Medication Reconciliation Practices in Canadian Emergency Departments: A National Survey

Clinical Pharmacy Services in Canadian Emergency Departments: A 2022 National Survey

Background

Support for the role of an emergency department (ED) clinical pharmacy team is evidence-based and recognized in numerous professional guidelines, yet previous literature suggests a low prevalence of ED clinical pharmacy services in Canadian hospitals.

Objectives

To update (from a survey conducted in 2013) the description and quantification of clinical pharmacy services in Canadian EDs.

Methods

All Canadian hospitals with an ED and at least 50 acute care beds were contacted to identify the presence of dedicated ED pharmacy services (defined as at least 0.5 full-time equivalent [FTE] position). Three separate electronic surveys were distributed by email to ED pharmacy team members (if available), pharmacy managers (at hospitals without an ED pharmacy team), and ED managers (all hospitals). The surveys were completed between November 2021 and January 2022.

Results

Of the 254 hospitals identified, 117 (46%) had at least 0.5 FTE clinical pharmacy services in the ED (based on initial telephone screening). Of the 51 (44%) of 115 ED pharmacy team survey responses included in the analysis, 94% (48/51) had pharmacists and 55% (28/51) had pharmacy technicians. The majority of pharmacy managers and ED managers identified the need for ED pharmacy services where such services did not exist. Inadequate funding, competing priorities, and lack of training remain the most commonly reported barriers to providing this service. Personal safety concerns were reported by 20% (10/51) of respondents.

Conclusions

Although the establishment of clinical pharmacy services in Canadian EDs has grown over the past 8 years, lack of funding and ED-specific training continue to limit this evidence-supported role in Canadian hospitals.

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.

Practice, Skill Mix, and Education: The Evolving Role of Pharmacy Technicians in Great Britain

Pharmacy technicians’ roles are rapidly evolving in Great Britain (GB) as they undertake more extended activities with increased autonomy across the different pharmacy sectors. This paper compares the GB pharmacy regulator initial education and training standards recently introduced (2017) with the qualifications currently used in practice and discusses whether future qualifications will be ‘fit for purpose’. In this context, knowledge, skills, and competence are reviewed to assess whether they will meet the expectations and underpin the evolving pharmacy technician role as integral to healthcare provision. Based on drivers, policy change, and the changing GB healthcare landscape, effectiveness of skill mix is analysed to establish whether this is being optimised to support person-centred pharmacy in response to the challenges and pressures faced within the NHS. On this basis and given there is a limited evidence base, this review has highlighted a need for larger scale research to reassure the pharmacy and wider healthcare professions, and the public, that the evolving pharmacy technician role presents no increased risk to patient safety and contributes significantly to releasing pharmacists time for person-centred clinical activities.

Incidence of clinically relevant medication errors in the era of electronically prepopulated medication reconciliation forms: a retrospective chart review

BACKGROUND

To reduce medication discrepancies (unintended differences between a patient's outpatient and inpatient medication regimens), Canadian institutions have implemented medication reconciliation forms that are prepopulated with outpatient medication dispensing data. These may prompt prescribers to reorder discontinued medications or continue newly contraindicated medications. Our objective was to evaluate the incidence of medication discrepancies and errors of commission after the implementation of such forms.

METHODS

This retrospective chart review included patients previously enrolled in an observational study in which a research pharmacist prospectively collected best-possible medication histories in the emergency department. Research assistants uninvolved with the parent study compared medication orders written in the first 48 hours after admission with the research pharmacist's best-possible medication history to identify medication discrepancies and errors of commission, defined as inappropriate medication continuations and reordering of previously stopped medications. An independent panel adjudicated the clinical significance of the errors.

RESULTS

Of 151 patients, 71 (47.0% [95% confidence interval (CI) 39.2-54.9]) were exposed to 112 medication errors on admission. Of the 112 errors, 24 (21.4% [95% CI 14.9-29.9]) were clinically significant. Errors of commission accounted for 24.1% (27/112 [95% CI 17.3-32.8]) of all errors; 10 (37.0% [95% CI 18.8-55.2]) of the errors of commission were clinically significant.

INTERPRETATION

Medication errors were common after the implementation of electronically prepopulated medication reconciliation forms. Prospective research is required to examine the impact of prepopulated medication reconciliation forms and ensure they do not facilitate errors of commission.

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.

Clinical Pharmacy Services in Canadian Emergency Departments: A National Survey

BACKGROUND

Providing clinical pharmacy services in emergency departments (EDs) is important because adverse drug events commonly occur before, during, and after ED encounters. Survey studies in the United States have indicated a relatively low presence of clinical pharmacy services in the ED setting, but a descriptive survey specific to Canada has not yet been performed.

OBJECTIVES

To describe the current status of pharmacy services in Canadian EDs and potential barriers to implementing pharmacy services in this setting.

METHODS

All Canadian hospitals with an ED and at least 50 acute care beds were contacted to identify the presence of dedicated ED pharmacy services (defined as at least 0.5 full-time equivalent [FTE] position). Three different electronic surveys were then distributed by e-mail to ED pharmacy team members (if available), pharmacy managers (at hospitals without an ED pharmacy team), and ED managers (all hospitals). The surveys were completed between July and September 2013.

RESULTS

Of the 243 hospitals identified, 95 (39%) had at least 0.5 FTE clinical pharmacy services in the ED (based on initial telephone screening). Of the 60 ED pharmacy teams that responded to the survey, 56 had pharmacists (27 of which also had ED pharmacy technicians) and 4 had pharmacy technicians (without pharmacists). Forty-four (79%) of the 56 ED pharmacist services had been established within the preceding 10 years. Order clarification, troubleshooting, medication reconciliation, and assessment of renal dosing were the services most commonly provided. The large majority of pharmacy managers and ED managers identified the need for ED pharmacy services where such services do not yet exist. Inadequate funding, competing priorities, and lack of training were the most commonly reported barriers to providing this service.

CONCLUSIONS

Although the establishment of ward-based pharmacy services in Canadian EDs has increased over the past 10 years, lack of funding and a lack of ED training for pharmacists were reported as significant barriers to the expansion of this role in most hospitals.