Medication reconciliation for reducing drug-discrepancy adverse events

BACKGROUND

Medication reconciliation is a technique for identifying discrepancies in drug regimens prescribed in different care settings or at different time points to inform prescribing decisions and prevent medication errors.

OBJECTIVE

This study examined the effect of pharmacist-conducted medication reconciliation on the occurrence of discrepancy-related adverse drug events (ADEs) associated with drugs ordered at the time of a resident's return from the hospital to the nursing home.

METHODS

This was a preintervention/postintervention study conducted in a consecutive sample of residents of a 514-bed, urban, not-for-profit nursing home who were hospitalized in its primary referral hospital, an 1171-bed academic tertiary care hospital, and returned to the nursing home between December 2002 and January 2005. In the intervention phase, a pharmacist conducted a reconciliation of drugs ordered on return to the nursing home with those received before hospitalization, and communicated prescribing discrepancies to the physician. The primary outcome was the occurrence of discrepancy-related ADEs, as ascertained by a review of the medical records performed by 2 independent physician raters.

RESULTS

During the study period, 168 nursing home residents had 259 hospital stays. The reconciliation intervention identified 696 total prescribing discrepancies, of which physicians responded to 598 (85.9%). Among the 112 cases selected for ADE ascertainment, 11 discrepancy-related ADEs were identified, 1 in the postintervention group and 10 in the preintervention group, for an incidence of 2.3% and 14.5%, respectively (relative risk, 0.16; 95% CI, 0.02-1.2; P = NS). After adjustment for baseline ADE risk, the odds of having a discrepancy-related ADE were significantly lower in the postintervention group compared with the preintervention group (odds ratio, 0.11; 95% CI, 0.01-1.0; P = 0.05). The most commonly identified discrepancy-related ADE was pain from the omission of an analgesic (3/11 [27.3%]), and antibiotics and analgesics were the most common causes of discrepancy-related ADEs (each, 3/11 [27.3%]).

CONCLUSIONS

Pharmacist medication reconciliation and communication with the physician reduced discrepancy-related ADEs in these patients transferred between the hospital and nursing home. Studies are needed to identify the most efficient ways of carrying out this task and to adapt the reconciliation process to all care settings.

Inter-facility transfer of patient information before and after HIPAA privacy measures

OBJECTIVES

The study objectives were (1) to test whether interfacility communication of health information at the time of patient transfer changed as a result of implementation of US privacy protection measures (HIPAA) in April 2003, and (2) to examine patient, transfer, and illness characteristics correlated with interfacility transfer document completion.

DESIGN

Observational study.

PARTICIPANTS AND SETTING

Individuals transferred between a 514-bed urban nursing home and a 1171-bed academic hospital in New York City.

MEASUREMENTS

Research staff reviewed medical records of patients transferred both ways between nursing home and hospital, examining interfacility transfer documents for 12 items important for continuity of care. Transfer document completeness equaled the percentage of items recorded and legible in transfer documents. Transfers were classified by direction (nursing home-to-hospital [NH-to-H] or hospital-to-nursing home [H-to-NH]), urgency (urgent or not), timing (weekday 9 am to 6 pm or other), and by whether they occurred before 12 am April 14, 2003 (pre-HIPAA), or after (post-HIPAA).

RESULTS

Seventy-eight nursing home residents experienced 100 hospital admissions. NH-to-H transfer documents were more complete than H-to-NH documents (86.7% vs 69.0%; P = .002). There were no significant differences between content of transfer documents between pre- and post-HIPAA transfers in either direction of transfer, with and without controlling for patient and illness characteristics. Older age, female gender, dementia diagnosis, shorter duration of nursing home residence, and off-hours hospital transfer were associated with less complete NH-to-H transfer documents, and shorter hospital length of stay was associated with less complete H-to-NH transfer documents.

CONCLUSION

There was no change in written health information communicated during patient transfer between an urban nursing home and an academic hospital before and after HIPAA privacy protection measures were implemented. This suggests that the rule's intent to not restrict the sharing of information needed to treat patients is being followed by providers at these sites in the situation of interfacility patient transfer.

Ineffective communication of mental status information during care transfer of older adults

BACKGROUND

Monitoring and documenting the mental status of older patients transferred between providers or facilities is important because mental status change can be a sign of acute disease and mental status abnormalities necessitate specific approaches to care.

OBJECTIVES

To identify patient and illness factors associated with presence of a mental status description in inter-facility transfer documents and to describe the content and concurrent validity of transfer mental status descriptions when they occur.

DESIGN

Retrospective study.

PARTICIPANTS

Individuals transferred between 5 long-term and 2 acute care facilities in an urban setting.

MEASUREMENTS

Trained research personnel reviewed hospital and nursing home medical records and inter-facility transfer documents. Mental status descriptions in transfer documents were coded as abnormal or normal within 5 domains: alertness, communication, orientation/memory, behavior, and mood. Descriptions were compared with mental status items in the nursing home Minimum Data Set and in a transfer communication checklist.

RESULTS

In all, 123 nursing home residents experienced 174 hospital admissions. Mental status descriptions were present in 69% of transfer documents. A total of 67% of patients missing a transfer mental status description upon nursing home-to-hospital transfer had dementia. Factors associated with presence of a transfer mental status description were urgent transfer, nursing home of origin, and among patients without dementia, greater cognitive impairment. When present, a mean of 1.47 (SD=0.81) cognitive domains were documented in transfer mental status descriptions. Agreement between transfer mental status descriptions and comparison sources was fair to good (kappa=.31 to .73).

CONCLUSION

Mental status documentation during transfer of older adults between nursing home and hospital did not identify all patients with dementia and did not completely characterize patients' cognitive status.

Inter-facility transfer of patient information before and after HIPAA privacy measures

OBJECTIVES

The study objectives were (1) to test whether interfacility communication of health information at the time of patient transfer changed as a result of implementation of US privacy protection measures (HIPAA) in April 2003, and (2) to examine patient, transfer, and illness characteristics correlated with interfacility transfer document completion.

DESIGN

Observational study.

PARTICIPANTS AND SETTING

Individuals transferred between a 514-bed urban nursing home and a 1171-bed academic hospital in New York City.

MEASUREMENTS

Research staff reviewed medical records of patients transferred both ways between nursing home and hospital, examining interfacility transfer documents for 12 items important for continuity of care. Transfer document completeness equaled the percentage of items recorded and legible in transfer documents. Transfers were classified by direction (nursing home-to-hospital [NH-to-H] or hospital-to-nursing home [H-to-NH]), urgency (urgent or not), timing (weekday 9 am to 6 pm or other), and by whether they occurred before 12 am April 14, 2003 (pre-HIPAA), or after (post-HIPAA).

RESULTS

Seventy-eight nursing home residents experienced 100 hospital admissions. NH-to-H transfer documents were more complete than H-to-NH documents (86.7% vs 69.0%; P = .002). There were no significant differences between content of transfer documents between pre- and post-HIPAA transfers in either direction of transfer, with and without controlling for patient and illness characteristics. Older age, female gender, dementia diagnosis, shorter duration of nursing home residence, and off-hours hospital transfer were associated with less complete NH-to-H transfer documents, and shorter hospital length of stay was associated with less complete H-to-NH transfer documents.

CONCLUSION

There was no change in written health information communicated during patient transfer between an urban nursing home and an academic hospital before and after HIPAA privacy protection measures were implemented. This suggests that the rule's intent to not restrict the sharing of information needed to treat patients is being followed by providers at these sites in the situation of interfacility patient transfer.