Effect of Medication Reconciliation at Hospital Admission on 30-Day Returns to Hospital: A Randomized Clinical Trial

IMPORTANCE

According to international recommendations, hospitals should use medication reconciliation to prevent medication errors and improve patient safety.

OBJECTIVE

To assess the impact of medication reconciliation at hospital admission on patient-centered health care outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This parallel group, open-label randomized controlled trial used centralized randomization to the intervention group (ie, individuals with medication reconciliation) or control group (ie, individuals with only standard, physician-acquired medication history). Outcome assessors and data analysts were blinded to group allocation. Participants included 1702 patients aged 85 years or older, with more than 10 medications at hospital admission, or meeting both conditions at 2 regional secondary teaching hospitals in southern Switzerland. Study duration was 14.5 months, from November 1, 2018, to January 15, 2020. Data were analyzed from December 2018 through March 2020.

INTERVENTIONS

Medication reconciliation was performed at hospital admission in 3 steps: (1) the pharmacy assistant obtained the list of the patient's current medications (ie, the best possible medication history [BPMH]); (2) the clinical pharmacist led reconciliation of the BPMH with the list of home medications recorded at hospital admission by the attending physician (according to the hospital standard procedure); and (3) medication discrepancies were communicated to the attending physician, and, when necessary, medications prescribed at admission were adapted.

MAIN OUTCOMES AND MEASURES

The primary outcome was a composite postdischarge health care use variable quantified as the proportion of patients with unplanned all-cause hospital visits (including visits to the emergency department and hospital readmissions) within 30 days after discharge from the hospital when medication reconciliation took place. A time-to-event analysis was performed.

RESULTS

Among 1702 patients (median [interquartile range] age, 86.0 [79.0-89.0] years; 720 [42.3%] men), 866 patients (50.9%) were allocated to the intervention group and 836 patients (49.1%) to the control group. The primary outcome occurred among 340 participants (39.3%) in the intervention group and 330 participants (39.5%) in the control group (P = .93). In time-to-event analyses at study closeout, unplanned all-cause hospital visits to the emergency department (log-rank P = .08) and unplanned all-cause hospital readmissions (log-rank P = .10) occurred similarly in the intervention and control groups.

CONCLUSIONS AND RELEVANCE

These findings suggest that medication reconciliation at hospital admission has no impact on postdischarge health care outcomes among patients aged 85 years or older, with more than 10 medications at hospital admission, or meeting both conditions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03654963.

High occurrence of postintensive care syndrome identified in surgical ICU survivors after implementation of a multidisciplinary clinic

BACKGROUND

Postintensive care syndrome (PICS) has been identified in a large proportion of medical intensive care unit survivors; however, the occurrence surgical intensive care unit (SICU) survivors is unknown. We implemented a multidisciplinary critical care outpatient clinic (CCOC) to identify the occurrence of PICS in SICU survivors.

METHODS

Seventy acute care surgery and trauma patients, 18 years or older, who remained in the SICU for 72 hours or longer at a Level I trauma center were seen in CCOC at 2 weeks, 12 weeks, and 24 weeks after hospital discharge. The CCOC staffing included a nurse coordinator, social worker, critical care pharmacist, physical therapist, and acute care surgeon who identified PICS sequelae in their respective specialties by clinical criteria and screening questionnaires.

RESULTS

Of 82 eligible patients, 70 (85.4%) were seen at least once for 116 total visits. Forty-three (61.4%) patients suffered traumatic injuries and 27 (38.6%) underwent emergent general surgery. Sixty-seven (95.7%) demonstrated at least one PICS criterion. Over all visits, 26 (37.1%) patients presented with one PICS criterion, 24 (34.3%) patients with two, and 17 (24.3%) with three. Cognitive impairment was observed in 29 (41.4%) patients, psychiatric in 30 (42.9%), and physical symptoms in 65 (92.9%). Activity Measure for Post-Acute Care scores improved from severe impairment at admission to full function by 12 weeks postdischarge, yet 6 Minute Walk Test scores remained below age-matched references through all visits. Patients expressed mild to moderate depression based on Patient Health Questionnaire-9 scores. A medication reconciliation was completed at 96.5% (112/116) of the visits with 116 total medication recommendations. By 24 weeks following discharge, only 26.4% (14/53) of previously employed patients had resumed work.

CONCLUSION

Through the successful implementation of a multidisciplinary CCOC, this study identifies an exorbitant rate of PICS among SICU survivors.

LEVEL OF EVIDENCE

Therapeutic/epidemiological, level III.

Evaluation of the completeness of information sources used to prepare the best possible medication histories at a tertiary teaching hospital in Jordan

OBJECTIVES

In this study we aimed to evaluate the completeness of three different medication information sources that are commonly used to collect and obtain the Best Possible Medication History (BPMH).

METHODS

This is an observational study which was held at Jordan University Hospital. After identifying eligible patients, the BPMH was obtained from three different sources separately. These sources include medical file, pharmacy database, and patients' interview. Information from all of these sources was compiled to create the BPMH. The BPMH was used as the standard against which every other information source was compared and given a "completeness score" according to a systematic scoring system.

RESULTS

Among the 196 participating patients who were included in the study, 113 (57.7%) were recruited from internal medicine and 83 (42.3%) from surgical department. Patients' interview showed the highest median completeness score (71.4%) among the three used sources followed by pharmacy database (35.3%), and medical files (28.2%). The median completeness score for the compiled BPMH obtained by the pharmacist was 93.0%. The compiled BPMH completeness score was inversely proportional to the numbers of medications in the compiled BPMH (R = -.392, P value < .001). Moreover, patients with lower income showed better median BPMH completeness score compared with those with higher income (95.2% (IQR = 16.7%) vs 88.9% (IQR = 15.7%), respectively, P value = .042).

CONCLUSION

The results show that pharmacist's interview with the patients scored the highest percentage of completeness compared with hospital pharmacy database and medical file and is, therefore, considered more comprehensive in obtaining the BPMH.

Tele-transitions of care (TTOC): a 12-month, randomized controlled trial evaluating the use of Telehealth to achieve triple aim objectives

BACKGROUND

Poor transitions of care leads to increased health costs, over-utilization of emergency room departments, increased re-hospitalizations and causes poor patient experiences and outcomes. This study evaluated Telehealth feasibility in improving transitions of care.

METHODS

This is a 12-month randomized controlled trial, evaluating the use of telehealth (remote patient monitoring and video visits) versus standard transitions of care with the primary outcomes of hospital readmission and emergency department utilization and secondary outcomes of access to care, medication management and adherence and patient engagement. Electronic Medical Record data, Health Information Exchange data and phone survey data was collected. Multi-variable logistic regression models were created to evaluate the effect of Telehealth on hospital readmission, emergency department utilization, medication adherence. Chi-square tests or Fisher's exact tests were used to compare the percentages of categorical variables between the Telehealth and control groups. T tests or Wilcoxon rank sum tests were used to compared means and medians between the two randomized groups.

RESULTS

The study conducted between June 2017 and 2018, included 102 patients. Compared with the standard of care, Telehealth patients were more likely to have medicine reconciliation (p = 0.013) and were 7 times more likely to adhere to medication than the control group (p = 0.03). Telehealth patients exhibited enthusiasm (p = 0.0001), and confidence that Telehealth could improve their healthcare (p = 0.0001). Telehealth showed no statistical significance on emergency department utilization (p = 0.691) nor for readmissions (p = 0.31). 100% of Telehealth patients found the intervention to be valuable, 98% if given the opportunity, reported they would continue using telehealth to manage their healthcare needs, and 94% reported that the remote patient monitoring technology was useful.

CONCLUSIONS

Telehealth can improve transitions of care after hospital discharge improving patient engagement and adherence to medications. Although this study was unable to show the effect of Telehealth on reduced healthcare utilization, more research needs to be done in order to understand the true impact of Telehealth on preventing avoidable hospital readmission and emergency department visits.

TRIAL REGISTRATION

ClinicalTrials.Gov ID: NCT03528850 Date Registered (Retrospective): 5/18/2018. Status: Completed. IRB #: 970227.

Description of a transitions of care and telemedicine simulation lab activity

BACKGROUND AND PURPOSE

Transitions of Care (ToC) is an important clinical practice area requiring trained health care professionals, but there is limited literature describing ToC in the didactic curriculum. The purpose of this study was to describe and evaluate a ToC telemedicine simulation activity in a doctor of pharmacy curriculum.

EDUCATIONAL ACTIVITY AND SETTING

A one-hour lecture and simulation activity was incorporated into a second-year course. Student teams participated in discharge and telemedicine encounters with standardized patients (SPs). Six medication-related problems (MRPs) were incorporated into the activity. Activity documents were collected to identify student competency.

FINDINGS

Fifty-nine student pharmacists in 16 teams participated. All teams accurately identified five of the six MRPs. Fourteen teams (87.5%) accurately identified the sixth MRP after completion of the telemedicine encounter. Six teams (62.5%) completed the discharge medication list accurately and completely. All teams provided medication education, and 93.8% (n = 15) of teams identified follow-up was needed. Ten teams utilized effective interview sequence and structure during both encounters. Activity challenges included resources, financial support and SP training.

SUMMARY

Case-based learning and the use of simulation has good evidence supporting its use in education. Utilizing these techniques to reinforce concepts may be a beneficial way for students to be trained effectively to deliver impactful ToC services.

Pharmacy students' medication history taking competency: Simulation and feedback learning intervention

INTRODUCTION

Obtaining accurate patient medication histories and performing medication reconciliation are core pharmacy practice skills that optimize patient safety at transitions of care. Competency-based learning and assessment of medication reconciliation skills are essential methods in undergraduate pharmacy education. The aim of this study was to investigate the impact of an in-classroom simulation- and feedback-driven training activity on pharmacy students' medication reconciliation skills, self-perceived confidence, and overall student satisfaction.

METHODS

Over a three-day learning activity in 2016, pharmacy students from a private university in Jordan were assessed by roleplay on their ability to conduct a simulated patient medication interview, obtain the Best Possible Medication History, reconcile the history against a hospital medication chart, identify discrepancies, and document findings. Students received immediate feedback and observed peers undergo the assessment process. Pre- and post-simulation questionnaires and supplementary focus groups enabled collection of quantitative and qualitative data pertaining to student self-perceived confidence, perceptions, experiences, and usefulness of the course.

RESULTS

Assessment-based competency scores demonstrated significant improvement in student performance during the activity. Self-perceived confidence scores significantly improved after the medication reconciliation training intervention. Focus group content analysis yielded positive responses such as students valuing receiving feedback on performance and recommendations for future training.

CONCLUSIONS

Simulation with feedback was a useful tool to teach pharmacy students medication reconciliation in Jordan. Subsequent to the study, medication reconciliation and interactive teaching methods were added to curriculum to supplement traditional teaching modalities.

Effect of an Electronic Medication Reconciliation Intervention on Adverse Drug Events: A Cluster Randomized Trial

IMPORTANCE

Adverse drug events (ADEs) account for up to 16% of emergency department (ED) visits and 7% of hospital admissions. Medication reconciliation is required for hospital accreditation because it can reduce medication discrepancies, but there is no evidence that reducing discrepancies reduces ADEs or other adverse outcomes.

OBJECTIVE

To evaluate whether electronic medication reconciliation reduces ADEs, medication discrepancies, and other adverse outcomes compared with usual care.

DESIGN, SETTING, AND PARTICIPANTS

This cluster randomized trial involved 3491 patients who were discharged from 2 medical units and 2 surgical units at the McGill University Health Centre, Montreal, Quebec, Canada, between October 2014 and November 2016. Data analysis took place from July 2017 to July 2019.

INTERVENTION

The RightRx intervention electronically retrieved community drugs from the provincial insurer and aligned them with in-hospital drugs to facilitate reconciliation and communication at care transitions.

MAIN OUTCOMES AND MEASURES

The primary outcome was ADEs in 30 days after discharge. Secondary outcomes included medication discrepancies, ED visits, hospital readmissions, and a composite outcome of ED visits, readmissions, and death up to 90 days after discharge.

RESULTS

Of 4656 eligible patients, 3567 (76.6%) consented to participate (2060 [57.8%] men; mean [SD] age, 69.8 [14.9] years). Overall, 76 patients died during the hospital stay, so 3491 patients were included in the analysis. There was no significant difference in the risk of ADEs between intervention and control groups (76 [4.6%] vs 73 [4.0%]; OR, 0.97; 95% CI, 0.33-1.48), ED visits (433 [26.2%] vs 488 [26.6%]; OR, 0.83; 95% CI, 0.36-1.42), hospital readmission (170 [10.3%] vs 261 [14.2%]; OR, 0.22; 95% CI, 0.06-1.14), or the composite outcome (447 [27.0%] vs 506 [27.6%]; OR, 0.75; 95% CI, 0.34-1.27) at 30 days. Medication discrepancies were significantly reduced in the intervention group compared with the control group (437 [26.4%] vs 1029 [56.0%]; OR, 0.24; 95% CI, 0.12-0.57). Changes made to community medications (OR, 1.05; 95% CI, 1.01-1.10) and new medications (OR, 1.09; 95% CI, 1.01-1.18) were significant risk factors for ADEs.

CONCLUSIONS AND RELEVANCE

Electronic medication reconciliation reduced medication discrepancies but did not reduce ADEs or other adverse outcomes. Hospital accreditation should focus on interventions that reduce the risk of adverse events for patients with multiple changes to community medications.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01179867.

Prevalence, clinical relevance and predictive factors of medication discrepancies revealed by medication reconciliation at hospital admission: prospective study in a Swiss internal medicine ward

OBJECTIVE

Medication reconciliation (MedRec) is a relevant safety procedure in medication management at transitions of care. The aim of this study was to evaluate the impact of MedRec, including a best possible medication history (BPMH) compared with a standard medication history in patients admitted to an internal medicine ward.

DESIGN

Prospective interventional study. Data were analysed using descriptive statistics followed by univariate and multivariate Poisson regression models and a zero-inflated Poisson regression model.

SETTING

Internal medicine ward in a secondary care hospital in Southern Switzerland.

PARTICIPANTS

The first 100 consecutive patients admitted in an internal medicine ward.

PRIMARY AND SECONDARY OUTCOME MEASURES

Medication discrepancies between the medication list obtained by the physician and that obtained by a pharmacist according to a systematic approach (BPMH) were collected, quantified and assessed by an expert panel that assigned a severity score. The same procedure was applied to discrepancies regarding allergies. Predicting factors for medication discrepancies were identified.

RESULTS

The median of medications per patient was 8 after standard medication history and 11 after BPMH. Total admission discrepancies were 524 (5.24 discrepancies per patient) with at least 1 discrepancy per patient. For 47 patients, at least one discrepancy was classified as clinically relevant. Discrepancies were classified as significant and serious in 19% and 2% of cases, respectively. Furthermore, 67% of the discrepancies were detected during the interview conducted by the pharmacist with the patients and/or their caregivers. The number of drugs used and the autonomous management of home therapy were associated with an increased number of clinically relevant discrepancies in a multivariable Poisson regression model.

CONCLUSION

Even in an advanced healthcare system, a standardised MedRec process including a BPMH represents an important strategy that may contribute to avoid a notable number of clinically relevant discrepancies and potential adverse drug events.

Decision-maker and staff perceptions of the pharmacist's role in transitions of care programs

OBJECTIVES

To identify perceptions of decision-makers and staff at a local hospital about the pharmacist's role in transitions of care (TOC) programs.

SETTING

Independent community pharmacy located inside a local community hospital.

PRACTICE DESCRIPTION

Pharmacy personnel offer a bedside delivery service to hospital patients and have professional relationships with administration.

PRACTICE INNOVATION

Pharmacy personnel intend to expand the bedside delivery service to a comprehensive TOC program. Researchers believed it would be important to gather the perceptions of pharmacist's role in TOC programs from nonpharmacist clinicians and administration to successfully develop the program.

EVALUATION

This project would identify perceptions to help develop a TOC program.

METHODS

A 22-question survey was developed after consulting with key staff and informed by literature regarding TOC and pharmacists' roles in patient care services. Collected demographic information included primary department, number of years worked at the institution, and involvement in TOC. After an 8-week survey distribution period, descriptive statistics were performed on the data collected.

RESULTS

A total of 13 decision-makers and staff responded to the survey with a response rate of 87%. Eleven of 12 respondents (92%) thought that pharmacists should be involved in TOC and can be the communication link between patients and other health care providers to ensure continuity of care. All of the participants thought that pharmacists should provide medication reconciliation and patient and caregiver education through TOC services. The participants were less likely to think that pharmacists should offer follow-up care after discharge.

CONCLUSION

Participants agreed that pharmacists should be involved in TOC services but had varied perceptions on the pharmacist's specific role. Decision-maker and staff perceptions identified in this study will be used to develop the pharmacist's role in a TOC program at the institution.

The prevalence and clinical seriousness of medication discrepancies identified upon hospital admission of pediatric patients

BACKGROUND

Medication discrepancies are seen frequently in hospital setting upon admission or discharge. Medication Reconciliation service is a practice designed to ensure that patients' medications are ordered in a correct manner upon hospital admission, thus reducing the risk of having medication discrepancies. This study aimed to determine the prevalence of medication discrepancies and their clinical seriousness in pediatric patients at the time of hospital admission.

METHODS

A prevalence cross-sectional study was conducted at the pediatric departement at the Jordan University hospital between March-May 2018. During the study period, 100 pediatric patients were enrolled using a convenience sampling method. Patients' medical records were reviewed by two clinical pharmacist-reserachers to obtain patients' demographic, medical, and admission medication information. All parents were interviewed to obtain information regarding their children's Best Possible Medication History (BPMH). Following data collection, differences between patient's current admission medications and the BPMH were identified as medication discrepancies, and then they were classified into either undocumented intentional or unintentional discrepancies.

RESULTS

Among the 100 medication records reviewed, 13.0% (13 out of 100) contained at least one unintentional discrepancy, with the majority (n = 11, 84.6%) being classified to be associated with mild potential harm to patients. Of those discrepancies, 8 were omission of medications (61.5%) and 5 were addition of unnecessary medication (38.5%). On the other hand, 35.0% (35 out of 100) of medication records contained at least one intentional undocumented discrepancy.

CONCLUSIONS

This study revealed that unintentional medication discrepancies exist at the time of hospital admission for pediatric patients but with low proportion. The low proportion of medication discrepancies might be explained by the recent implementation of medication reconciliation service at the studied hospital. Also, intentional undocumented discrepancies were common, which may carry a potential harm to such vulnerable population at discharge. These data may inform the need for a strict policies to regulate medication documentation, thus decreasing the possibilities of medication errors.

Impact of medication reconciliation for improving transitions of care

BACKGROUND

Transitional care provides for the continuity of care as patients move between different stages and settings of care. Medication discrepancies arising at care transitions have been reported as prevalent and are linked with adverse drug events (ADEs) (e.g. rehospitalisation).Medication reconciliation is a process to prevent medication errors at transitions. Reconciliation involves building a complete list of a person's medications, checking them for accuracy, reconciling and documenting any changes. Despite reconciliation being recognised as a key aspect of patient safety, there remains a lack of consensus and evidence about the most effective methods of implementing reconciliation and calls have been made to strengthen the evidence base prior to widespread adoption.

OBJECTIVES

To assess the effect of medication reconciliation on medication discrepancies, patient-related outcomes and healthcare utilisation in people receiving this intervention during care transitions compared to people not receiving medication reconciliation.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, seven other databases and two trials registers on 18 January 2018 together with reference checking, citation searching, grey literature searches and contact with study authors to identify additional studies.

SELECTION CRITERIA

We included only randomised trials. Eligible studies described interventions fulfilling the Institute for Healthcare Improvement definition of medication reconciliation aimed at all patients experiencing a transition of care as compared to standard care in that institution. Included studies had to report on medication discrepancies as an outcome.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts, assessed studies for eligibility, assessed risk of bias and extracted data. Study-specific estimates were pooled, using a random-effects model to yield summary estimates of effect and 95% confidence intervals (CI). We used the GRADE approach to assess the overall certainty of evidence for each pooled outcome.

MAIN RESULTS

We identified 25 randomised trials involving 6995 participants. All studies were conducted in hospital or immediately related settings in eight countries. Twenty-three studies were provider orientated (pharmacist mediated) and two were structural (an electronic reconciliation tool and medical record changes). A pooled result of 20 studies comparing medication reconciliation interventions to standard care of participants with at least one medication discrepancy showed a risk ratio (RR) of 0.53 (95% CI 0.42 to 0.67; 4629 participants). The certainty of the evidence on this outcome was very low and therefore the effect of medication reconciliation to reduce discrepancies was uncertain. Similarly, reconciliation's effect on the number of reported discrepancies per participant was also uncertain (mean difference (MD) -1.18, 95% CI -2.58 to 0.23; 4 studies; 1963 participants), as well as its effect on the number of medication discrepancies per participant medication (RR 0.13, 95% CI 0.01 to 1.29; 2 studies; 3595 participants) as the certainty of the evidence for both outcomes was very low.Reconciliation may also have had little or no effect on preventable adverse drug events (PADEs) due to the very low certainty of the available evidence (RR 0.37. 95% CI 0.09 to 1.57; 3 studies; 1253 participants), with again uncertainty on its effect on ADE (RR 1.09, 95% CI 0.91 to 1.30; 4 studies; 1363 participants; low-certainty evidence). Evidence of the effect of the interventions on healthcare utilisation was conflicting; it probably made little or no difference on unplanned rehospitalisation when reported alone (RR 0.72, 95% CI 0.44 to 1.18; 5 studies; 1206 participants; moderate-certainty evidence), and had an uncertain effect on a composite measure of hospital utilisation (emergency department, rehospitalisation RR 0.78, 95% CI 0.50 to 1.22; 4 studies; 597 participants; very low-certainty evidence).

AUTHORS' CONCLUSIONS

The impact of medication reconciliation interventions, in particular pharmacist-mediated interventions, on medication discrepancies is uncertain due to the certainty of the evidence being very low. There was also no certainty of the effect of the interventions on the secondary clinical outcomes of ADEs, PADEs and healthcare utilisation.

[Medication reconciliation errors according to patient risk and type of physician prescriber identified by prescribing tool used]

OBJECTIVES

To study the frequency of medication reconciliation errors (MREs) in hospitalized patients and explore the profiles of patients at greater risk. To compare the rates of errors in prescriptions written by emergency physicians and ward physicians, who each used a different prescribing tool.

MATERIAL AND METHODS

Prospective cross-sectional study of a convenience sample of patients admitted to medical, geriatric, and oncology wards over a period of 6 months. A pharmacist undertook the medication reconciliation report, and data were analyzed for possible associations with risk factors or prescriber type (emergency vs ward physician).

RESULTS

A total of 148 patients were studied. Emergency physicians had prescribed for 68 (45.9%) and ward physicians for 80 (54.1%). A total of 303 MREs were detected; 113 (76.4%) patients had at least 1 error. No statistically significant differences were found between prescriber types. Factors that conferred risk for a medication error were use polypharmacy (odds ratio [OR], 3.4; 95% CI, 1.2-9.0; P=.016) and multiple chronic conditions in patients under the age of 80 years (OR, 3.9; 95% CI, 1.1-14.7; P=.039).

CONCLUSION

The incidence of MREs is high regardless of whether the prescriber is an emergency or ward physician. The patients who are most at risk are those taking several medications and those under the age of 80 years who have multiple chronic conditions.

Medication errors at hospital admission and discharge in Type 1 and 2 diabetes

AIMS

To assess the prevalence and characteristics of medication errors at hospital admission and discharge in people with Type 1 and Type 2 diabetes, and identify potential risk factors for these errors.

METHODS

This prospective observational study included all people with Type 1 (n = 163) and Type 2 diabetes (n = 508) admitted to the Diabetology-Department of the University Hospital of Montpellier, France, between 2013 and 2015. Pharmacists conducted medication reconciliation within 24 h of admission and at hospital discharge. Medication history collected from different sources (patient/family interviews, prescriptions/medical records, contact with community pharmacies/general practitioners/nurses) was compared with admission and discharge prescriptions to detect unintentional discrepancies in medication indicating involuntary medication changes. Medication errors were defined as unintentional medication discrepancies corrected by physicians. Risk factors for medication errors and serious errors (i.e. errors that may cause harm) were assessed using logistic regression.

RESULTS

A total of 322 medication errors were identified and were mainly omissions. Prevalence of medication errors in Type 1 and Type 2 diabetes was 21.5% and 22.2% respectively at admission, and 9.0% and 12.2% at discharge. After adjusting for age and number of treatments, people with Type 1 diabetes had nearly a twofold higher odds of having medication errors (odds ratio (OR) 1.72, 95% confidence interval (CI) 1.02-2.94) and serious errors (OR 2.17, 95% CI 1.02-4.76) at admission compared with those with Type 2 diabetes.

CONCLUSIONS

Medication reconciliation identified medication errors in one third of individuals. Clinical pharmacists should focus on poly-medicated individuals, but also on other high-risk people, for example, those with Type 1 diabetes.

[Lack of time is the greatest impeding factor to carrying out clinical medication reviews]

Clinical medication reviews can be useful in improving pharmacotherapy for elderly. This study aimed to investigate the view and knowledge of clinical medication reviews among primary care physicians in order to identify perceived barriers and facilitating factors. Data were collected via a questionnaire given to primary care physicians in southern Sweden. Eight out of ten of the respondents were familiar with the concept of clinical medication review, and four out of ten of these, used the method on a regular basis. Lack of time was identified as the greatest impeding factor. Although necessary for a medication review, medication reconciliation was often lacking. Regardless of the theoretical knowledge of medications which are potentially inappropriate for elderly, the respondents still perceived difficulties in decisions made for the individual patient. Further education about medication reviews should be offered to primary care physicians, irrespective of time in the profession.

Discrepancies in drug histories at admission to gastrointestinal surgery, internal medicine and geriatric hospital wards in Central Norway: a cross-sectional study

OBJECTIVES

To compare discrepancies in drug histories among patients acutely admitted to different hospital wards, classify the discrepancies according to their potential clinical impact and identify appropriate selection criteria for patients that should be subject to a detailed drug history at admission.

DESIGN

Cross-sectional study.

SETTING

Two gastrointestinal surgery wards and one geriatric ward at St Olav's University Hospital in Trondheim and two general internal medicine wards at Ålesund Hospital in Ålesund, Norway.

PARTICIPANTS

All patients acutely admitted to these wards during a period of three months were asked to participate in the study. A total of 168 patients were included. For each patient, drug information available at admission was compared with information from drug lists obtained from the general practitioner and (if applicable) the home care services/the nursing home.

PRIMARY AND SECONDARY OUTCOME MEASURES

Number of patients with one or more discrepancies in their drug history. Type and clinical impact of the discrepancies found. Selection criteria for patients that should be subject to a detailed drug history.

RESULTS

In total, 83% had at least one discrepancy in their drug history. Omission of a drug accounted for 72% of the discrepancies, whereas a difference in dosing was the cause of the remaining 28%. 9% of the discrepancies had the potential to cause severe harm or discomfort. We found no significant differences in the number of discrepancies between hospital wards, genders, ages or levels of care.

CONCLUSIONS

This study demonstrates the importance of collecting drug information from all available sources when a patient is admitted to hospital. As we found no significant differences in discrepancies between subgroups of patients, we suggest that medication reconciliation should be performed for all patients.

Effect of house officer clerking on short-term outcomes in paediatric orthopaedic patients

AIM

Children who are admitted with acute orthopaedic problems are often fit and healthy. The house officer (ie, intern) is required to carry out the formal clerking/admission of inpatients. However, they are often also busy with sick ward patients, which leads to delays in formal clerking of these children until after they have been to the operating theatre (OT). The aim of this study was to assess what information, if any, is missed in children who were seen by a house officer prior to going to OT, compared to those who were not.

METHODS

All patients admitted to the paediatric surgical ward, under the orthopaedics service care, between 1 September 2015 and 30 November 2015 were included in this study. Information on age, sex, medical background, details of the admission and post-operative complications were collected.

RESULTS

A total of 139 children were admitted during the study period. The median age was 7.4 years (range, 0.2-17.5) and a male:female ratio of 1.3:1. In this study, there was no statistically significant difference in patient characteristics, post-operative complications or length of hospital stay. However, patients clerked by house officers had better documentation of their regular medications and non-orthopaedic examination findings.

CONCLUSION

To the author's knowledge, this is the first study to examine the effect of house officer admission on paediatric orthopaedic patient outcomes. A suggested solution would be to encourage documentation of medication history and examination findings by the anaesthetic registrar, since all patients must be reviewed pre-operatively.

Medication Reconciliation Failures in Children and Young Adults With Chronic Disease During Intensive and Intermediate Care

OBJECTIVES

Although medication reconciliation has become standard during hospital admission, rates of unintentional medication discrepancies during intensive care of pediatric patients with chronic disease are unknown. Such discrepancies are an important cause of adverse drug events in adults with chronic illness and are associated with unintentional discontinuation of chronic medications. We sought to determine the rate, type, timing, and predictors of potentially harmful unintentional medication discrepancies in children and young adults with chronic disease.

DESIGN

Prospective observational cohort study.

SETTING

Patients discharged from the intensive and intermediate care units at a tertiary care children's hospital from September 2013 to May 2014.

PATIENTS

Consecutive sample of 308 patients less than 25 years old with chronic disease defined by prescription of at least one predetermined class of chronic medication prior to hospitalization.

MEASUREMENTS AND MAIN RESULTS

The number of unintentional medication discrepancies with the potential for harm, as well as patient and medication-related factors predisposing patients to these errors were assessed. Two thousand seven hundred thirty-nine medication discrepancies were identified; 284 (10%) were unintentional and had the potential for harm (0.9/patient). Of these, 128 (45%) were due to errors in taking the preadmission medication history, whereas 156 (55%) were due to errors reconciling the medication history with orders. Most events occurred at admission (66%) and were dosing errors (45%). In multivariable negative binomial regression analyses (adjusted rate ratios [95% CI]), each additional preadmission medication (1.07 [1.04-1.10]), chronic respiratory medications (1.51 [1.01-2.28]), and chronic noninvasive ventilation (1.53 [1.07-2.19]) were associated with increased risk of a discrepancy.

CONCLUSIONS

Unintentional medication discrepancies with the potential for harm are common among children and young adults with chronic disease during critical care admission due to both failure to obtain an accurate medication history and errors in reconciling the history with patient orders. The use of current medication reconciliation processes is insufficient to prevent errors in this high-risk population.

The medication reconciliation process and classification of discrepancies: a systematic review

AIMS

Medication reconciliation is a part of the medication management process and facilitates improved patient safety during care transitions. The aims of the study were to evaluate how medication reconciliation has been conducted and how medication discrepancies have been classified.

METHODS

We searched MEDLINE, EMBASE, CINAHL, PubMed, International Pharmaceutical Abstracts (IPA), and Web of Science (WOS), in accordance with the PRISMA statement up to April 2016. Studies were eligible for inclusion if they evaluated the types of medication discrepancy found through the medication reconciliation process and contained a classification system for discrepancies. Data were extracted by one author based on a predefined table, and 10% of included studies were verified by two authors.

RESULTS

Ninety-five studies met the inclusion criteria. Approximately one-third of included studies (n = 35, 36.8%) utilized a 'gold' standard medication list. The majority of studies (n = 57, 60%) used an empirical classification system and the number of classification terms ranged from 2 to 50 terms. Whilst we identified three taxonomies, only eight studies utilized these tools to categorize discrepancies, and 11.6% of included studies used different patient safety related terms rather than discrepancy to describe the disagreement between the medication lists.

CONCLUSIONS

We suggest that clear and consistent information on prevalence, types, causes and contributory factors of medication discrepancy are required to develop suitable strategies to reduce the risk of adverse consequences on patient safety. Therefore, to obtain that information, we need a well-designed taxonomy to be able to accurately measure, report and classify medication discrepancies in clinical practice.

Comparison of Information Available in the Medication Profile of an Electronic Health Record and the Inpatient Best Possible Medication History in a Mother and Child Teaching Hospital Center

BackgroundMedication reconciliation (MedRec) can improve patient safety. In Canada, most provinces are implementing electronic health records (EHR). The Quebec Health Record (QHR) can theoretically be used for medication reconciliation. However, the quantity and the quality of information available in this EHR have not been studied. ObjectivesThe main objective was to compare the quantity and quality of the information collected between the inpatient best possible medication history (BPMH) and the QHR.   MethodsThis is a descriptive prospective study conducted at CHU Sainte-Justine, a 500-bed tertiary mother-and-child university hospital center. All inpatients from May 19-26, 2015 were considered for inclusion. Every prescription line in the BPMH and QHR were compared. ResultsThe study included 344 patients and 1,039 prescription lines were analyzed. The medications' name and dosing were more often available in the QHR (95%) than in the BPMH (61%). Concordance between the medication names between QHR and BPMH was found in 48% of the prescription lines; this rate fell to 29% when also factoring daily dosage.  ConclusionsThis study suggests that the QHR can provide high-quality information to support the MedRec hospital process. However, it should be used as a second source to optimize the BPMH obtained from a thorough interview with the patient and/or his or her family. More studies are required to confirm the most optimal way to integrate the QHR to the MedRec process in hospitals.

Evaluation of an Electronic Module for Reconciling Medications in Home Health Plans of Care

OBJECTIVES

Transitions in patient care pose an increased risk to patient safety. One way to reduce this risk is to ensure accurate medication reconciliation during the transition. Here we present an evaluation of an electronic medication reconciliation module we developed to reduce the transition risk in patients referred for home healthcare.

METHODS

Nineteen physicians with experience in managing home health referrals were recruited to participate in this within-subjects experiment. Participants completed medication reconciliation for three clinical cases in each of two conditions. The first condition (paper-based) simulated current practice - reconciling medication discrepancies between a paper plan of care (CMS 485) and a simulated Electronic Health Record (EHR). For the second condition (electronic) participants used our medication reconciliation module, which we integrated into the simulated EHR. To evaluate the effectiveness of our medication reconciliation module, we employed repeated measures ANOVA to test the hypotheses that the module will: 1) Improve accuracy by reducing the number of unaddressed medication discrepancies, 2) Improve efficiency by reducing the reconciliation time, 3) have good perceived usability.

RESULTS

The improved accuracy hypothesis is supported. Participants left more discrepancies unaddressed in the paper-based condition than the electronic condition, F (1,1) = 22.3, p < 0.0001 (Paper Mean = 1.55, SD = 1.20; Electronic Mean = 0.45, SD = 0.65). However, contrary to our efficiency hypothesis, participants took the same amount of time to complete cases in the two conditions, F (1, 1) =0.007, p = 0.93 (Paper Mean = 258.7 seconds, SD = 124.4; Electronic Mean = 260.4 seconds, SD = 158.9). The usability hypothesis is supported by a composite mean ability and confidence score of 6.41 on a 7-point scale, 17 of 19 participants preferring the electronic system and an SUS rating of 86.5.

CONCLUSION

We present the evaluation of an electronic medication reconciliation module that increases detection and resolution of medication discrepancies compared to a paper-based process. Further work to integrate medication reconciliation within an electronic medical record is warranted.

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

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Medication Discrepancies and Associated Risk Factors Identified in Home Health patients

Medication discrepancies can place patients at increased risk for adverse drug events. We sought to determine the frequency, type, and reason for medication discrepancies in patients receiving home healthcare following hospital discharge. We conducted a retrospective, observational study of adults discharged from an academic medical center who received home healthcare following hospital discharge from one affiliated home healthcare agency. Medication discrepancies were identified by comparing the hospital discharge medication list to what the patient was taking at the first home healthcare visit. Almost all patients (66/70, 94%) had at least one medication discrepancy. The median number of discrepancies per patient was 5. Nearly half of the discrepancies were omissions (46%), in which the patient was not taking a medication on the discharge medication list. Increased age was significantly associated with fewer medication discrepancies overall (IRR = 0.99, p < 0.05). Higher health literacy was associated with more omissions (IRR = 1.85, p < 0.05).

Unintentional Discontinuation of Chronic Medications for Seniors in Nursing Homes: Evaluation of a National Medication Reconciliation Accreditation Requirement Using a Population-Based Cohort Study

Transitions of care leave patients vulnerable to the unintentional discontinuation of medications with proven efficacy for treating chronic diseases. Older adults residing in nursing homes may be especially susceptible to this preventable adverse event. The effect of large-scale policy changes on improving this practice is unknown.The objective of this study was to analyze the effect of a national medication reconciliation accreditation requirement for nursing homes on rates of unintentional medication discontinuation after hospital discharge.It was a population-based retrospective cohort study that used linked administrative records between 2003 and 2012 of all hospitalizations in Ontario, Canada. We identified nursing home residents aged ≥66 years who had continuous use of ≥1 of the 3 selected medications for chronic disease: levothyroxine, HMG-CoA reductase inhibitors (statins), and proton pump inhibitors (PPIs).In 2008 medication reconciliation became a required practice for accreditation of Canadian nursing homes.The main outcome measures included the proportion of patients who restarted the medication of interest after hospital discharge at 7 days. We also performed a time series analysis to examine the impact of the accreditation requirement on rates of unintentional medication discontinuation.The study included 113,088 adults aged ≥66 years who were nursing home residents, had an acute hospitalization, and were discharged alive to the same nursing home. Overall rates of discontinuation at 7-days after hospital discharge were highest in 2003-2004 for all nursing homes: 23.9% for thyroxine, 26.4% for statins, and 23.9% for PPIs. In most of the cases, these overall rates decreased annually and were lowest in 2011-2012: 4.0% for thyroxine, 10.6% for statins, and 8.3% for PPIs. The time series analysis found that nursing home accreditation did not significantly lower medication discontinuation rates for any of the 3 drug groups.From 2003 to 2012, there were marked improvements in rates of unintentional medication discontinuation among hospitalized older adults who were admitted from and discharged to nursing homes. This change was not directly associated with the new medication reconciliation accreditation requirement, but the overall improvements observed may have been reflective of multiple processes and not 1 individual intervention.

Discharge Time Out: An Innovative Nurse-Driven Protocol for Medication Reconciliation

An innovative method for discharge medication reconciliation was developed by nurses to ensure safe transition of care and improved patient outcomes. The discharge time-out process has empowered nurses to take a more active role in discharging their patients, and has fostered a more collaborative relationship between nurses and physicians.

Medical reconciliation of dietary supplements: don't ask, don't tell

OBJECTIVE

To explore inpatient reconciliation of dietary supplement (DS) use and determine characteristics associated with DS documentation.

METHODS

We analyzed DS use among 558 inpatients recruited from the Re-Engineered Discharge clinical trial to identify: (1) if patients self-reported DS and (2) if DS use was documented at admission. We examined socio-demographics for association with documentation using chi squares and t-tests. Logistic regression was performed to assess adjusted associations with DS documentation.

RESULTS

Sixty percent reported DS use (n=333). Among users, 36% had admission DS documentation, 20% were asked about use at admission, 18% reported disclosing use to a provider, and 48% reported they would continue to use DS. Overall, 6% of participants were asked, disclosed, and had documentation of DS. Logistic regression revealed increased age associated with lower odds of DS documentation. Identifying as Hispanic or African American reduces DS documentation odds compared to those identifying as white.

CONCLUSIONS

There is lack of consistent DS medical reconciliation in the inpatient setting. While more than half of patients used DS prior to hospitalization, most were not asked about use on admission.

PRACTICE IMPLICATIONS

This study adds to literature on medical reconciliation which requires that providers inquire and document patient DS use.

Referral letters to the emergency department: is the medication list accurate?

Medication errors are common when patients transfer across healthcare boundaries. This study was designed to investigate the quality of information on medicines provided by general practitioners (GPs) on emergency department (ED) referral letters. A convenience sample of referral letters to the ED of a teaching hospital was reviewed. The medication list and/or patient's drug allergy status were noted. Medicines reconciliation including patient (or carer) interview was conducted to determine the patient's actual home medication list. This was compared with the GP list and any discrepancies were identified and addressed. A total of 92 referral letters were included in the analysis of which 60 were computer-generated and 32 were hand-written. GPs provided dose and frequency of administration information in 47 (51%) of the letters sampled i.e. 44 (71%) computer-generated versus 3 (10%) hand-written; p < 0.001. In addition, the patient was taking their medicines exactly as per the GP list in 20 (22%) of cases. The patient's drug allergy status was documented in 13 (14%) of the letters.

Patient Safety at Transitions of Care: Use of a Compulsory Electronic Reconciliation Tool in an Academic Hospital

Medication errors are responsible for most inpatient adverse events. Medication reconciliation emerged as an effective strategy to decrease these problems, enhancing patient safety. Electronic health records with reconciliation tools could improve the process, but many aspects should be considered in order to reach expected outcomes. In this paper we analyzed how a compulsory, electronic reconciliation application was used at Hospital Italiano in Buenos Aires, through admission and discharge processes. We evaluated all medications that were reconciled during patient admission and discharge since its implementation, from February to November 2014. During that period, there were 78,714 reconciled medications regarding 37,741 admissions (2.08 reconciled medications per hospitalization), of 27,375 patients (2.88 medications per patient). At admission, 63% of medications were confirmed and the remaining were paused or deleted. At discharge, 41% of all medications were reconfirmed. In the creation of the best possible medication history, the use of an electronic reconciliation tool would clean overloaded lists, but at the same time medications could be erroneously deleted.

Usability Evaluation of a Medication Reconciliation and Allergy Review (MRAR) Kiosk: A Methodological Approach for Analyzing User Interactions

Internationally, major efforts are underway to improve medication safety and reduce medication errors during transitions of care. One strategy that has emerged to improve data accuracy and close information gaps is the introduction of software applications and workflow models that allow patients to review, enter, and modify their own patient data (e.g. information about medications they are taking). Evaluating the quality and effectiveness of such patient-facing healthcare applications is critical, especially when this approach is applied to high-stakes clinical tasks such as medication reconciliation. In this paper we describe an approach that has been used to assess the usability of a patient-facing medication reconciliation and allergy review (MRAR) kiosk. The phases involved are described along with implications and challenges of carrying out this work.

Medication Review: Human Factors Study Aiming at Helping an Acute Geriatric Unit to Sustain and Systematize the Process

BACKGROUND

Medication Review (MRev) has been implemented in many hospitals to improve patient safety and well-being. However, it seems sometimes difficult to implement, maintain and systematize this process, especially when key-elements are absent. This study focuses on the analysis of a MRev process implemented in an Acute Geriatric Unit (AGU) which, at the time of the study, had no Computerized Physician Order Entry (CPOE) and no sufficient staff to - normally - support the process.

OBJECTIVE

This study describes the MRev process as existing in the AGU with a particular focus on the preparatory MRev meeting phase and presents our recommendations to maintain and optimize it.

METHODS

Human Factor experts have collected and analyzed data during MRev process by interviews, shadowing observations and video recording from April to October 2014 at Lille University Hospital.

RESULTS

MRev process consists of three phases (meeting preparation, MRev meeting and patient discharge) and includes seven main tasks for which actors, documented supports, outcomes and difficulties are identified. Although allocating a fulltime pharmacist for the AGU would solve several problems, the main realistic recommendations concern training for junior and senior actors according to their roles and the improvement of some tasks processes.

CONCLUSION

Despite less than optimal conditions as compared to those recommended by the literature, the observed AGU performs an efficient review based on well designed tools and processes.

[Different models are used to obtain medication history and medication review in Danish hospitals]

The objective of the article is to characterize the models used by pharmacists to obtain medication history and medication review in Danish hospitals. The models are characterized based on the sources used to create an overview of the patient's medication as well as the time spent per patient. Currently pharmacists perform medication review at 16 departments. The sources frequently used are the patient journal (81%) and clinical data (81%). The patient contributes to the medication review in 25%.

Considerations for using the 'brown bag' strategy to reconcile medications during routine outpatient office visits

BACKGROUND

Among medication reconciliation studies, varying methods are used to determine which medications patients are actually taking. One recommended approach is to ask patients to "brown bag" their medications for routine office visits.

AIMS

To determine if 'brown bag' practices performed during routine office visits improve the accuracy of provider-documented medication lists.

METHODS

This cross-sectional pilot study was conducted in a university affiliated community geriatric clinic. Forty-six cognitively intact elders who managed their own medications enrolled. Participants self-selected into two groups: 'brown-baggers' (BBs) and 'non-brown-baggers' (NBBs). Three medication lists were compared for each patient: provider-documented in patient's chart (chart list); researcher-generated by post-appointment semistructured interview (point-of-care [POC] list); post-appointment semi-structured telephone interview (telephone list, reference standard). Accuracy of chart and POC lists were compared with reference lists among BBs and NBBs.

RESULTS

Thirty-three (72%) patients brought some of their medications to scheduled appointments (BBs); of these, 39% bagged all of their medications. Excluding route as a variable, 35% of provider-documented chart lists were complete; only 6.5% were accurate. Some 76% of chart-documented medication lists contained inclusion, omission and/or dosing instruction discrepancies, with no differences between BBs and NBBs. However, POC lists obtained using a semi-structured interview included fewer inclusion and omission discrepancies among BBs than NBBs (42% v 77%, P = 0.05). In subset analyses by medication type, over-the-counter (OTC) medication documentation was more accurate among BBs than NBBs. Overall, chart lists contained two to three times more discrepancies than lists generated at POC.

CONCLUSION

Most BBs do not bag all their medications for office visits. Chart list accuracy is no better among BBs than NBBs, although patients who 'brown bag' their medications for office visits may prompt providers to conduct a more thorough medication history. Lists generated by semistructured interviewing, regardless of BB status, are more accurate than chart lists. Findings challenge benefits of the 'brown bag' unless coupled with in-depth questioning and processes for transferring information to chart lists.

Medication reconciliation service in Tan Tock Seng Hospital

PURPOSE

Medication reconciliation is integral to every hospital. Approximately 60 percent of all hospital medication errors occur at admission, intra-hospital transfer or discharge. Effectively and consistently performing medication reconciliation at care-interfaces continues to be a challenge. Tan Tock Seng Hospital (TTSH) averages 4,700 admissions monthly. Many patients are elderly (> 65 years old) at risk from poly-pharmacy. As part of a medication safety initiative, pharmacy staff started a medication reconciliation service in 2007, which expanded to include all patients in October 2009. This article aims to describe the TTSH medication reconciliation system and to highlight common medication errors occurring following incomplete medication reconciliation.

DESIGN/METHODOLOGY/APPROACH

Where possible, patients admitted into TTSH are seen by pharmacy staff within 24 hours of admission. A form was created to document their medications, which is filed into the case sheets for referencing purposes. Any discrepancies in medicines are brought to doctors' attention. Patients are also counseled about changes to their medications. Errors picked up were captured in an Excel database.

FINDINGS

The most common medication error was prescribers missing out medications. The second commonest was recording different doses and regimens. The reason was mainly due to doctors transcribing medications inaccurately.

RESEARCH LIMITATIONS/IMPLICATIONS

This is a descriptive study and no statistical tests were carried out. Data entry was done by different pharmacy staff, and not a dedicated person; hence, data might be under-reported.

PRACTICAL IMPLICATIONS

The findings demonstrate the importance of medication reconciliation on admission. Accurate medication reconciliation can help to reduce transcription errors and improve service quality.

ORIGINALITY/VALUE

The article highlights medication reconciliation's importance and has implications for healthcare professionals in all countries.

Medication reconciliation: barriers and facilitators from the perspectives of resident physicians and pharmacists

BACKGROUND

Medication reconciliation can prevent medication errors and harm when patients transition between hospital and other care settings. Though a Joint Commission hospital Patient Safety Goal since 2006, organizations continue to have difficulty implementing the process.

OBJECTIVE

To determine factors that influence performance of medication reconciliation in a hospital setting with a computerized medication reconciliation tool.

DESIGN

Cognitive task analysis (CTA) and focus group interviews.

SETTING

Urban, academic, tertiary-care Veterans Affairs medical center.

PARTICIPANTS

Internal medicine house staff physicians (n = 23) and inpatient staff pharmacists (n = 12).

MEASUREMENTS

CTA participants verbalized their thoughts while they completed medication reconciliation with the computerized tool. Focus group participants described medication reconciliation's purpose and effectiveness, how they completed the task, and its barriers and facilitators. Interviews were recorded and analyzed using social science methods for analyzing qualitative data.

RESULTS

Participants agreed that a central goal of medication reconciliation is to prevent prescribing errors, but disagreed about whether it achieves this goal. Computerization facilitated the task, but participants said that computers and patients can be unreliable sources of information. Participants varied in how they sequenced components of the task. When time was limited, physicians considered other responsibilities higher priority. Both physicians and pharmacists expressed low self-efficacy, ie, low perceived capability to achieve the objectives of the process.

CONCLUSION

Key barriers to medication reconciliation are unreliable sources of medication information and tasks that compete for providers' time and attention that they consider higher priority. Addressing these barriers while increasing providers' self-efficacy might improve medication reconciliation and its outcomes.

Assessing the accuracy of drug profiles in an electronic medical record system of a Washington state hospital

OBJECTIVES

To determine the accuracy of patients' electronic medical record (EMR) drug profiles, to assess the relationship of copayment status with errors of commission and omission within drug profiles, and to evaluate the association between errors of commission in primary and secondary sections of the drug profiles.

STUDY DESIGN

Cross-sectional analysis of patients' EMR drug profiles at a 46-bed hospital in Washington state.

METHODS

Patients' drug profiles were compared against hospital staff interviews. Drug profiles listing each medication the patient was taking, without listing drugs the patient was not taking, exhibited perfect accuracy. We evaluated associations between errors of commission and omission, copayment status between errors of commission and omission, and associations between errors of commission in primary and secondary sections of the drug profiles.

RESULTS

Demographics of study patients are similar to previously published research, and accuracy outcomes seem to be better than those of previously published studies. Fifty-six percent of drug profiles in our study hospital exhibited perfect accuracy. Errors of commission and omission were unassociated with copayment status; errors of commission in the primary section of the drug profile were unassociated with errors of commission in the secondary section of the drug profile.

CONCLUSIONS

A medication reconciliation program may have led to a high rate of perfectly accurate drug profiles; while its purpose is to increase accuracy and to decrease errors, it may also assist in reducing adverse drug events. Results show that copayment amounts influence drug utilization; these may be associated with errors of commission and omission and not simply with copayment status.