonacademic hospital to (1) describe discrepancies between inpatient discharge summaries and patient-reported medication lists, (2) identify patient and system factors related to breakdowns in medication documentation, and (3) determine reasons for medication discrepancies. During a four-month period, 17 patients at high risk for medication misadventures while transitioning from hospital care to outpatient follow-up were contacted by telephone soon after discharge and asked to provide information on all medications they were taking. Patient-reported medication lists were compared with the corresponding discharge summaries, and medication discrepancies were categorized by patient- and system-level factors using a validated instrument.

RESULTS

Of the total of 96 discrepancies identified, more than two thirds (n = 67, 68%) involved the omission of a prescribed medication from either the patient-reported list or the discharge summary. Cardiovascular medications, including antihypertensives, antilipemics, diuretics, and antiarrhythmics, accounted for almost one quarter of all medication discrepancies. About 15% (n = 14) and 16% (n = 15) of identified discrepancies related to medication dose and frequency, respectively.

CONCLUSION

Among 17 patients transitioning from inpatient to outpatient care, nearly 100 discrepancies between patient-reported medication lists and discharge summaries were identified. Most discrepancies were attributed to nonintentional nonadherence and resumption of home medications without instructions to do so. All 17 patients had at least 1 medication discrepancy categorized as involving a system-level factor.

[Medication reconciliation at admission and discharge. A consolidated experience]

Medication reconciliation is currently one of the main strategies to reduce medication errors related to transitional care.

OBJECTIVE

To describe a method that would ensure continuity of patient care as regards drug therapy from admission to discharge.

METHODS

A description is presented on the methodology implemented in a tertiary hospital and the main results of medication reconciliation at admission and discharge of patients older than 75 years in the Trauma Unit during 2014.

RESULTS

The phases of the methodology were: 1. Obtain medication history (at least two sources of information); 2. Analysis of discrepancies and validation of medication on admission: A checklist was made to standardise the process, 3. Report on the pharmacotherapeutic profile: a form was designed in electronic medical records, and 4. Medication reconciliation at discharge and patient information: presenting the dosing schedule and recommendations to the patient. The medication of 318 patients admitted to Trauma was reconciled (294 at admission and discharge) by applying this methodology during the study period. There was at least one medication reconciliation error in 35% of cases. The mean error per patient reconciled was 0.69. Written discharge information was given to 74.1% of patients.

CONCLUSIONS

This methodology has allowed a workflow to be established that facilitates coordination between healthcare providers, in order to reduce medication errors and to respond to one of the main problems of continuity of care.

A Systematic Review of Patient Safety Measures in Adult Primary Care

Safety measure development has focused on inpatient care despite outpatient visits far outnumbering inpatient admissions. Some measures are clearly identified as outpatient safety measures when published, yet outcomes from quality improvement studies also may be useful measures. The authors conducted a systematic review of the literature to identify published articles detailing safety measures applicable to adult primary care. A total of 21 articles were identified, providing specifications for 182 safety measures. Each measure was classified into one of 6 outpatient safety dimensions: medication management, sentinel events, care coordination, procedures and treatment, laboratory testing and monitoring, and facility structures/resources. Compared to the multitude of available inpatient safety measures, the number of existing adult primary care measures is low. The measures identified by this systematic review may yield further insight into the breadth of safety events causing harm in primary care, while also identifying areas of patient safety in primary care that may be understudied.

Adverse events and near misses relating to information management in a hospital

Objective:

This study described information management incidents and adverse event reporting choices of health professionals.

Methods:

Hospital adverse events reported in an anonymous electronic reporting system were analysed using directed content analysis and descriptive and inferential statistics. The data consisted of near miss and adverse event incident reports ( n = 3075) that occurred between January 2008 and the end of December 2009.

Results:

A total of 824 incidents were identified. The most common information management incident was failure in written information transfer and communication, when patient data were copied or documented incorrectly. Often patient data were transferred using paper even though an electronic patient record was in use. Reporting choices differed significantly among professional groups; in particular, registered nurses reported more events than other health professionals.

Conclusion:

A broad spectrum of information management incidents was identified, which indicates that preventing adverse events requires the development of safe practices, especially in documentation and information transfer.

Medication reconciliation at admission and discharge: an analysis of prevalence and associated risk factors

INTRODUCTION

Medication errors are frequent at care transition points and can have serious repercussions. Study objectives were to examine the frequency/type of reconciliation errors at hospital admission and discharge and to report on the drugs involved, associated risk factors and potential to cause harm in a healthcare setting with comprehensive digital health records.

MATERIAL AND METHODS

A prospective observational 2-year study was conducted in the Internal Medicine Department of a regional hospital. The best possible medication history was obtained from different sources by clinical pharmacists and compared with prescriptions at admission and discharge. The frequency and type of reconciliation errors were studied at admission and discharge, evaluating risk factors for their occurrence and their potential to cause harm.

RESULTS

The study included 814 patients (mean age: 80.2 years). At least one reconciliation error was detected in 525 (64.5%) patients at admission, with a mean of 2.2 ± 1.3 errors per patient and in 235 (32.4%) patients at discharge. Drug omission was the most frequent reconciliation error (73.6% at admission and 71.4% at discharge); 39% of errors at admission and 51% at discharge had potential to cause moderate or severe harm. The risk of error at admission was higher with more pre-admission drugs (p < 0.001) and, among patients with reconciliation errors, the number of errors was significantly higher in those receiving more drugs pre-admission or with more comorbidities. The risk at discharge was higher in patients with more drugs prescribed at discharge (p = 0.04) and in those with a longer hospital stay (p = 0.03).

CONCLUSIONS

Medication reconciliation procedures are required to minimise medication discrepancies and enhance patient safety. Integration of patient health records across care levels is necessary but not sufficient to prevent errors.

Discrepancies on Medication Plans detected in German Community Pharmacies

RATIONALE, AIMS AND OBJECTIVES

A current medication plan was identified as important patient safety factor. Information is needed on how many patients possess such a plan and what problems can be identified with its use. This study tried to define factors that influence accuracy of medication plans and to detect discrepancies from planned and actually administered medication in polypharmacy patients.

METHODS

Participants of the 'Apo-AMTS' course in Germany evaluated medication plans from their patients during performing medication reviews in community pharmacies. Discrepancies were defined as additional or missing drugs and deviations in dosage and drug names for Rx drugs and missing or additional self-medication.

RESULTS

Eighty per cent of the patients possessed a medication plan mainly written by general practitioners. Only 6.5% of the plans showed no discrepancies. Most discrepancies were seen on medication plans written by medical specialists and general practitioners, mainly name aberrations (41%) followed by additional drugs taken (30%) and prescribed drugs no longer taken (18%). Dosage variance was seen in 11% of all discrepancies. Deviations from the plan were observed frequently with antihypertensives (31.4%), analgesics (11.3%) and antidepressants/hypnotics as well as lipid-lowering drugs (6.7%). Four hundred thirty-three OTC drugs were not listed, mainly analgesics, mineral supplements and laxatives.

CONCLUSION

Many patients possess a medication plan but most of these plans showed discrepancies which limits the use as patient safety indicator. Community pharmacies offering medication reviews have an essential position to use the medication plan as a central link between patients and their prescribers, and therefore improve patient safety.

Patterns and predictors of medication discrepancies in primary care

RATIONALE, AIMS AND OBJECTIVES

Identifying medication discrepancies across transitions of care is a common patient safety problem. Research examining relations between medication discrepancies and adherence, however, is limited. The objective of this investigation is to explore the relations between adherence and patient-provider medication discrepancies, and to test the hypothesis that non-adherence would be associated with medication discrepancies.

METHODS

Three hundred twenty-eight outpatients completed a current medication list and measures of health literacy, adherence, perceived physical functioning and subjective well-being. Patient lists were compared with active medications in the electronic medical record. Multivariate analyses identified demographic, clinical and patient-reported variables associated with discrepancies involving prescribed daily medications.

RESULTS

Despite high rates of self-reported adherence, patients reported taking fewer medications than the number of active medications in their medical record (3.79 vs. 4.83, P < 0.001). We identified one or more discrepancies in most records (294/328 or 89.6%). Identified discrepancies were completely reconciled in only 21.1% of patients with discrepancies. Discrepancies were associated with lower health literacy, poorer physical health status and subjective well-being, and poorer adherence to the regimen patients believed they had been prescribed. Multivariate analysis indicated that the number of medical record-reported medications and subjective well-being independently predicted the presence of discrepancies.

CONCLUSIONS

Findings suggest a complex relation between treatment adherence and medication discrepancies in which patient well-being and regimen complexity work in tandem to create discordance between patient and provider medication plans. Simplifying regimens when possible and attending to patient life satisfaction may improve adherence to a regimen constructed jointly between patient and provider.

Which Medication Is the Patient Taking at Admission to the Emergency Ward? Still Unclear Despite the Swedish Prescribed Drug Register

INTRODUCTION

Correct information on patients' medication is crucial for diagnosis and treatment in the Emergency Department. The aim of this study was to investigate the concordance between the admission chart and two other records of the patient's medication.

METHODS

This cohort study includes data on 168 patients over 18 years admitted to the Emergency Ward between September 1 and 30, 2008. The record kept by the general practitioner and the patient record of dispensed drugs in the Swedish Prescribed Drug Register were compared to the admission chart record.

RESULTS

Drug record discrepancies of potential clinical significance between the admission chart record and the Swedish Prescribed Drug Register or general practitioner record were present in 79 and 82 percent, respectively. For 63 percent of the studied patients the admission chart record did not include all drugs registered in the Swedish Prescribed Drug Register. For 62 percent the admission chart record did not include all drugs registered in the general practitioner record. In addition, for 32 percent of the patients the admission chart record included drugs not registered in the Swedish Prescribed Drug Register and for 52 percent the admission chart record included drugs not found in the general practitioner record. The most discordant drug classes were cardiovascular and CNS-active drugs. Clinically significant drug record discrepancies were more frequent in older patients with multiple medication and caregivers.

CONCLUSION

The apparent absence of an accurate record of the patient's drugs at admission to the Emergency Ward constitutes a potential patient safety hazard. The available sources in Sweden, containing information on the drugs a particular patient is taking, do not seem to be up to date. These results highlight the importance of an accurate list of currently used drugs that follows the patient and can be accessed upon acute admission to the hospital.

An end-to-end hybrid algorithm for automated medication discrepancy detection

BACKGROUND

In this study we implemented and developed state-of-the-art machine learning (ML) and natural language processing (NLP) technologies and built a computerized algorithm for medication reconciliation. Our specific aims are: (1) to develop a computerized algorithm for medication discrepancy detection between patients' discharge prescriptions (structured data) and medications documented in free-text clinical notes (unstructured data); and (2) to assess the performance of the algorithm on real-world medication reconciliation data.

METHODS

We collected clinical notes and discharge prescription lists for all 271 patients enrolled in the Complex Care Medical Home Program at Cincinnati Children's Hospital Medical Center between 1/1/2010 and 12/31/2013. A double-annotated, gold-standard set of medication reconciliation data was created for this collection. We then developed a hybrid algorithm consisting of three processes: (1) a ML algorithm to identify medication entities from clinical notes, (2) a rule-based method to link medication names with their attributes, and (3) a NLP-based, hybrid approach to match medications with structured prescriptions in order to detect medication discrepancies. The performance was validated on the gold-standard medication reconciliation data, where precision (P), recall (R), F-value (F) and workload were assessed.

RESULTS

The hybrid algorithm achieved 95.0%/91.6%/93.3% of P/R/F on medication entity detection and 98.7%/99.4%/99.1% of P/R/F on attribute linkage. The medication matching achieved 92.4%/90.7%/91.5% (P/R/F) on identifying matched medications in the gold-standard and 88.6%/82.5%/85.5% (P/R/F) on discrepant medications. By combining all processes, the algorithm achieved 92.4%/90.7%/91.5% (P/R/F) and 71.5%/65.2%/68.2% (P/R/F) on identifying the matched and the discrepant medications, respectively. The error analysis on algorithm outputs identified challenges to be addressed in order to improve medication discrepancy detection.

CONCLUSION

By leveraging ML and NLP technologies, an end-to-end, computerized algorithm achieves promising outcome in reconciling medications between clinical notes and discharge prescriptions.

Factors associated with medication information in diabetes care: differences in perceptions between patients and health care professionals

PURPOSE

This qualitative study in patients with type 2 diabetes and health care professionals (HCPs) aimed to investigate which factors they perceive to enhance or impede medication information provision in primary care. Similarities and differences in perspectives were explored.

METHODS

Eight semistructured focus groups were conducted, four with type 2 diabetes patients (n=25) and four with both general practitioners (n=13) and health care assistants (n=10). Sessions were audio and video recorded, transcribed verbatim, and subjected to computer-aided qualitative content analysis.

RESULTS

Diabetes patients and HCPs broadly highlighted similar factors as enablers for satisfactory medication information delivery. Perceptions substantially differed regarding impeding factors. Both patients and HCPs perceived it to be essential to deliver tailored information, to have a trustful and continuous patient-provider relationship, to regularly reconcile medications, and to provide tools for medication management. However, substantial differences in perceptions related to impeding factors included the causes of inadequate information, the detail required for risk-related information, and barriers to medication reconciliation. Medication self-management was a prevalent topic among patients, whereas HCPs' focus was on fulfilling therapy and medication management responsibilities.

CONCLUSION

The findings suggest a noteworthy gap in perceptions between information provision and patients' needs regarding medication-related communication. Medication safety and adherence may be improved if HCPs collaborate more closely with diabetes patients in managing their medication, in particular by incorporating the patients' perspective. Health care systems need to be structured in a way that supports this process.

Feasibility of the implementation of medication reconciliation in Hungary

Introduction: For medication safety improvement medication reconciliation was proven to be an effective method transferable between different healthcare providers and ward profiles. Aim: Gaining a better understanding of the process of reconciling medicines. Mapping the driving and restraining forces of introducing medication reconciliation. Method: A search of the literature was conducted. 19 databases were searched using 7 different search engines. The relevance of the papers was rated by two independent experts. Data were extracted based on a previously compiled extraction tool. Results: 230 articles were evaluated. Limits and driving forces of implementing medication reconciliation were set out. Often mentioned implementation obstacles were: communication issues, disengagement of the leaders, unpredictable resources and competence problems. Recommendations mainly consisted of process redesign techniques, presentation of cost-effectiveness data and arranging special training for staff. Conclusions: For improvement of medication safety in Hungarian hospitals implementing medication reconciliation should be considered. The conclusion of ongoing on-site trials as well as limits and success factors identified in this paper should taken into account. Orv. Hetil., 2014, 155(35), 1395–1405.

Urine specimen detection of zolpidem use in patients with pain

This study examined zolpidem and concurrent opioid, benzodiazepine, other central nervous system (CNS) depressants, and alcohol use. Urine specimens were analyzed using liquid chromatography-mass spectrometry (LC-MS/MS). Specimens were tested for zolpidem (n = 71,919) and separated into a provider-reported medication list documenting (n = 5,257) or not documenting zolpidem use (n = 66,662). Zolpidem-positive specimens were further separated into reported and unreported use cohorts. The total number of zolpidem-positive specimens in the reported and unreported use cohorts was 3,391 and 3,190, respectively. Non-informed prescribers were 4.4% (3,190/71,919) among the general population and 48.5% (3,190/6,581) when only zolpidem users were considered. In the zolpidem user population, the most common concurrent opioids in both cohorts were hydrocodone and oxycodone. Alprazolam and clonazepam were higher in the unreported use cohort (P ≤ 0.05). The unreported use cohort also had a higher detection of zolpidem plus a benzodiazepine (49.7 vs. 46%; P ≤ 0.05), zolpidem plus an opioid and a benzodiazepine (40.8% vs. 37.4%; P ≤ 0.05) and zolpidem plus an opioid, a benzodiazepine, and an other CNS depressant (12.9 vs. 10.9%; P ≤ 0.05). Concurrent use of zolpidem, an opioid, a benzodiazepine and an other CNS depressant is prevalent in a pain patient population.

Predictors of completeness of patients' self-reported personal medication lists and discrepancies with clinic medication lists

BACKGROUND

Transfer of medication information during transitions in care is crucial to preventing medication errors. Few studies evaluate patients' self-reported personal medication lists.

OBJECTIVES

To assess completeness of personal medication lists and identify factors associated with incomplete personal lists and discrepancies between personal and clinic medication lists.

METHODS

We analyzed patients' personal medication lists at an academic hospital preoperative clinic from January 2010 to October 2010. Completeness of personal medication lists was measured as reporting the name, dose, and frequency for all prescription and nonprescription medications or dietary supplements. Discrepancies between personal and clinic medication lists were measured as omitted medications or differing directions.

RESULTS

Among 94 patients meeting inclusion criteria, 82 (87%) personal medication lists were evaluated. Most personal lists were incomplete (56%; 46/82), missing information for at least one medication reported; 94% (77/82) of personal lists had at least one discrepancy with clinic medication lists (median 4 discrepancies per patient list). On multivariate analyses, taking 10 or more medications (adjusted odds ratio [OR] = 3.52; 95% CI = 1.37 to 9.08) and being divorced, widowed, or single (adjusted OR = 3.10; 95% CI = 1.05 to 9.12) were independent predictors of incomplete personal medication lists. Taking 10 or more medications (adjusted OR = 3.44; 95% CI = 1.35 to 8.78) was also associated with higher rates of medication discrepancies.

CONCLUSIONS

Patients' self-reported personal medication lists are often incomplete and have discrepancies with clinic medication lists. Interventions are needed to improve medication information transfer between patients, providers and healthcare systems.

EHR-based medication support and nurse-led medication therapy management: rationale and design for a three-arm clinic randomized trial

BACKGROUND

Patients with chronic conditions often use complex medical regimens. A nurse-led strategy to support medication therapy management incorporated into primary care teams may lead to improved use of medications for disease control. Electronic health record (EHR) tools may offer a lower-cost, less intensive approach to improving medication management.

METHODS AND RESULTS

The Northwestern and Access Community Health Network Medication Education Study is a health center-level cluster-randomized trial being conducted within a network of federally qualified community health centers. Health centers have been enrolled in groups of 3 and randomized to (1) usual care, (2) EHR-based medication management tools alone, or (3) EHR tools plus nurse-led medication therapy management. Patients with uncontrolled hypertension who are prescribed ≥ 3 medications of any kind are recruited from the centers. EHR tools include a printed medication list to prompt review at each visit and automated plain-language medication information within the after-visit summary to encourage proper medication use. In the nurse-led intervention, patients receive one-on-one counseling about their medication regimens to clarify medication discrepancies and identify drug-related concerns, safety issues, and nonadherence. Nurses also provide follow-up telephone calls following new prescriptions and periodically to perform medication review. The primary study outcome is systolic blood pressure after 1 year. Secondary outcomes include measures of understanding of dosing instructions, discrepancies between patient-reported medications and the medical record, adherence, and intervention costs.

CONCLUSIONS

The Northwestern and Access Community Health Network Medication Education Study will assess the effects of 2 approaches to support outpatient medication management among patients with uncontrolled hypertension in federally qualified health center settings.

Integrating patient safety and clinical pharmacy services into the care of a high-risk, ambulatory population: a collaborative approach

OBJECTIVES

Lincoln Community Health Center participated in a Health Resources and Services Administration-sponsored Patient Safety and Clinical Pharmacy Services Collaborative aimed at facilitating integration of pharmacy services proven to enhance patient safety into care provided to a high-risk, ambulatory population.

METHODS

The Collaborative used the Plan-Do-Study-Act (PDSA) cycle of learning from the Model for Improvement endorsed by the Institute for Healthcare Improvement to guide changes. Outcomes targeted for improvement included medication reconciliation, obesity screening and follow-up planning, adverse drug events (patient safety), and delivery of clinical pharmacy services.

RESULTS

Primary changes that resulted from conducting 54 PDSA cycles of learning included enhanced data access, centralized medication access through formulary expansion, implemented a medication reconciliation guideline, designated a single point of accountability in the pharmacy, improved efficiency, staff performed nontraditional roles, extended the existing adverse drug event program, and improved communication.

CONCLUSIONS

Changes made to integrate patient safety and clinical pharmacy services into the care of a high-risk, ambulatory population not only improved all targeted outcomes but also helped establish Lincoln Community Health Center as the patient's medical home.