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Vasilevskis EE, Trumbo SP, Shah AS, Hollingsworth EK, Shotwell MS, Mixon AS, Simmons SF. Medication Discrepancies among Older Hospitalized Adults Discharged from Post-Acute Care Facilities to Home. J Am Med Dir Assoc 2024; 25:105017. [PMID: 38754476 DOI: 10.1016/j.jamda.2024.105017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 03/29/2024] [Accepted: 04/02/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVES The epidemiology of medication discrepancies during transitions from post-acute care (PAC) to home is poorly described. We sought to describe the frequency and types of medication discrepancies among hospitalized older adults transitioning from PAC to home. DESIGN A nested cohort analysis. SETTING AND PARTICIPANTS Included participants enrolled in a patient-centered deprescribing trial, for patients (aged ≥50 years and taking at least 5 medications) transitioning from one of 22 PACs to home. METHODS We assessed demographic and medication measures at the initial hospitalization. The primary outcome measure was medication discrepancies, with the PAC discharge list serving as reference for comparison to the participant's self-reported medication list at 7 days following PAC discharge. Discrepancies were categorized as additions, omissions, and dose discrepancies and were organized by common medication classes and risk of harm (eg, 2015 Beers Criteria). Ordinal logistic regression assessed for patient risk factors for PAC discharge discrepancy count. RESULTS A total of 184 participants had 7-day PAC discharge medication data. Participants were predominately female (67%) and Caucasian (83%) with a median of 16 prehospital medications [interquartile range (IQR) 11, 20]. At the 7-day follow-up, 98% of participants had at least 1 medication discrepancy, with a median number of 7 medication discrepancies (IQR 4, 10) per person, 4 (IQR 2, 6) of which were potentially inappropriate medications as defined by the Beers Criteria. Higher medication discrepancies at index hospital admission and receipt of caregiver assistance with medications were 2 key predictors of medication discrepancies in the week after PAC discharge to home. CONCLUSIONS AND IMPLICATIONS Older patients transitioning home from a PAC facility are at high risk for medication discrepancies. This study underscores the need for interventions targeted at this overlooked transition period, especially as patients resume responsibility for managing their own medications after both a hospital and PAC stay.
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Affiliation(s)
- Eduard Eric Vasilevskis
- Division of Hospital Medicine, Department of Medicine, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA; Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN, USA; Section of Hospital Medicine, Division of General Internal Medicine & Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA; Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN, USA.
| | - Silas P Trumbo
- Department of Medicine, University of Central Florida College of Medicine, Orlando, FL, USA
| | - Avantika Saraf Shah
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Emily Kay Hollingsworth
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN, USA; Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Amanda S Mixon
- Section of Hospital Medicine, Division of General Internal Medicine & Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA; Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Sandra Faye Simmons
- Center for Quality Aging, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN, USA; Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN, USA; Division of Geriatrics, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Kaplan HC, Goldstein SL, Rubinson C, Daraiseh N, Zhang F, Rodgers IM, Dahale DS, Askenazi DJ, Somers MJG, Zaritsky JJ, Misurac J, Chadha V, Yonekawa KE, Sutherland SM, Weng PL, Walsh KE. Prospective Study of the Multisite Spread of a Medication Safety Intervention: Factors Common to Hospitals With Improved Outcomes. Am J Med Qual 2024; 39:21-32. [PMID: 38127682 DOI: 10.1097/jmq.0000000000000161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Context and implementation approaches can impede the spread of patient safety interventions. The objective of this article is to characterize factors associated with improved outcomes among 9 hospitals implementing a medication safety intervention. Nephrotoxic Injury Negated by Just-in-Time Action (NINJA) is a pharmacist-driven intervention that led to a sustained reduction in nephrotoxic medication-associated acute kidney injury (NTMx-AKI) at 1 hospital. Using qualitative comparative analysis, the team prospectively assessed the association between context and implementation factors and NTMx-AKI reduction during NINJA spread to 9 hospitals. Five hospitals reduced NTMx-AKI. These 5 had either (1) a pharmacist champion and >2 pharmacists working on NINJA (Scon 1.0, Scov 0.8) or (2) a nephrologist-implementing NINJA with minimal competing organizational priorities (Scon 1.0, Scov 0.2). Interviews identified ways NINJA team leaders obtained pharmacist support or successfully implemented without that support. In conclusion, these findings have implications for future spread of NINJA and suggest an approach to study spread of safety interventions more broadly.
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Affiliation(s)
- Heather C Kaplan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Division of Neonatology, Perinatal Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Stuart L Goldstein
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Claude Rubinson
- Department of Social Sciences, University of Houston-Downtown, Houston, TX
| | - Nancy Daraiseh
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Fang Zhang
- Division of Health Policy and Insurance Research, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
| | | | - Devesh S Dahale
- Operational Effectiveness Department, Southeast Health, Dothan, AL
| | - David J Askenazi
- Division of Nephrology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | | | | | - Jason Misurac
- Department of Pediatrics, University of Iowa, Stead Family Children's Hospital, Iowa City, IA
| | - Vimal Chadha
- Division of Nephrology, Children's Mercy Hospital, Kansas City, MO
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Karyn E Yonekawa
- Division of Nephrology, Seattle Children's Hospital, Seattle, WA
| | - Scott M Sutherland
- Division of Nephrology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
- Division of Nephrology, Lucille Packard Stanford Children's Hospital, Palo Alto, CA
| | - Patricia L Weng
- Division of Nephrology, Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles, CA
| | - Kathleen E Walsh
- Division of General Pediatrics, Boston Children's Hospital, Boston, MA
- Department of General Pediatrics, Harvard Medical School, Boston, MA
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Rhoten B, Jones AC, Maxwell C, Stolldorf DP. Hospital Adaptions to Mitigate the COVID-19 Pandemic Effects on MARQUIS Toolkit Implementation and Sustainability. J Healthc Qual 2024; 46:1-11. [PMID: 37788425 PMCID: PMC10840884 DOI: 10.1097/jhq.0000000000000406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
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.
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Flynn R, Cassidy C, Dobson L, Al-Rassi J, Langley J, Swindle J, Graham ID, Scott SD. Knowledge translation strategies to support the sustainability of evidence-based interventions in healthcare: a scoping review. Implement Sci 2023; 18:69. [PMID: 38049900 PMCID: PMC10694920 DOI: 10.1186/s13012-023-01320-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 11/13/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND Knowledge translation (KT) strategies are widely used to facilitate the implementation of EBIs into healthcare practices. However, it is unknown what and how KT strategies are used to facilitate the sustainability of EBIs in institutional healthcare settings. OBJECTIVES This scoping review aimed to consolidate the current evidence on (i) what and how KT strategies are being used for the sustainability of EBIs in institutional healthcare settings; (ii) the reported KT strategy outcomes (e.g., acceptability) for EBI sustainability, and (iii) the reported EBI sustainability outcomes (e.g., EBI activities or component of the intervention continue). METHODS We conducted a scoping review of five electronic databases. We included studies describing the use of specific KT strategies to facilitate the sustainability of EBIs (more than 1-year post-implementation). We coded KT strategies using the clustered ERIC taxonomy and AIMD framework, we coded KT strategy outcomes using Tierney et al.'s measures, and EBI sustainability outcomes using Scheirer and Dearing's and Lennox's taxonomy. We conducted descriptive numerical summaries and a narrative synthesis to analyze the results. RESULTS The search identified 3776 studies for review. Following the screening, 25 studies (reported in 27 papers due to two companion reports) met the final inclusion criteria. Most studies used multi-component KT strategies for EBI sustainability (n = 24). The most common ERIC KT strategy clusters were to train and educate stakeholders (n = 38) and develop stakeholder interrelationships (n = 34). Education was the most widely used KT strategy (n = 17). Many studies (n = 11) did not clearly report whether they used different or the same KT strategies between EBI implementation and sustainability. Seven studies adapted KT strategies from implementation to sustainability efforts. Only two studies reported using a new KT strategy for EBI sustainability. The most reported KT strategy outcomes were acceptability (n = 10), sustainability (n = 5); and adoption (n = 4). The most commonly measured EBI sustainability outcome was the continuation of EBI activities or components (n = 23), followed by continued benefits for patients, staff, and stakeholders (n = 22). CONCLUSIONS Our review provides insight into a conceptual problem where initial EBI implementation and sustainability are considered as two discrete time periods. Our findings show we need to consider EBI implementation and sustainability as a continuum and design and select KT strategies with this in mind. Our review has emphasized areas that require further research (e.g., KT strategy adaptation for EBI sustainability). To advance understanding of how to employ KT strategies for EBI sustainability, we recommend clearly reporting the dose, frequency, adaptations, fidelity, and cost of KT strategies. Advancing our understanding in this area would facilitate better design, selection, tailored, and adapted use of KT strategies for EBI sustainability, thereby contributing to improved patient, provider, and health system outcomes.
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Affiliation(s)
- Rachel Flynn
- School of Nursing and Midwifery, Brookfield Health Sciences Complex, University College of Cork, College Road Cork, Cork, T12 AK54, Ireland.
- Faculty of Nursing, Level 3, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Avenue, Edmonton, Alberta, T6G 1C9, Canada.
| | - Christine Cassidy
- School of Nursing, Faculty of Health, Dalhousie University, Room N21, Forrest Bldg., PO Box 15000 5869 University Avenue Halifax, Nova Scotia, B3H 4R2, Canada.
| | - Lauren Dobson
- Faculty of Nursing, Level 3, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Avenue, Edmonton, Alberta, T6G 1C9, Canada
| | - Joyce Al-Rassi
- School of Nursing, Faculty of Health, Dalhousie University, Room N21, Forrest Bldg., PO Box 15000 5869 University Avenue Halifax, Nova Scotia, B3H 4R2, Canada
| | - Jodi Langley
- School of Nursing, Faculty of Health, Dalhousie University, Room N21, Forrest Bldg., PO Box 15000 5869 University Avenue Halifax, Nova Scotia, B3H 4R2, Canada
| | - Jennifer Swindle
- Faculty of Nursing, Level 3, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Avenue, Edmonton, Alberta, T6G 1C9, Canada
| | - Ian D Graham
- School of Epidemiology and Public Health, University of Ottawa, 600 Peter Morand Crescent, Ottawa, ON, K1G 5Z3, Canada
- The Centre for Implementation Research, Ottawa Hospital Research Institute, 501 Smyth Road, Box 241, Ottawa, Ontario, K1H 8L6, Canada
| | - Shannon D Scott
- Faculty of Nursing, Level 3, Edmonton Clinic Health Academy, University of Alberta, 11405 87 Avenue, Edmonton, Alberta, T6G 1C9, Canada
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Cardinale S, Saraon T, Lodoe N, Alshehry A, Raffoul M, Caspers C, Vider E. Clinical Pharmacist Led Medication Reconciliation Program in an Emergency Department Observation Unit. J Pharm Pract 2023; 36:1156-1163. [PMID: 35465767 DOI: 10.1177/08971900221091174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
| | | | | | | | - Melanie Raffoul
- Department of Medicine, NYU Langone Health, New York, NY, USA
| | | | - Etty Vider
- Department of Pharmacy Practice, LIU Pharmacy, Brooklyn, NY, USA
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Schnipper JL, Reyes Nieva H, Yoon C, Mallouk M, Mixon AS, Rennke S, Chu ES, Mueller SK, Smith GR, Williams MV, Wetterneck TB, Stein J, Dalal AK, Labonville S, Sridharan A, Stolldorf DP, Orav EJ, Gresham M, Goldstein J, Platt S, Nyenpan CT, Howell E, Kripalani S. What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study. BMJ Qual Saf 2023; 32:457-469. [PMID: 36948542 PMCID: PMC11046420 DOI: 10.1136/bmjqs-2022-014806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 01/31/2023] [Indexed: 03/24/2023]
Abstract
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.
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Affiliation(s)
- Jeffrey L Schnipper
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Hospital Medicine Unit, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
| | - Harry Reyes Nieva
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Catherine Yoon
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
| | - Meghan Mallouk
- Center for Quality Improvement, Society of Hospital Medicine, Philadelphia, Pennsylvania, USA
| | - Amanda S Mixon
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Stephanie Rennke
- UCSF Health and Department of Medicine, Division of Hospital Medicine, University of California San Francisco Medical Center, San Francisco, California, USA
| | - Eugene S Chu
- Parkland Health and Hospital System and Hospital Medicine Service, Department of Internal Medicine, University of Texas Southwestern School of Medicine, Dallas, Texas, USA
| | - Stephanie K Mueller
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Hospital Medicine Unit, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
| | - G Randy Smith
- Division of Hospital Medicine, Northwestern University Feinberg School of Medicine and Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Mark V Williams
- Division of Hospital Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Tosha B Wetterneck
- Department of Medicine, Center for Quality and Productivity Improvement, University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison College of Engineering, Madison, Wisconsin, USA
| | - Jason Stein
- Section of Hospital Medicine, Emory University Hospital and 1Unit, Atlanta, Georgia, USA
| | - Anuj K Dalal
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Hospital Medicine Unit, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
| | - Stephanie Labonville
- Department of Pharmacy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Anirudh Sridharan
- Department of Medicine, Howard County General Hospital, Columbia, Maryland, USA
| | - Deonni P Stolldorf
- Geriatric Research, Education, and Clinical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- School of Nursing, Vanderbilt University, Nashville, Tennessee, USA
| | - Endel John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
- Department of Health Policy and Management, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Marcus Gresham
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital Department of Medicine, Boston, Massachusetts, USA
| | - Jenna Goldstein
- Center for Quality Improvement, Society of Hospital Medicine, Philadelphia, Pennsylvania, USA
| | - Sara Platt
- Center for Quality Improvement, Society of Hospital Medicine, Philadelphia, Pennsylvania, USA
| | | | - Eric Howell
- Division of Hospital Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
- Society of Hospital Medicine, Philadelphia, Pennsylvania, USA
| | - Sunil Kripalani
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Section of Hospital Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Ring LM, Cinotti J, Hom LA, Mullenholz M, Mangum J, Ahmed-Winston S, Cheng JJ, Randolph E, Harahsheh AS. A Quality Improvement Initiative to Improve Pediatric Discharge Medication Safety and Efficiency. Pediatr Qual Saf 2023; 8:e671. [PMID: 37434598 PMCID: PMC10332828 DOI: 10.1097/pq9.0000000000000671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 06/13/2023] [Indexed: 07/13/2023] Open
Abstract
Medication errors are a leading safety concern, especially for families with limited English proficiency and health literacy, and patients discharged on multiple medications with complex schedules. Integration of a multilanguage electronic discharge medication platform may help decrease medication errors. This quality improvement (QI) project's primary aim (process measure) was to increase utilization in the electronic health record (EHR) of the integrated MedActionPlanPro (MAP) for cardiovascular surgery and blood and marrow transplant patients at hospital discharge and for the first clinic follow-up visit to 80% by July 2021. Methods This QI project occurred between August 2020 and July 2021 on 2 subspecialty pediatric acute care inpatient units and respective outpatient clinics. An interdisciplinary team developed and implemented interventions, including integration of MAP within EHR; the team tracked and analyzed outcomes for discharge medication matching, and efficacy and safety MAP integration occurred with a go-live date of February 1, 2021. Statistical process control charts tracked progress. Results Following the implementation of the QI interventions, there was an increase from 0% to 73% in the utilization of the integrated MAP in the EHR across the acute care cardiology unit-cardiovascular surgery/blood and marrow transplant units. The average user hours per patient (outcome measure) decreased 70% from the centerline of 0.89 hours during the baseline period to 0.27 hours. In addition, the medication matching between Cerner inpatient and MAP inpatient increased significantly from baseline to postintervention by 25.6% (P < 0.001). Conclusion MAP integration into the EHR was associated with improved inpatient discharge medication reconciliation safety and provider efficiency.
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Affiliation(s)
- Lisa M. Ring
- Children’s National Heart Institute, Children’s National Hospital, Washington, D.C
- Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, D.C
- Department of Advanced Practice Providers, Children’s National Hospital, Washington, D.C
| | - Jamie Cinotti
- Global Services, Children’s National Hospital, Washington, D.C
| | - Lisa A. Hom
- Children’s National Heart Institute, Children’s National Hospital, Washington, D.C
- Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, D.C
| | - Mary Mullenholz
- Children’s National Heart Institute, Children’s National Hospital, Washington, D.C
| | - Jordan Mangum
- Children’s National Heart Institute, Children’s National Hospital, Washington, D.C
| | | | - Jenhao Jacob Cheng
- Children’s National Heart Institute, Children’s National Hospital, Washington, D.C
| | - Ellie Randolph
- Global Services, Children’s National Hospital, Washington, D.C
| | - Ashraf S. Harahsheh
- Children’s National Heart Institute, Children’s National Hospital, Washington, D.C
- Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, D.C
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Wilson P, Kislov R. Learning how and why complex improvement interventions work: insights from implementation science. BMJ Qual Saf 2023:bmjqs-2023-016008. [PMID: 37045588 DOI: 10.1136/bmjqs-2023-016008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2023] [Indexed: 04/14/2023]
Affiliation(s)
- Paul Wilson
- Centre for Primary Care and Health Services Research, The University of Manchester, Manchester, UK
| | - Roman Kislov
- Faculty of Business and Law, Manchester Metropolitan University, Manchester, UK
- School of Health Sciences, The University of Manchester, Manchester, UK
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Chu ES, El-Kareh R, Biondo A, Chang J, Hartman S, Huynh T, Medders K, Nguyen A, Yam N, Succari L, Koenig K, Williams MV, Schnipper J. Implementation of a Medication Reconciliation Risk Stratification Tool Integrated within an electronic health record: A Case Series of Three Academic Medical Centers. Healthcare (Basel) 2022; 10:100654. [DOI: 10.1016/j.hjdsi.2022.100654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 03/25/2022] [Accepted: 08/25/2022] [Indexed: 11/25/2022] Open
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10
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Addison J, Razzaghi H, Bailey C, Dickinson K, Corathers SD, Hartley DM, Utidjian L, Carle AC, Rhodes ET, Alonso GT, Haller MJ, Gannon AW, Indyk JA, Arbeláez AM, Shenkman E, Forrest CB, Eckrich D, Magnusen B, Davies SD, Walsh KE. Testing an Automated Approach to Identify Variation in Outcomes among Children with Type 1 Diabetes across Multiple Sites. Pediatr Qual Saf 2022; 7:e602. [PMID: 38584961 PMCID: PMC10997286 DOI: 10.1097/pq9.0000000000000602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 08/21/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction Efficient methods to obtain and benchmark national data are needed to improve comparative quality assessment for children with type 1 diabetes (T1D). PCORnet is a network of clinical data research networks whose infrastructure includes standardization to a Common Data Model (CDM) incorporating electronic health record (EHR)-derived data across multiple clinical institutions. The study aimed to determine the feasibility of the automated use of EHR data to assess comparative quality for T1D. Methods In two PCORnet networks, PEDSnet and OneFlorida, the study assessed measures of glycemic control, diabetic ketoacidosis admissions, and clinic visits in 2016-2018 among youth 0-20 years of age. The study team developed measure EHR-based specifications, identified institution-specific rates using data stored in the CDM, and assessed agreement with manual chart review. Results Among 9,740 youth with T1D across 12 institutions, one quarter (26%) had two or more measures of A1c greater than 9% annually (min 5%, max 47%). The median A1c was 8.5% (min site 7.9, max site 10.2). Overall, 4% were hospitalized for diabetic ketoacidosis (min 2%, max 8%). The predictive value of the PCORnet CDM was >75% for all measures and >90% for three measures. Conclusions Using EHR-derived data to assess comparative quality for T1D is a valid, efficient, and reliable data collection tool for measuring T1D care and outcomes. Wide variations across institutions were observed, and even the best-performing institutions often failed to achieve the American Diabetes Association HbA1C goals (<7.5%).
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Affiliation(s)
- Jessica Addison
- From the Division of Adolescent and Young Adult Medicine, Boston Children’s Hospital, Boston, Mass
| | - Hanieh Razzaghi
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pa
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Pa
| | - Charles Bailey
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pa
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Pa
| | - Kimberley Dickinson
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pa
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Pa
| | - Sarah D. Corathers
- Division of Endocrinology, Cincinnati Children’s Hospital, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David M. Hartley
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital, Cincinnati, Ohio
| | - Levon Utidjian
- Applied Clinical Research Center, Children’s Hospital of Philadelphia, Philadelphia, Pa
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Pa
| | - Adam C. Carle
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital, Cincinnati, Ohio
- Department of Psychology, College of Arts and Sciences, University of Cincinnati, Cincinnati, Ohio
| | - Erinn T. Rhodes
- Division of Endocrinology, Boston Children’s Hospital, Boston, Mass
- Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - G. Todd Alonso
- University of Colorado Anschutz Medical Campus, Barbara Davis Center, Aurora, Colo
| | | | | | - Justin A. Indyk
- Section of Endocrinology, Nationwide Children’s Hospital, Columbus, Ohio
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Ana Maria Arbeláez
- Washington University in St. Louis, St. Louis, Mo
- St. Louis Children’s Hospital, St. Louis, Mo
| | - Elizabeth Shenkman
- University of Florida, College of Medicine, Department of Health Outcomes and Biomedical Informatics, Gainesville, Fla
| | | | | | | | - Sara Deakyne Davies
- University of Colorado Anschutz Medical Campus, Barbara Davis Center, Aurora, Colo
| | - Kathleen E. Walsh
- Department of Pediatrics, Harvard Medical School, Boston, Mass
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Mass
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11
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Schnipper JL, Reyes Nieva H, Mallouk M, Mixon A, Rennke S, Chu E, Mueller S, Smith GRR, Williams MV, Wetterneck TB, Stein J, Dalal A, Labonville S, Sridharan A, Stolldorf DP, Orav EJ, Levin B, Gresham M, Yoon C, Goldstein J, Platt S, Nyenpan CT, Howell E, Kripalani S. Effects of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals: results of the MARQUIS2 study. BMJ Qual Saf 2022; 31:278-286. [PMID: 33927025 PMCID: PMC10964422 DOI: 10.1136/bmjqs-2020-012709] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 03/26/2021] [Accepted: 04/10/2021] [Indexed: 11/04/2022]
Abstract
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.
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Affiliation(s)
- Jeffrey L Schnipper
- Hospital Medicine Unit, Brigham Health, Boston, MA, USA
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Harry Reyes Nieva
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Meghan Mallouk
- Center for Quality Improvement, Society of Hospital Medicine, Philadelphia, PA, USA
| | - Amanda Mixon
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research, Education, and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN, USA
| | - Stephanie Rennke
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco Medical Center, San Francisco, CA, USA
| | - Eugene Chu
- Division of Hospital Medicine, Parkland Health and Hospital System and Department of Internal Medicine, University of Texas Southwestern School of Medicine, Dallas, TX, USA
| | - Stephanie Mueller
- Hospital Medicine Unit, Brigham Health, Boston, MA, USA
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Gregory Randy R Smith
- Division of Hospital Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Mark V Williams
- Division of Hospital Medicine, Department of Internal Medicine, University of Kentucky Medical Center, Lexington, KY, USA
| | - Tosha B Wetterneck
- Division of General Internal Medicine, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | | | - Anuj Dalal
- Hospital Medicine Unit, Brigham Health, Boston, MA, USA
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | | | | | - E John Orav
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA
| | - Brian Levin
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Marcus Gresham
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Cathy Yoon
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jenna Goldstein
- Center for Quality Improvement, Society of Hospital Medicine, Philadelphia, PA, USA
| | - Sara Platt
- Center for Quality Improvement, Society of Hospital Medicine, Philadelphia, PA, USA
| | | | - Eric Howell
- Society of Hospital Medicine, Philadelphia, PA, USA
- Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Sunil Kripalani
- Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Center for Clinical Quality and Implementation Research, Nashville, TN, USA
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12
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Haverhals LM, Gilman C, Manheim C, Bauers C, Kononowech J, Levy C. Implementation of VA's Life-Sustaining Treatment Decisions Initiative: Facilitators and Barriers to Early Implementation Across Seven VA Medical Centers. J Pain Symptom Manage 2021; 62:125-133.e2. [PMID: 33157178 DOI: 10.1016/j.jpainsymman.2020.10.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 10/05/2020] [Accepted: 10/27/2020] [Indexed: 11/16/2022]
Abstract
CONTEXT In 2017, Veterans Health Administration (VHA) National Center for Ethics in Health Care began system-wide implementation of the Life-Sustaining Treatment Decisions Initiative (LSTDI). The LSTDI is a national VHA policy and practice to promote conducting goals of care conversations and documenting veterans' preferences for life-sustaining treatments (LSTs). OBJECTIVES The aim of this article is to describe facilitators and barriers to early implementation of the LSTDI within one VHA Veterans Integrated Service Network. METHODS From September 2016 to December 2018, we conducted site visits and semistructured phone interviews with implementation coordinators who championed the LSTDI rollout at seven VHA medical centers. We applied the Consolidated Framework for Implementation Research (CFIR) to assess facilitators and barriers to implementing the LSTDI and assigning interview data to specific CFIR constructs and CFIR valence ratings. We simultaneously benchmarked VHA medical centers' implementation progress as outlined by the National Center for Ethics in Health Care implementation guidebook. RESULTS We divided sites into three descriptive groups based on implementation progress: successfully implemented (n = 2); moving forward, but delayed (n = 3); and implementation stalled (n = 2). Five CFIR constructs emerged as facilitators or barriers to implementation of the LSTDI: 1) self-efficacy of implementation coordinators; 2) leadership engagement; 3) compatibility with pre-existing workflows; 4) available resources; and 5) overall implementation climate. CONCLUSION Although self-efficacy proved key to overcoming obstacles, degree of perceived workflow compatibility of the LSTDI policy, available resources, and leadership engagement must be adequate for successful implementation within the implementation time line. Without these components, successful implementation was hindered or delayed.
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Affiliation(s)
- Leah M Haverhals
- VA Eastern Colorado Health Care System, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA.
| | - Carrie Gilman
- VA Eastern Colorado Health Care System, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
| | - Chelsea Manheim
- VA Eastern Colorado Health Care System, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
| | - Courtney Bauers
- VA Eastern Colorado Health Care System, Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA
| | - Jennifer Kononowech
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Cari Levy
- Division of Health Care Policy and Research, VA Eastern Colorado Health Care System, Rocky Mountain Regional VA Medical Center and University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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13
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Baughman AW, Triantafylidis LK, O'Neil N, Norstrom J, Okpara K, Ruopp MD, Linsky A, Schnipper J, Mixon AS, Simon SR. Improving Medication Reconciliation with Comprehensive Evaluation at a Veterans Affairs Skilled Nursing Facility. Jt Comm J Qual Patient Saf 2021; 47:646-653. [PMID: 34244044 DOI: 10.1016/j.jcjq.2021.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 05/19/2021] [Accepted: 06/04/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Unintentional medication discrepancies due to inadequate medication reconciliation pose a threat to patient safety. Skilled nursing facilities (SNFs) are an important care setting where patients are vulnerable to unintentional medication discrepancies due to increased medical complexity and care transitions. This study describes a quality improvement (QI) approach to improve medication reconciliation in an SNF setting as part of the Multi-Center Medication Reconciliation Quality Improvement Study 2 (MARQUIS2). METHODS This study was conducted at a 112-bed US Department of Veterans Affairs SNF. The researchers used several QI methods, including data benchmarking, stakeholder surveys, process mapping, and a Healthcare Failure Mode and Effect Analysis (HFMEA) to complete comprehensive baseline assessments. RESULTS Baseline assessments revealed that medication reconciliation processes were error-prone, with high rates of medication discrepancies. Provider surveys and process mapping revealed extremely labor-intensive and highly complex processes lacking standardization. Factors contributing were polypharmacy, limited resources, electronic health record limitations, and patient exposure to multiple care transitions. HFMEA enabled a methodical approach to identify and address challenges. The team validated the best possible medication history (BPMH) process for hospital settings as outlined by MARQUIS2 for the SNF setting and found it necessary to use additional medication lists to account for multiple care transitions. CONCLUSION SNFs represent a critical setting for medication reconciliation efforts due to challenges completing the reconciliation process and the concomitant high risk of adverse drug events in this population. Initial baseline assessments effectively identified existing problems and can be used to guide targeted interventions.
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14
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Stolldorf DP, Ridner SH, Vogus TJ, Roumie CL, Schnipper JL, Dietrich MS, Schlundt DG, Kripalani S. Implementation strategies in the context of medication reconciliation: a qualitative study. Implement Sci Commun 2021; 2:63. [PMID: 34112265 PMCID: PMC8193884 DOI: 10.1186/s43058-021-00162-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 05/19/2021] [Indexed: 11/12/2022] Open
Abstract
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.
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Affiliation(s)
- Deonni P Stolldorf
- Vanderbilt University School of Nursing, 461 21st Ave S., Nashville, TN, USA.
| | - Sheila H Ridner
- Vanderbilt University School of Nursing, 461 21st Ave S., Nashville, TN, USA
| | - Timothy J Vogus
- Vanderbilt University Owen Graduate School of Management, 401 21st Ave S., Nashville, TN, USA
| | - Christianne L Roumie
- Vanderbilt University Medical Center, 1211 Medical Center Drive, Nashville, TN, 37232, USA.,VA Tennessee Valley Healthcare System, 1310 24th Ave S., Nashville, TN, 37212, USA
| | - Jeffrey L Schnipper
- Division of General Internal Medicine, Brigham and Women's Hospital and Harvard Medical School, 1620 Tremont St., Boston, MA, USA
| | - Mary S Dietrich
- Vanderbilt University School of Medicine, Vanderbilt University School of Nursing, Nashville, TN, USA
| | - David G Schlundt
- Vanderbilt University Department of Psychology, 323 Wilson Hall, 2301 Vanderbilt Place, Nashville, TN, 37240, USA
| | - Sunil Kripalani
- Center for Clinical Quality and Implementation Research, Vanderbilt University Medical Center, 2525 West End Ave, Suite 1200, Nashville, TN, 37203, USA
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15
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Pevnick JM, Keller MS, Kennelty KA, Nuckols TK, Ko EM, Amer K, Anderson L, Armbruster C, Conti N, Fanikos J, Guan J, Knight E, Leang DW, Llamas-Sandoval R, Matta L, Moriarty D, Murry LT, Muske AM, Nguyen AT, Phung E, Rosen O, Rosen SL, Salandanan A, Shane R, Schnipper JL. The Pharmacist Discharge Care (PHARM-DC) study: A multicenter RCT of pharmacist-directed transitional care to reduce post-hospitalization utilization. Contemp Clin Trials 2021; 106:106419. [PMID: 33932574 DOI: 10.1016/j.cct.2021.106419] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 03/29/2021] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Joshua M Pevnick
- Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America; Division of Informatics, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America.
| | - Michelle S Keller
- Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America; Division of Informatics, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America; Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, United States of America
| | - Korey A Kennelty
- College of Pharmacy, University of Iowa, Iowa City, IA, United States of America; Carver College of Medicine, University of Iowa, Iowa City, IA, United States of America
| | - Teryl K Nuckols
- Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - EunJi Michelle Ko
- Department of Quality and Safety, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Kallie Amer
- Department of Pharmacy, Cedar-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Laura Anderson
- Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Christine Armbruster
- Department of Pharmacy, Cedar-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Nicole Conti
- Dept of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, United States of America
| | - John Fanikos
- Dept of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, United States of America
| | - James Guan
- Department of Pharmacy, Cedar-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Emmanuel Knight
- Department of Pharmacy, Cedar-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Donna W Leang
- Department of Pharmacy, Cedar-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Ruby Llamas-Sandoval
- Department of Pharmacy, Cedar-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Lina Matta
- Dept of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Dylan Moriarty
- Dept of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Logan T Murry
- College of Pharmacy, University of Iowa, Iowa City, IA, United States of America
| | - Anne Marie Muske
- Dept of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, United States of America
| | - An T Nguyen
- Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Emily Phung
- Department of Pharmacy, Cedar-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Olga Rosen
- Department of Pharmacy, Cedar-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Sonja L Rosen
- Section of Geriatric Medicine, Division of Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Audrienne Salandanan
- Department of Pharmacy, Cedar-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Rita Shane
- Department of Pharmacy, Cedar-Sinai Medical Center, Los Angeles, CA, United States of America
| | - Jeffrey L Schnipper
- Brigham Health Hospital Medicine Unit, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America
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Zhang K, Chia K, Hawley CE, Uricchio MJ, Driver JA, Salow M. A blueprint for success: Using an implementation framework to create a medication history technician pilot program. J Am Pharm Assoc (2003) 2021; 61:e301-e315. [PMID: 33583750 DOI: 10.1016/j.japh.2021.01.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 12/21/2020] [Accepted: 01/10/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Medication discrepancies at transitions of care may compromise patient safety. Trained pharmacy technicians can reduce harmful medication discrepancies at transitions of care by collecting medication histories. OBJECTIVE We describe how to create a program integrating medication history technicians (MHTs) into the hospital discharge process using implementation science. PRACTICE DESCRIPTION We created our MHT program at a Veterans Affairs (VA) hospital. PRACTICE INNOVATION We used an evidence-based framework and implementation science to tailor our MHT program to meet local stakeholder needs. EVALUATION METHODS We completed a literature review and review of current discharge practices. Then, we completed a workflow pilot, a needs assessment, and semistructured interviews with pharmacy technicians and pharmacists. We integrated these findings to identify barriers of MHT program implementation. Finally, we mapped these barriers to implementation strategies to create an MHT program implementation blueprint. RESULTS The literature review and review of current discharge practices revealed opportunities for our program to reduce medication discrepancies. We applied these findings to our proof-of-concept workflow pilot, which reduced medication discrepancy rates at discharge. When we explored barriers in the needs assessment, we learned that 4 of 6 pharmacy technicians had some training conducting medication histories, but 5 of 6 requested additional training for the new MHT role. We explored these and additional barriers in semistructured interviews. Four themes emerged: elements of pharmacy technician training, challenges to implementation, program logistics and workflow, and pharmacy technician self-efficacy. We mapped barriers to implementation strategies to create an MHT program implementation blueprint, including developing pharmacy technician training materials, modifying our workflow, creating program evaluation materials, and strategizing how to overcome anticipated and current implementation barriers. CONCLUSIONS We used implementation science to create a tailored MHT program. Others may adapt our implementation blueprint to fit local stakeholder needs.
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Medication review and reconciliation in older adults. Eur Geriatr Med 2021; 12:499-507. [PMID: 33583002 DOI: 10.1007/s41999-021-00449-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 01/07/2021] [Indexed: 12/19/2022]
Abstract
Older people are frequently exposed to polypharmacy, inappropriate prescribing, and adverse drug events. Two clinical processes can help geriatricians to optimize and increase the safety of drug prescriptions for older adults: medication reconciliation and medication review. Medication reconciliation provides the best possible medication history and identifies and resolves discrepancies in drug prescriptions. During the medication review, the best possible medication history is crosschecked against other data, including morbidities, patient's preferences, or geriatric syndromes, to produce a personalized medication strategy. Alignment of treatment recommendations with patient preferences and goals through shared decision-making is particularly important in medication review. Medication reconciliation and medication review have proven to be effective, but their broad implementation remains difficult. Indeed, these procedures are time-consuming and require specific skills, coordination between different healthcare professionals, organizations and dedicated means. The involvement of geriatricians therefore remains essential for the successful implementation of medication reconciliation and medication review in geriatric settings and among frail older people.
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Snyder MS, Fogel J, Pyatigorskaya S, Rubinstein S. Dose adjustment of antidiabetic medications in chronic kidney disease. Avicenna J Med 2021; 11:33-39. [PMID: 33520787 PMCID: PMC7839266 DOI: 10.4103/ajm.ajm_110_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Purpose: The purpose of this study is to identify whether Internal Medicine house-staff (IMHS) have awareness and knowledge about the correct dosage of antidiabetic medications for patients with chronic kidney disease (CKD), as dosing errors result in adverse patient outcomes for those with diabetes mellitus (DM) and CKD. Methods: There were 353 IMHS surveyed to evaluate incorrect level of awareness of medication dose adjustment in patients with CKD (ILA) and incorrect level of knowledge of glomerular filtration rate level for medication adjustment (ILK-GFR) for Glipizide, Pioglitazone, and Sitagliptin. Results: Lack of awareness and knowledge was high, with the highest for Pioglitazone at 72.8%. For ILA, the percentages were: Pioglitazone: 72.8%, Glipizide: 43.9%, and Sitagliptin: 42.8%. For ILK-GFR, the percentages were: Pioglitazone: 72.8%, Glipizide: 68.3%, and Sitagliptin: 65.4%. Conclusions: IMHS have poor awareness and knowledge for antidiabetic medication dose adjustment in patients with DM and CKD. Both Electronic Medical Rerecord best practice advisory and physician–pharmacist collaborative drug therapy management can enhance safe drug prescribing in patients with CKD. In addition, IMHS’s practice for antidiabetic medication dose adjustment was better with Nephrology exposure. A formal didactic educational training during medical school and residency for antidiabetic medication dose adjustment in patients with DM and CKD is highly encouraged to prevent medication dosing errors and to more effectively and safely allow IMHS to manage complex treatment regimens.
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Affiliation(s)
- Matthew Salvatore Snyder
- New York Institute of Technology College of Osteopathic Medicine, 101 Northern Boulevard, Old Westbury, NY, USA
| | - Joshua Fogel
- Department of Business Management, Brooklyn College, 218 Whitehead Hall, Brooklyn, NY, USA
| | - Svetlana Pyatigorskaya
- Division of Nephrology and Hypertension, Nassau University Medical Center, 2201 Hempstead Turnpike, East Meadow, NY, USA
| | - Sofia Rubinstein
- Division of Nephrology and Hypertension, Nassau University Medical Center, 2201 Hempstead Turnpike, East Meadow, NY, USA
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