Rationale and design of the Multicenter Medication Reconciliation Quality Improvement Study (MARQUIS)

Hospital Adaptions to Mitigate the COVID-19 Pandemic Effects on MARQUIS Toolkit Implementation and Sustainability

OBJECTIVE

To explore the perceived effects of COVID-19 on MARQUIS toolkit implementation and sustainability, challenges faced by hospitals in sustaining medication reconciliation efforts, and the strategies used to mitigate the negative effects of the pandemic.

DATA SOURCES AND STUDY SETTINGS

Primary qualitative data were extracted from a Web-based survey. Data were collected from hospitals that participated in MARQUIS2 ( n = 18) and the MARQUIS Collaborative ( n = 5).

STUDY DESIGN

A qualitative, cross-sectional study was conducted.

DATA COLLECTION/DATA EXTRACTION

Qualitative data were extracted from a Research Electronic Data Capture survey databased and uploaded into an Excel data analysis template. Two coders independently coded the data with a third coder resolving discrepancies.

PRINCIPAL FINDINGS

Thirty-one team members participated, including pharmacists ( n = 20; 65%), physicians ( n = 9; 29%), or quality-improvement (QI) specialists ( n = 2; 6%) with expertise in medication reconciliation (MedRec) (14; 45%) or QI (10; 32%). Organizational resources were limited, including funding, staffing, and access to pharmacy students. To support program continuation, hospitals reallocated staff and used new MedRec order sets. Telemedicine, workflow adaptations, leadership support, QI team involvement, and ongoing audits and feedback promoted toolkit sustainability.

CONCLUSIONS

COVID-19 affected the capacity of hospitals to sustain the MARQUIS toolkit. However, hospitals adapted various strategies to sustain the toolkit.

Clinical Pharmacist Led Medication Reconciliation Program in an Emergency Department Observation Unit

Objectives: Medication reconciliation is the process of comparing a patient's hospital medication orders to all of the medications that the patient has been taking prior to admission. The primary aim of this study was to evaluate the effectiveness of pharmacist-led medication reconciliation in reducing ED visit rates. The secondary aim of this study was to evaluate if a clinical pharmacist reduces medication errors in an ED observation unit (OBS). Methods: This was a retrospective, IRB approved, chart review conducted at New York University Langone Health-Tisch Hospital. The study defines the year before a clinical pharmacist was present on the unit (July 5, 2016 through July 4, 2017) as the control group and the first year a clinical pharmacist was present on the unit (July 5, 2017 through July 4, 2018) as the intervention group. The primary endpoint was 30-day ED re-visits. The secondary endpoints were 60-and 90-day ED re-visits, number, type and severity of medication history and reconciliation discrepancies. Results: The primary endpoint of 30-day ED visits occurred in 153 patients in the no pharmacist group and 88 patients in the OBS clinical pharmacist group (19.1% vs 9.9%, P < .00001). The secondary endpoint of 60- day ED visits occurred in 53 patients in the no pharmacist group and 39 patients in the OBS clinical pharmacist group (8.2% vs 4.9%, P = .01). The secondary endpoint of 90- day ED visits occurred in 31 patients in the no pharmacist group and 26 patients in the OBS clinical pharmacist group (5.2% vs 3.4%, P = .01). Conclusion: The benefits of having a clinical pharmacist perform medication reconciliation are highlighted by the reduction in ED visits, cost savings, and the prolific amount of errors corrected.

What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study

BACKGROUND

The second Multicenter Medication Reconciliation Quality Improvement Study demonstrated a marked reduction in medication discrepancies per patient. The aim of the current analysis was to determine the association of patient exposure to each system-level intervention and receipt of each patient-level intervention on these results.

METHODS

This study was conducted at 17 North American Hospitals, the study period was 18 months per site, and sites typically adopted interventions after 2-5 months of preintervention data collection. We conducted an on-treatment analysis (ie, an evaluation of outcomes based on patient exposure) of system-level interventions, both at the category level and at the individual component level, based on monthly surveys of implementation site leads at each site (response rate 65%). We then conducted a similar analysis of patient-level interventions, as determined by study pharmacist review of documented activities in the medical record. We analysed the association of each intervention on the adjusted number of medication discrepancies per patient in admission and discharge orders, based on a random sample of up to 22 patients per month per site, using mixed-effects Poisson regression with hospital site as a random effect. We then used a generalised linear mixed-effects model (GLMM) decision tree to determine which patient-level interventions explained the most variance in discrepancy rates.

RESULTS

Among 4947 patients, patient exposure to seven of the eight system-level component categories was associated with modest but significant reductions in discrepancy rates (adjusted rate ratios (ARR) 0.75-0.97), as were 15 of the 17 individual system-level intervention components, including hiring, reallocating and training personnel to take a best possible medication history (BPMH) and training personnel to perform discharge medication reconciliation and patient counselling. Receipt of five of seven patient-level interventions was independently associated with large reductions in discrepancy rates, including receipt of a BPMH in the emergency department (ED) by a trained clinician (ARR 0.40, 95% CI 0.37 to 0.43), admission medication reconciliation by a trained clinician (ARR 0.57, 95% CI 0.50 to 0.64) and discharge medication reconciliation by a trained clinician (ARR 0.64, 95% CI 0.57 to 0.73). In GLMM decision tree analyses, patients who received both a BPMH in the ED and discharge medication reconciliation by a trained clinician experienced the lowest discrepancy rates (0.08 per medication per patient).

CONCLUSION AND RELEVANCE

Patient-level interventions most associated with reductions in discrepancies were receipt of a BPMH of admitted patients in the ED and admission and discharge medication reconciliation by a trained clinician. System-level interventions were associated with modest reduction in discrepancies for the average patient but are likely important to support patient-level interventions and may reach more patients. These findings can be used to help hospitals and health systems prioritise interventions to improve medication safety during care transitions.

Improving Safety During Transitions of Care Through the Use of Electronic Referral Loops to Receive and Reconcile Health Information

BACKGROUND

Medicare's Promoting Interoperability Program evaluates how often organizations completely reconcile differences between the internal medical record with problems, medications, and allergies received from outside electronic health records (EHRs) during hospitalizations. This quality improvement project sought to increase rates of complete reconciliation of patient problems, medications, and allergies to 80% of hospitalizations for 90 consecutive days at all eight hospitals in an academic medical system by December 31, 2021.

METHODS

Baseline characteristics were determined using monthly reconciliation performance from October 2019 to October 2020. The intervention period occurred from November 2020 to December 2021 and consisted of 26 Plan-Do-Study-Act cycles. Performance was monitored from January 2022 to June 2022 to observe the sustainability of the initiative. Statistical process control charts were used to identify special cause variation in system-level performance.

RESULTS

All eight hospitals successfully recorded 90 consecutive days of complete reconciliation above 80% in 2021, and seven of eight hospitals maintained this goal in the sustainability period. Average baseline reconciliation was 22.1%. System-level performance satisfied criteria for baseline shift after PDSA 17, when the average performance was recalculated as 52.4%. Criteria for a second baseline shift were satisfied during the sustainability period, when the average performance was recalculated at 79.9%. Overall performance has remained within the recalculated control limits throughout the sustainability period.

CONCLUSION

An intervention that included enhancing EHR workflows, training medical providers, and communicating division performance was successful in increasing and sustaining complete reconciliation of clinical information in a multihospital medical system.

Use of complete medication history to identify and correct transitions-of-care medication errors at psychiatric hospital admission

Methods for categorizing the scale and severity of medication errors corrected by pharmacy staff during admission medication reconciliation using complete medication history continue to evolve. We established a rating scale that is effective for generating error reports to health system quality leadership. These reports are needed to quantify the value of investment in transitions-of-care pharmacy staff. All medication errors that were reported by pharmacy staff in the admission medication reconciliation process during a period of 6 months were eligible for inclusion. Complete medication history data source was utilized by admitting providers and all pharmacist staff and a novel medication error scoring methodology was developed. This methodology included: medication error category, medication error type, potential medication error severity, and medication non-adherence. We determined that 82 medication errors were detected from 72 patients and assessed that 74 of these errors may have harmed patients if they were not corrected through pharmacist intervention. Most of these errors were dosage discrepancies and omissions. With hospital system budgets continually becoming leaner, it is important to measure the effectiveness and value of staff resources to optimize patient care. Pharmacists performing admission medication reconciliation can detect subtle medication discrepancies that may be overlooked by other clinician types. This methodology can serve as a foundation for error reporting and predicting the severity of adverse drug events.

Interprofessional survey on medication reconciliation activities in the US Department of Veterans' Affairs: development and validation of an Implementation Readiness Questionnaire

BACKGROUND

Medication reconciliation (MR) can detect medication history discrepancies at interfaces-in-care and help avoid downstream adverse drug events. However, organisations have struggled to implement high-quality MR programmes. The literature has identified systems barriers, including technology capabilities and data interoperability. However, organisational culture as a root cause has been underexplored.

OBJECTIVES

Our objectives were to develop an implementation readiness questionnaire and measure staff attitudes towards MR across a healthcare enterprise.

METHODS

We developed and distributed a questionnaire to 170 Veterans' Health Affairs (VHA) sites using Research Electronic Data Capture (REDCap) software. The questionnaire contained 21 Likert-scale items that measured three constructs, such as: (1) the extent that clinicians valued MR; (2) perceptions of workflow compatibility and (3) perceptions concerning organisational climate of implementation.

RESULTS

8704 clinicians and staff responded to our questionnaire (142 of 170 VHA facilities). Most staff believed reconciling medications can improve medication safety (approximately 90% agreed it was 'important'). However, most (approximately 90%) also expressed concerns about changes to their workflow. One-third of respondents prioritised other duties over MR and reported barriers associated with implementation climate. Only 47% of respondents agreed they had enough resources to address discrepancies when identified.

INTERPRETATION

Our findings indicate that an MR readiness assessment can forecast challenges and inform development of a context-sensitive implementation bundle. Clinicians surveyed struggled with resources, technology challenges and implementation climate. A strong campaign should include clear leadership messaging, credible champions and resources to overcome technical challenges.

CONCLUSIONS

This manuscript provides a method to conduct a readiness assessment and highlights the importance of organisational culture in an MR campaign. The data can help assess site or network readiness for an MR change management programme.

Effects of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals: results of the MARQUIS2 study

BACKGROUND

The first Multicenter Medication Reconciliation Quality Improvement (QI) Study (MARQUIS1) demonstrated that mentored implementation of a medication reconciliation best practices toolkit decreased total unintentional medication discrepancies in five hospitals, but results varied by site. The objective of this study was to determine the effects of a refined toolkit on a larger group of hospitals.

METHODS

We conducted a pragmatic quality improvement study (MARQUIS2) at 18 North American hospitals or hospital systems from 2016 to 2018. Incorporating lessons learnt from MARQUIS1, we implemented a refined toolkit, offering 17 system-level and 6 patient-level interventions. One of eight physician mentors coached each site via monthly calls and performed one to two site visits. The primary outcome was number of unintentional medication discrepancies in admission or discharge orders per patient. Time series analysis used multivariable Poisson regression.

RESULTS

A total of 4947 patients were sampled, including 1229 patients preimplementation and 3718 patients postimplementation. Both the number of system-level interventions adopted per site and the proportion of patients receiving patient-level interventions increased over time. During the intervention, patients experienced a steady decline in their medication discrepancy rate from 2.85 discrepancies per patient to 0.98 discrepancies per patient. An interrupted time series analysis of the 17 sites with sufficient data for analysis showed the intervention was associated with a 5% relative decrease in discrepancies per month over baseline temporal trends (adjusted incidence rate ratio: 0.95, 95% CI 0.93 to 0.97, p<0.001). Receipt of patient-level interventions was associated with decreased discrepancy rates, and these associations increased over time as sites adopted more system-level interventions.

CONCLUSION

A multicentre medication reconciliation QI initiative using mentored implementation of a refined best practices toolkit, including patient-level and system-level interventions, was associated with a substantial decrease in unintentional medication discrepancies over time. Future efforts should focus on sustainability and spread.

Defining Minimum Necessary Communication During Care Transitions for Patients on Antihyperglycemic Medication: Consensus of the Care Transitions Task Force of the IPRO Hypoglycemia Coalition

INTRODUCTION

Antihyperglycemic agents are significant contributors to adverse drug events, responsible for emergency department visits, hospitalizations, and death. Nationally, the rate of serious hypoglycemic events associated with these agents remains high despite widespread efforts to improve drug safety. Transitions of care between healthcare settings can lead to communication challenges between care professionals and increase the risk of adverse drug events. System-based improvements are needed to assure the safe transitions for patients with diabetes who are on antihyperglycemic agents. The objective of this study was to develop a consensus list of requisite elements that should be communicated between care settings during transitions of patients who are prescribed antihyperglycemic agents.

METHODS

The Island Peer Review Organization (IPRO) Hypoglycemia Coalition identified suboptimal transitions of care as a barrier to improving patient safety and quality of diabetes care. The Coalition formed a multidisciplinary Task Force with experts in the field of diabetes care. The Task Force created a draft list of requisite communication elements through literature review and deliberation on monthly conference calls. A blinded iterative Delphi process was subsequently performed to generate a consensus list of requisite communication elements that participating experts agreed were necessary to safely and effectively assume the management of patients with diabetes upon care transitions.

RESULTS

The Task Force completed a series of four iterative polls from September 2015 to August 2016, resulting in a final list of 22 requisite communication elements (the Diabetes Management Discharge Communication List), with the elements conceptually categorized into three domains: diagnosis and treatment, factors affecting glycemic control or patient risk, and patient self-management.

CONCLUSIONS

The Diabetes Management Discharge Communication List provides an initial framework for the development of diabetes-specific resources to improve clinical communication between care settings.

Quantifying Discharge Medication Reconciliation Errors at 2 Pediatric Hospitals

Introduction:

Medication reconciliation errors (MREs) are common and can lead to significant patient harm. Quality improvement efforts to identify and reduce these errors typically rely on resource-intensive chart reviews or adverse event reporting. Quantifying these errors hospital-wide is complicated and rarely done. The purpose of this study is to define a set of 6 MREs that can be easily identified across an entire healthcare organization and report their prevalence at 2 pediatric hospitals.

Methods:

An algorithmic analysis of discharge medication lists and confirmation by clinician reviewers was used to find the prevalence of the 6 discharge MREs at 2 pediatric hospitals. These errors represent deviations from the standards for medication instruction completeness, clarity, and safety. The 6 error types are Duplication, Missing Route, Missing Dose, Missing Frequency, Unlisted Medication, and See Instructions errors.

Results:

This study analyzed 67,339 discharge medications and detected MREs commonly at both hospitals. For Institution A, a total of 4,234 errors were identified, with 29.9% of discharges containing at least one error and an average of 0.7 errors per discharge. For Institution B, a total of 5,942 errors were identified, with 42.2% of discharges containing at least 1 error and an average of 1.6 errors per discharge. The most common error types were Duplication and See Instructions errors.

Conclusion:

The presented method shows these MREs to be a common finding in pediatric care. This work offers a tool to strengthen hospital-wide quality improvement efforts to reduce pediatric medication errors.

Implementation strategies in the context of medication reconciliation: a qualitative study

Background

Medication reconciliation (MedRec) is an important patient safety initiative that aims to prevent patient harm from medication errors. Yet, the implementation and sustainability of MedRec interventions have been challenging due to contextual barriers like the lack of interprofessional communication (among pharmacists, nurses, and providers) and limited organizational capacity. How to best implement MedRec interventions remains unclear. Guided by the Expert Recommendations for Implementing Change (ERIC) taxonomy, we report the differing strategies hospital implementation teams used to implement an evidence-based MedRec Toolkit (the MARQUIS Toolkit).

Methods

A qualitative study was conducted with implementation teams and executive leaders of hospitals participating in the federally funded “Implementation of a Medication Reconciliation Toolkit to Improve Patient Safety” (known as MARQUIS2) research study. Data consisted of transcripts from web-based focus groups and individual interviews, as well as meeting minutes. Interview data were transcribed and analyzed using content analysis and the constant comparison technique.

Results

Data were collected from 16 hospitals using 2 focus groups, 3 group interviews, and 11 individual interviews, 10 sites’ meeting minutes, and an email interview of an executive. Major categories of implementation strategies predominantly mirrored the ERIC strategies of “Plan,” “Educate,” “Restructure,” and “Quality Management.” Participants rarely used the ERIC strategies of finance and attending to policy context. Two new non-ERIC categories of strategies emerged—“Integration” and “Professional roles and responsibilities.” Of the 73 specific strategies in the ERIC taxonomy, 32 were used to implement the MARQUIS Toolkit and 11 new, and non-ERIC strategies were identified (e.g., aligning with existing initiatives and professional roles and responsibilities).

Conclusions

Complex interventions like the MARQUIS MedRec Toolkit can benefit from the ERIC taxonomy, but adaptations and new strategies (and even categories) are necessary to fully capture the range of approaches to implementation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00162-5.

The Pharmacist Discharge Care (PHARM-DC) study: A multicenter RCT of pharmacist-directed transitional care to reduce post-hospitalization utilization

BACKGROUND

Older adults commonly face challenges in understanding, obtaining, administering, and monitoring medication regimens after hospitalization. These difficulties can lead to avoidable morbidity, mortality, and hospital readmissions. Pharmacist-led peri-discharge interventions can reduce adverse drug events, but few large randomized trials have examined their effectiveness in reducing readmissions. Demonstrating reductions in 30-day readmissions can make a financial case for implementing pharmacist-led programs across hospitals.

METHODS/DESIGN

The PHARMacist Discharge Care, or the PHARM-DC intervention, includes medication reconciliation at admission and discharge, medication review, increased communication with caregivers, providers, and retail pharmacies, and patient education and counseling during and after discharge. The intervention is being implemented in two large hospitals: Cedars-Sinai Medical Center and the Brigham and Women's Hospital. To evaluate the intervention, we are using a pragmatic, randomized clinical trial design with randomization at the patient level. The primary outcome is utilization within 30 days of hospital discharge, including unforeseen emergency department visits, observation stays, and readmissions. Randomizing 9776 patients will achieve 80% power to detect an absolute reduction of 2.5% from an estimated baseline rate of 27.5%. Qualitative analysis will use interviews with key stakeholders to study barriers to and facilitators of implementing PHARM-DC. A cost-effectiveness analysis using a time-and-motion study to estimate time spent on the intervention will highlight the potential cost savings per readmission.

DISCUSSION

If this trial demonstrates a business case for the PHARM-DC intervention, with few barriers to implementation, hospitals may be much more likely to adopt pharmacist-led peri-discharge medication management programs.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04071951.

Implementation and sustainability of a medication reconciliation toolkit: A mixed methods evaluation

PURPOSE

MARQUIS (Multi-Center Medication Reconciliation Quality Improvement Study) provided participating hospitals with a toolkit to assist in developing robust medication reconciliation programs. Here we describe hospitals' implementation of the MARQUIS toolkit, barriers and facilitators, and important factors that may enhance the spread and sustainability of the toolkit.

METHODS

We used a mixed methods, quantitative-qualitative study design. We invited site leaders of the 5 hospitals that participated in MARQUIS to complete a Web-based survey and phone interview. The Consolidated Framework for Implementation Research guided question development. We analyzed the collected data using descriptive statistics (for survey responses) and thematic content analysis (for interview results).

RESULTS

Site leaders from each MARQUIS hospital participated. They reported that MARQUIS toolkit implementation augmented their hospitals' existing but limited medication reconciliation practices. Survey results indicated executive leadership support for toolkit implementation but limited institutional support for hiring staff (reported by 20% of respondents) and/or budgetary support for implementation (reported by 60% of respondents). Most participating hospitals (80%) shifted staff responsibilities to support medication reconciliation. Interview findings showed that inner setting (ie, organizational setting) and process factors (eg, designation of champions) both inhibited and facilitated implementation. Hospitals adopted a variety of toolkit interventions (eg, discharge medication counseling) using a range of implementation strategies, including development of educational tools and tip sheets for staff members and electronic health record templates.

CONCLUSION

Despite limited institutional support, hospitals can successfully implement, spread, and sustain the MARQUIS toolkit by shifting staff responsibilities, adding pharmacy staff, and using a variety of strategies to facilitate implementation. Although leadership support and resources for data collection and dissemination facilitated implementation, limited staff buy-in and competing priorities may hinder implementation.

Emerging approaches to polypharmacy among older adults

Polypharmacy is a major health issue for older adults. Entangled with several geriatric syndromes, including frailty, falls and cognitive decline, research focused on polypharmacy has been challenged by heterogeneity in its definition, confounding by comorbidities and limited prospective data. In this Review, we discuss varying definitions for polypharmacy and highlight the need for a uniform definition for future studies. We critically appraise strategies for reducing medication prescriptions and implementing deprescribing as a mechanism to reduce the potential harmful effects of polypharmacy. As we look to the future, we assess the role of novel analytics and high-throughput technology, including multiomics profiling, to advance research in polypharmacy and the development of new strategies for risk stratification in the age of precision medicine.

[Medical reconciliation for hospitalized patients in orthopedic surgery department: Return of experience over 2 years of practice]

OBJECTIVES

Some medication errors can be prevented by pharmacist action such as medication reconciliation. The main objective of this study was to evaluate the medication reconciliation activity after two years of practice. The secondary objective was to assess the medical staff's satisfaction following the setting up of the activity.

METHODS

This retrospective study was realized over a period of two years in our hospital. Patients meeting the following criteria were included: 65 years and over, hospitalized in orthopedic surgery department, preferentially after a discharge of the emergency room. After the best possible medication history was established, it is compared to medicines ordered. The discrepancies were defined as intended or unintended. Study data were collected and analyzed using Excel and SPSS statistics®.

RESULTS

A total of 899 patients met the inclusion criteria during the study period, mean age was 78 years (27; 104). A total of 84 % of our cohort was admitted after a discharge of the emergency room. Seventy five percent of the population had at least an unintended discrepancie, a mean of 2,3 unintended discrepancies per patient was identified. Seventy five percent of the unintended discrepancy were discussed and resolved. The medical staff was mostly satisfied of the activity.

CONCLUSION

The medication reconciliation secured the drug management of hospitalized patients.

Contribution of Healthcare Professionals in Issues that Relate to Quality Management

Background:

The health sector should adopt integrated quality systems because of the need to survive and develop in a highly competitive environment. Inefficiency of mechanistic procedures, along with inadequate administrative infrastructure, impose innovative appoaches to improve operations and increase revenues by reducing quality feilures.

Objective:

A health system that relies on quality healthcare services can directly benefit the entire society, may reduce mortality, disease severity, and increase life expectancy. The following literature review constitutes an attempt to assess the contribution of healthcare professionals in issues that relate to quality management over the course of recent years.

Methods:

This systematic review took place between May 2019 and June 2020 in the databases PubMed, Cochrane Library, Wiley Online Library, Web of Science, Google Scholar and Scopus search engine databases. Study Selection and Data Extraction: This review includes articles written in English language, which contain quantitative and qualitative analysis of healthcare professionals’ involvement in quality activities. Correspondingly, the exclusion criteria were: languages other than English, secondary surveys (general and systematic reviews or post-analyses), letters to the publisher, and editorials or articles that did not illuminate the subject under study. After an extensive literature review, a standardised Excel spreadsheet was developed for data extraction from the included studies. The main characteristics of the studies were recorded (author’s name, place and time of work, the article under study and the methodology) so that all research articles corresponding to the review could be included. 31 articles were included.

Results:

Healthcare professionals are engaged in quality improvement activities and there is high association between quality management strategies and clinical processes. A systematic approach on healthcare activities based on the input of healthcare professionals can help increase business performance, reduce errors, improve patient safety, and contribute to a more proactive care.

Conclusion:

Health professionals’ contribution in the strategic planning of healthcare organisations that address quality activities can lead to better output, both in patient satisfaction and safety.

Improving Transfer Medication Reconciliation in an Emirati Tertiary Hospital Utilizing the Irish Health Service Executive Model

Transfer is a vulnerable setting that increases the risk of medication errors. Medication reconciliation (MedRec) ensures accurate medication transfer at interfaces of care. It is addressed as a key performance indicator (KPI) in a tertiary hospital. The issue was failure to meet the KPI of more than 75%; the objective was to improve compliance with transfer MedRec. A quality improvement project was conducted utilizing physician active education, leadership support, and the Irish Health Service Executive (HSE) change model. Compliance with the KPI did not improve with monthly monitoring and physician education. Following leadership support, compliance increased from 56% to 72% but was not sustained. Adoption of the change model yielded a sustainable improvement from 65% to 81% within 1 year of the intervention and a reduction in medication errors. Improvement in the MedRec process requires a culture of accountability to change. HSE expedited stakeholders' engagement and implementation of the planned interventions.

[Reduction of reconciliation errors in chronic pediatric patients through an educational strategy]

BACKGROUND

Medication reconciliation errors, also known as unintentional discrepancies, are frequent during admission, especially in chronic patients, and have an impact on safety. Educational interventions can be a reduction strategy.

MATERIAL AND METHODS

Quasi-experimental study, before-after design. Participants were chronic patients admitted into hospitalization services. Medication reconciliation was conducted at admission. The intervention consisted of a training to each prescribing physician with study contents and printed educational material. To study the association between intervention and change of frequency of unintentional discrepancies was made a logistic regression model, adjusting for selected variables.

RESULTS

A sample of 54 patients was studied in each stage. In the first stage it was observed that 42.6% of patients had at least one unintentional discrepancy. After intervention the proportion of patients with at least one unintentional discrepancy decreased to 24.1% (p = 0.041). In both stages, omission was the main category of unintentional discrepancy. The significant reduction after the intervention is maintained by controlling for variables such as emergency admission and pre-admission service.

CONCLUSIONS

Incidence of unintentional discrepancies in admission is high in chronic hospitalized patients and can be reduced through an educative strategy.

Comparing medication histories obtained by pharmacy technicians and nursing staff in the emergency department

BACKGROUND

An accurate medication history is crucial for maintaining continuity of care. There are numerous opportunities for discrepancies to occur, such as medication omissions, commissions, incorrect dosing, incorrect frequencies, or incorrect formulations. Medication discrepancies may prolong hospital length of stay, increase the number of future emergency department (ED) visits, and increase hospital readmissions. Numerous studies have established the advantages of utilizing pharmacy technicians to complete medication histories. This study aimed to compare the accuracy of obtaining medication histories through pharmacy technicians compared to nursing staff.

OBJECTIVE

To compare the accuracy of obtaining medication histories through pharmacy technicians compared to nursing staff in the emergency department.

METHODS

This was a single-center, retrospective, observational analysis of patients presenting to the ED between December 2018 through January 2019. A pharmacy technician received on-site training on how to properly obtain a medication history and performed medication histories on the days the pharmacy resident was present between 10:00 and 18:00. Medication histories were obtained by nurses on the days the pharmacy technician was not present. All study medication histories were reviewed for discrepancies by the pharmacy resident.

RESULTS

Medication histories conducted by a pharmacy technician (n = 102) resulted in a greater number of accurate medication histories [96 (94.1%) versus 59 (57.8%); p < 0.01] when compared to those conducted by nurses (n = 102). A total of seven discrepancies were found in the pharmacy technician group compared to 131 in the nursing group (p < 0.01). There was also a statistically significant lower amount of high impact discrepancies in the pharmacy technician group compared to nursing (1 versus 15; p < 0.01).

CONCLUSIONS

Pharmacy technicians in the ED provided more accurate medication histories when compared to nursing staff, thereby reducing potential medication errors.

The Rural VA Multi-Center Medication Reconciliation Quality Improvement Study (R-VA-MARQUIS)

PURPOSE

High-quality medication reconciliation reduces medication discrepancies, but smaller hospitals serving rural patients may have difficulty implementing this because of limited resources. We sought to adapt and implement an evidence-based toolkit of best practices for medication reconciliation in smaller hospitals, evaluate the effect on unintentional medication discrepancies, and assess facilitators and barriers to implementation.

METHODS

We conducted a 2-year mentored-implementation quality improvement feasibility study in 3 Veterans Affairs (VA) hospitals serving rural patients. The primary outcome was unintentional medication discrepancies per medication per patient, determined by comparing the "gold standard" preadmission medication history to the documented preadmission medication list and admission and discharge orders.

RESULTS

In total, 797 patients were included; their average age was 68.7 years, 94.4% were male, and they were prescribed an average of 9.6 medications. Sites 2 and 3 implemented toolkit interventions, including clarifying roles among clinical personnel, educating providers on taking a best possible medication history, and hiring pharmacy professionals to obtain a best possible medication history and perform discharge medication reconciliation. Site 1 did not implement an intervention. Discrepancies improved in intervention patients compared with controls at Site 3 (adjusted incidence rate ratio [IRR], 0.55; 95% confidence interval [CI], 0.45-0.67) but increased in intervention patients compared with controls at Site 2 (adjusted IRR, 1.22; 95% CI, 1.08-1.36).

CONCLUSIONS

An evidence-based toolkit for medication reconciliation adapted to the VA setting was adopted in 2 of 3 small, rural, resource-limited hospitals, resulting in both reduced and increased unintentional medication discrepancies. We highlight facilitators and barriers to implementing evidence-based medication reconciliation in smaller hospitals.

Higher accuracy of complex medication reconciliation through improved design of electronic tools

Objective

Investigate the accuracy of 2 different medication reconciliation tools integrated into electronic health record systems (EHRs) using a cognitively demanding scenario and complex medication history.

Materials and Methods

Seventeen physicians reconciled medication lists for a polypharmacy patient using 2 EHRs in a simulation study. The lists contained 3 types of discrepancy and were transmitted between the systems via a Continuity of Care Document. Participants updated each EHR and their interactions were recorded and analyzed for the number and type of errors.

Results

Participants made 748 drug comparisons that resulted in 53 errors (93% accuracy): 12 using EHR2 (3% rate, 0-3 range) and 41 using EHR1 (11% rate, 0-9 range; P < .0001). Twelve clinicians made completely accurate reconciliations with EHR2 (71%) and 6 with EHR1 (35%). Most errors (28, 53%) occurred in medication entries containing discrepancies: 4 in EHR2 and 24 in EHR1 (P = .008). The order in which participants used the EHRs to complete the task did not affect the results.

Discussion

Significantly fewer errors were made with EHR2, which presented lists in a side-by-side view, automatically grouped medications by therapeutic class and more effectively identified duplicates. Participants favored this design and indicated that they routinely used several workarounds in EHR1.

Conclusion

Accurate assessment of the safety and effectiveness of electronic reconciliation tools requires rigorous testing and should prioritize complex rather than simpler tasks that are currently used for EHR certification and product demonstration. Higher accuracy of reconciliation is likely when tools are designed to better support cognitively demanding tasks.

Organisational context of hospitals that participated in a multi-site mentored medication reconciliation quality improvement project (MARQUIS2): a cross-sectional observational study

OBJECTIVES

Medication reconciliation (MedRec) is an important patient safety strategy and is widespread in US hospitals and globally. Nevertheless, high quality MedRec has been difficult to implement. As part of a larger study investigating MedRec interventions, we evaluated and compared organisational contextual factors and team cohesion by hospital characteristics and implementation team members' profession to better understand the environmental context and its correlates during a multi-site quality improvement (QI) initiative.

DESIGN

We conducted a cross-sectional observational study using a web survey (contextual factors) and a national hospital database (hospital characteristics).

SETTING

Hospitals participating in the second Multi-Centre Medication Reconciliation Quality Improvement Study (MARQUIS2).

PARTICIPANTS

Implementation team members of 18 participating MARQUIS2 hospitals.

OUTCOMES

Primary outcome: contextual factor ratings (ie, organisational capacity, leadership support, goal alignment, staff involvement, patient safety climate and team cohesion). Secondary outcome: differences in contextual factors by hospital characteristics.

RESULTS

Fifty-five team members from the 18 participating hospitals completed the survey. Ratings of contextual factors differed significantly by domain (p<0.001), with organisational capacity scoring the lowest (mean=4.0 out of 7.0) and perceived team cohesion and goal alignment scoring the highest (mean~6.0 out of 7.0). No statistically significant differences were observed in contextual factors by hospital characteristics (p>0.05). Respondents in the pharmacy profession gave lower ratings of leadership support than did those in the nursing or other professions group (p=0.01).

CONCLUSIONS

Hospital size, type and location did not drive differences in contextual factors, suggesting that tailoring MedRec QI implementation to hospital characteristics may not be necessary. Strong team cohesion suggests the use of interdisciplinary teams does not detract from cohesion when conducting mentored QI projects. Organisational leaders should particularly focus on supporting pharmacy services and addressing their concerns during MedRec QI initiatives. Future research should correlate contextual factors with implementation success to inform how best to prepare sites to implement complex QI interventions such as MedRec.

An On-Treatment Analysis of the MARQUIS Study: Interventions to Improve Inpatient Medication Reconciliation

It is unclear which medication reconciliation interventions are most effective at reducing inpatient medication discrepancies. Five United States hospitals' interdisciplinary quality improvement (QI) teams were virtually mentored by QI-trained physicians. Sites implemented one to seven evidence-based interventions in 791 patients during the 25-month implementation period. Three interventions were associated with significant decreases in potentially harmful discrepancy rates: (1) defining clinical roles and responsibilities, (2) training, and (3) hiring staff to perform discharge medication reconciliation. Two interventions were associated with significant increases in potentially harmful discrepancy rates: training staff to take medication histories and implementing a new electronic health record (EHR). Hospitals should focus first on hiring and training pharmacy staff to assist with medication reconciliation at discharge and delineating roles and responsibilities of clinical staff. We caution hospitals implementing a large vendor EHR, as medication discrepancies may increase. Finally, the effect of medication history training on discrepancies needs further study.

Design of MARQUIS2: study protocol for a mentored implementation study of an evidence-based toolkit to improve patient safety through medication reconciliation

BACKGROUND

The first Multi-center Medication Reconciliation Quality Improvement Study (MARQUIS1) demonstrated that implementation of a medication reconciliation best practices toolkit decreased total unintentional medication discrepancies in five hospitals. We sought to implement the MARQUIS toolkit in more diverse hospitals, incorporating lessons learned from MARQUIS1.

METHODS

MARQUIS2 is a pragmatic, mentored implementation QI study which collected clinical and implementation outcomes. Sites implemented a revised toolkit, which included interventions from these domains: 1) best possible medication history (BPMH)-taking; 2) discharge medication reconciliation and patient/caregiver counseling; 3) identifying and defining clinician roles and responsibilities; 4) risk stratification; 5) health information technology improvements; 6) improved access to medication sources; 7) identification and correction of real-time discrepancies; and, 8) stakeholder engagement. Eight hospitalists mentored the sites via one site visit and monthly phone calls over the 18-month intervention period. Each site's local QI team assessed opportunities to improve, implemented at least one of the 17 toolkit components, and accessed a variety of resources (e.g. implementation manual, webinars, and workshops). Outcomes to be assessed will include unintentional medication discrepancies per patient.

DISCUSSION

A mentored multi-center medication reconciliation QI initiative using a best practices toolkit was successfully implemented across 18 medical centers. The 18 participating sites varied in size, teaching status, location, and electronic health record (EHR) platform. We introduce barriers to implementation and lessons learned from MARQUIS1, such as the importance of utilizing dedicated, trained medication history takers, simple EHR solutions, clarifying roles and responsibilities, and the input of patients and families when improving medication reconciliation.

The missing piece: Clinical pharmacists enhancing the interprofessional nephrology clinic model

OBJECTIVES

To embed pharmacy residents in an interprofessional nephrology clinic to conduct medication reconciliation in targeted high-risk patients with nondialysis kidney disease.

SETTING

This pilot was a prospective quality improvement initiative conducted in an interprofessional outpatient nephrology clinic.

PRACTICE DESCRIPTION

The nephrology clinic team includes nephrology providers, a social worker, and a geriatrician. The team is responsible for the management of conditions such as nondialysis kidney disease, resistant hypertension, acute kidney injury, proteinuria, and nephropathy.

EVALUATION

Primary outcomes included the number and type of medication discrepancies and drug therapy problems identified. Secondary outcomes included the changes in care process directly resulting from the pharmacy residents' recommendations. The perceived value of the pharmacy residents to the interprofessional team was assessed through postintervention anonymous surveys and semistructured interviews.

RESULTS

The pharmacy residents conducted 118 visits for 87 unique patients (mean age 73 years, 97% male) with nondialysis kidney disease (89% stages III-V), polypharmacy (87% of patients taking > 10 medications), and a heavy comorbidity burden (85% hypertension, 80% dyslipidemia, 59% diabetes mellitus type II) from January to October 2017. Pharmacists identified 344 medication discrepancies and 301 drug therapy problems, resulting in 398 changes in care process. The most frequently identified discrepancies and drug therapy problems were the omission of an active medication from the medication list (86 of 344 discrepancies, 25%) and potentially inappropriate medications (106 of 301 drug therapy problems, 35%). Pharmacists recommended 228 medication changes, provided 76 adherence devices, facilitated 24 consults or referrals, and communicated with the primary care team on 70 occasions. The interprofessional team members all strongly agreed that patients and the team benefited from the pharmacists' involvement.

CONCLUSION

Pharmacy resident-led medication reconciliation resulted in the identification and resolution of medication discrepancies and drug therapy problems, leading to changes in the care process.

Systems engineering and human factors support of a system of novel EHR-integrated tools to prevent harm in the hospital

We established a Patient Safety Learning Laboratory comprising 2 core and 3 individual project teams to introduce a suite of digital health tools integrated with our electronic health record to identify, assess, and mitigate threats to patient safety in real time. One of the core teams employed systems engineering (SE) and human factors (HF) methods to analyze problems, design and develop improvements to intervention components, support implementation, and evaluate the system of systems as an integrated whole. Of the 29 participants, 19 and 16 participated in surveys and focus groups, respectively, about their perception of SE and HF. We identified 7 themes regarding use of the 12 SE and HF methods over the 4-year project. Qualitative methods (interviews, focus, groups, observations, usability testing) were most frequently used, typically by individual project teams, and generated the most insight. Quantitative methods (failure mode and effects analysis, simulation modeling) typically were used by the SE and HF core team but generated variable insight. A decentralized project structure led to challenges using these SE and HF methods at the project and systems level. We offer recommendations and insights for using SE and HF to support digital health patient safety initiatives.

Improving medication safety by cloud technology: Progression and value-added applications in Taiwan

OBJECTIVES

To develop and implement an integrated cloud technology with the aim of ensuring medication reconciliation during transitions of care and improve medication safety in aged societies.

METHODS

PharmaCloud is a new technical platform adopted by the National Health Insurance Administration of Taiwan to collect patients' medication information via cloud technology. Using this platform, healthcare providers can access patients' medication-related information with patient consent. Our hospital applied this technology and developed several approaches to collect and detect medication-related information and alert physicians for the purpose of enhancing patients' medication safety. In addition, pharmacists were involved in the admission process to access medication data and provide optimal suggestions to physicians. Several indicators, including a reduction in the number of drug items in each prescription and medication expenditure, were employed to evaluate the overall effects of the cloud inquiry.

RESULTS

After the application of PharmaCloud, the average number of prescribed drug items significantly decreased (change of 0.04 to -0.35 per prescription, p < 0.05), and the median medication expenditure significantly decreased by an average of 3.55 USD, (p < 0.05) per prescription. Intra-hospital medication duplication rates also showed a downward trend.

CONCLUSIONS

The use of the cloud technology and value-added applications significantly improved patient medication safety. Further long-term beneficial effects in terms of medication safety and medical cost savings are expected.

Improving Medication History at Admission Utilizing Pharmacy Students and Technicians: A Pharmacy-Driven Improvement Initiative

BACKGROUND

Because of the frequency of medication errors related to care transitions, patient-safety initiatives have recently focused on improving the patient medication list. Pharmacy student and technician participation in the medication-history process has been shown to improve the quality of medication histories. To improve patient care, a pharmacy-driven medication-history service utilizing a unique hybrid team of pharmacy students and technicians was launched at Inova Loudoun Hospital (ILH).

OBJECTIVE

The objective of the service was to improve patient safety and therapy by providing the Best Possible Medication History (BPMH) for admitted acute-care patients.

METHODS

Data for the medication-history service was collected for six months from July 2015 to January 2016. The service included pharmacy technicians and fourth-year pharmacy students using the BPMH approach to verify patients' allergies, medications, doses, and frequencies, and to ensure optimal documentation in the Electronic Health Record (EHR). Data on types and numbers of discrepancies and interventions were collected during the process. Readmission rates for the study group were calculated and compared to readmission rates for all patients.

RESULTS

Out of 4,070 patients interviewed, 77.7% (3,162) had at least one discrepancy in their medication list. Per patient, the average number of medications was 7.47, with an average of 1.8 discrepancies. Pharmacy students identified more discrepancies per patient than pharmacy technicians, 2.3 versus 1.5, respectively. Readmission rates for patients interviewed by the medication-history team was lower than for all patients during the same period, as well as for all patients during the same period in the previous year.

CONCLUSION

This pharmacy-driven medication-history service, staffed with pharmacy technicians and students using a structured BPMH approach, increased the accuracy of home-medication lists on patient admission. The service demonstrated a difference in the types of interventions provided by pharmacy students and technicians. Readmission rates were also lower for patients with completed BPMH.

Primary care workflow process mapping of medication-related activities performed by non-provider staff: A pilot project's approach

BACKGROUND

A workflow process mapping approach was previously developed to understand the impact of primary care medication use processes on medication safety. The workflow process mapping approach was applied to a pilot project in one primary care practice.

OBJECTIVES

The objective of this article is to: (1) exemplify how workflow process mapping was implemented in one primary care practice to characterize medication safety issues (i.e., critical workflow gaps/deviations), (2) discuss the identified critical medication safety workflow gaps and deviations, and (3) summarize the pragmatic, practice-level recommendations developed to enhance practice-level medication safety.

METHODS

Four medication-related activities were directly observed, including: (1) medication reconciliation, (2) warfarin medication management, (3) vaccination administration, and (4) medication renewal requests. Observations occurred with registered nurses, medical assistants, and telephone operators. An ideal-state and observed workflow process map was created for each medication-related activity and was compared to identify critical medication safety workflow gaps and deviations. Practice-level recommendations were developed to enhance workflow and medication safety across all medication-related activities.

RESULTS

111 medication-related observations were recorded over 6-weeks across all 4 workflows (100 observation hours). A total of 17 critical workflow safety gaps, 9 critical workflow step deviations, and 9 workflow sequence deviations were identified. Seventy-six percent of total workflow gaps resulted from inappropriate medication verification. Most workflow step deviations (33%) were due to inappropriate documentation, whereas most sequence deviations (44%) stemmed from inadequate medication verification. Practice-level recommendations to enhance warfarin medication safety were prioritized and implemented prior to the completion of the pilot project.

CONCLUSION

The results of this workflow mapping pilot project exemplify the need to enhance primary care medication safety for workflows conducted by non-provider staff members in primary care practices. Additionally, this approach can be used to identify opportunities for primary care pharmacist integration, particularly for practices with little or no prior pharmacist involvement.

Effects of a multifaceted medication reconciliation quality improvement intervention on patient safety: final results of the MARQUIS study

BACKGROUND

Unintentional discrepancies across care settings are a common form of medication error and can contribute to patient harm. Medication reconciliation can reduce discrepancies; however, effective implementation in real-world settings is challenging.

METHODS

We conducted a pragmatic quality improvement (QI) study at five US hospitals, two of which included concurrent controls. The intervention consisted of local implementation of medication reconciliation best practices, utilising an evidence-based toolkit with 11 intervention components. Trained QI mentors conducted monthly site phone calls and two site visits during the intervention, which lasted from December 2011 through June 2014. The primary outcome was number of potentially harmful unintentional medication discrepancies per patient; secondary outcome was total discrepancies regardless of potential for harm. Time series analysis used multivariable Poisson regression.

RESULTS

Across five sites, 1648 patients were sampled: 613 during baseline and 1035 during the implementation period. Overall, potentially harmful discrepancies did not decrease over time beyond baseline temporal trends, adjusted incidence rate ratio (IRR) 0.97 per month (95% CI 0.86 to 1.08), p=0.53. The intervention was associated with a reduction in total medication discrepancies, IRR 0.92 per month (95% CI 0.87 to 0.97), p=0.002. Of the four sites that implemented interventions, three had reductions in potentially harmful discrepancies. The fourth site, which implemented interventions and installed a new electronic health record (EHR), saw an increase in discrepancies, as did the fifth site, which did not implement any interventions but also installed a new EHR.

CONCLUSIONS

Mentored implementation of a multifaceted medication reconciliation QI initiative was associated with a reduction in total, but not potentially harmful, medication discrepancies. The effect of EHR implementation on medication discrepancies warrants further study.

TRIAL REGISTRATION NUMBER

NCT01337063.

Impact of a pharmacy technician-centered medication reconciliation program on medication discrepancies and implementation of recommendations

Objectives:

To evaluate the impact of a pharmacy-technician centered medication reconciliation (PTMR) program by identifying and quantifying medication discrepancies and outcomes of pharmacist medication reconciliation recommendations.

Methods:

A retrospective chart review was performed on two-hundred patients admitted to the internal medicine teaching services at Cooper University Hospital in Camden, NJ. Patients were selected using a stratified systematic sample approach and were included if they received a pharmacy technician medication history and a pharmacist medication reconciliation at any point during their hospital admission. Pharmacist identified medication discrepancies were analyzed using descriptive statistics, bivariate analyses. Potential risk factors were identified using multivariate analyses, such as logistic regression and CART. The priority level of significance was set at 0.05.

Results:

Three-hundred and sixty-five medication discrepancies were identified out of the 200 included patients. The four most common discrepancies were omission (64.7%), non-formulary omission (16.2%), dose discrepancy (10.1%), and frequency discrepancy (4.1%). Twenty-two percent of pharmacist recommendations were implemented by the prescriber within 72 hours.

Conclusion:

A PTMR program with dedicated pharmacy technicians and pharmacists identifies many medication discrepancies at admission and provides opportunities for pharmacist reconciliation recommendations.

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.

Medication Harmony: A Framework to Save Time, Improve Accuracy and Increase Patient Activation

Incompletely reconciled medication lists contribute to prescribing errors and adverse drug events. Providers expend time and effort at every point of patient contact attempting to curate a best possible medication list, and yet often the list is incomplete or inaccurate. We propose a framework that builds upon the existing infrastructure of a health information exchange (HIE), centralizes data and encourages patient activation. The solution is a constantly accessible, singular, patient-adjudicated medication list that incorporates useful information and features into the list itself. We aim to decrease medication errors across transitions of care, increase awareness of potential drug-drug interactions, improve patient knowledge and self-efficacy regarding medications, decrease polypharmacy, improve prescribing safety and ultimately decrease cost to the health-care system.

Training of pharmacy technicians for dispensing drugs in Primary Health Care

Few Brazilian articles discuss the importance of pharmacy technicians who offer direct assistance to patients. This paper describes an experience of the training of pharmacy technicians in drug dispensing. A descriptive, cross-sectional study was conducted in the primary healthcare setting. The technicians were trained by the pharmacist to advise patients at the time of drug dispensing and to screen cases that needed pharmaceutical consultation. Problems were identified by verifying the prescription and return date for dispensing the medication as well as through direct questioning of the patients. Flowcharts for problem identification and intervention were created for use by the technicians. After training, pharmacy technicians identified 3944 problems, the most common of which were the use of a lower dosage than that prescribed (26%) and non-adherence to pharmacological treatment. The findings of the present study demonstrate the importance of training pharmacy technicians with regard to dispensing drugs so that they can assist pharmacists in the process of identifying and solving drug-related problems, thereby making them active members of the care process in the public health system.

Process mapping evaluation of medication reconciliation in academic teaching hospitals: a critical step in quality improvement

BACKGROUND

Medication reconciliation (MedRec) has been a mandated or recommended activity in Canada, the USA and the UK for nearly 10 years. Accreditation bodies in North America will soon require MedRec for every admission, transfer and discharge of every patient. Studies of MedRec have revealed unintentional discrepancies in prescriptions but no clear evidence that clinically important outcomes are improved, leading to widely variable practices. Our objective was to apply process mapping methodology to MedRec to clarify current processes and resource usage, identify potential efficiencies and gaps in care, and make recommendations for improvement in the light of current literature evidence of effectiveness.

METHODS

Process engineers observed and recorded all MedRec activities at 3 academic teaching hospitals, from initial emergency department triage to patient discharge, for general internal medicine patients. Process maps were validated with frontline staff, then with the study team, managers and patient safety leads to summarise current problems and discuss solutions.

RESULTS

Across all of the 3 hospitals, 5 general problem themes were identified: lack of use of all available medication sources, duplication of effort creating inefficiency, lack of timeliness of completion of the Best Possible Medication History, lack of standardisation of the MedRec process, and suboptimal communication of MedRec issues between physicians, pharmacists and nurses.

DISCUSSION

MedRec as practised in this environment requires improvements in quality, timeliness, consistency and dissemination. Further research exploring efficient use of resources, in terms of personnel and costs, is required.

Preventability and Causes of Readmissions in a National Cohort of General Medicine Patients

IMPORTANCE

Readmission penalties have catalyzed efforts to improve care transitions, but few programs have incorporated viewpoints of patients and health care professionals to determine readmission preventability or to prioritize opportunities for care improvement.

OBJECTIVES

To determine preventability of readmissions and to use these estimates to prioritize areas for improvement.

DESIGN, SETTING, AND PARTICIPANTS

An observational study was conducted of 1000 general medicine patients readmitted within 30 days of discharge to 12 US academic medical centers between April 1, 2012, and March 31, 2013. We surveyed patients and physicians, reviewed documentation, and performed 2-physician case review to determine preventability of and factors contributing to readmission. We used bivariable statistics to compare preventable and nonpreventable readmissions, multivariable models to identify factors associated with potential preventability, and baseline risk factor prevalence and adjusted odds ratios (aORs) to determine the proportion of readmissions affected by individual risk factors.

MAIN OUTCOME AND MEASURE

Likelihood that a readmission could have been prevented.

RESULTS

The study cohort comprised 1000 patients (median age was 55 years). Of these, 269 (26.9%) were considered potentially preventable. In multivariable models, factors most strongly associated with potential preventability included emergency department decision making regarding the readmission (aOR, 9.13; 95% CI, 5.23-15.95), failure to relay important information to outpatient health care professionals (aOR, 4.19; 95% CI, 2.17-8.09), discharge of patients too soon (aOR, 3.88; 95% CI, 2.44-6.17), and lack of discussions about care goals among patients with serious illnesses (aOR, 3.84; 95% CI, 1.39-10.64). The most common factors associated with potentially preventable readmissions included emergency department decision making (affecting 9.0%; 95% CI, 7.1%-10.3%), inability to keep appointments after discharge (affecting 8.3%; 95% CI, 4.1%-12.0%), premature discharge from the hospital (affecting 8.7%; 95% CI, 5.8%-11.3%), and patient lack of awareness of whom to contact after discharge (affecting 6.2%; 95% CI, 3.5%-8.7%).

CONCLUSIONS AND RELEVANCE

Approximately one-quarter of readmissions are potentially preventable when assessed using multiple perspectives. High-priority areas for improvement efforts include improved communication among health care teams and between health care professionals and patients, greater attention to patients' readiness for discharge, enhanced disease monitoring, and better support for patient self-management.

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.

Automated Communication Tools and Computer-Based Medication Reconciliation to Decrease Hospital Discharge Medication Errors

This study sought to determine the effects of automated primary care physician (PCP) communication and patient safety tools, including computerized discharge medication reconciliation, on discharge medication errors and posthospitalization patient outcomes, using a pre-post quasi-experimental study design, in hospitalized medical patients with ≥2 comorbidities and ≥5 chronic medications, at a single center. The primary outcome was discharge medication errors, compared before and after rollout of these tools. Secondary outcomes were 30-day rehospitalization, emergency department visit, and PCP follow-up visit rates. This study found that discharge medication errors were lower post intervention (odds ratio = 0.57; 95% confidence interval = 0.44-0.74; P < .001). Clinically important errors, with the potential for serious or life-threatening harm, and 30-day patient outcomes were not significantly different between study periods. Thus, automated health system-based communication and patient safety tools, including computerized discharge medication reconciliation, decreased hospital discharge medication errors in medically complex patients.