387 - Pharmacist-Led Transition of Care Interventions Identify and Reduce Medication Errors in Heart Failure Patients Post-Discharge

Abstract

Background: Heart failure hospitalization typically results in new, complex medication regimens. Maintenance of guideline-directed medical therapy represents an evidence-based intervention to reduce rehospitalization and improve outcomes. However, patients must overcome significant affordability, access, and acceptance to remain on therapy. Objective: To quantify adherence to the discharge medication regimen, and qualitatively assess barriers to adherence to identify interventions for improvement. Methods: As part of a multidisciplinary transitional care initiative to reduce heart failure readmissions, we implemented pharmacist-led post-discharge transitional care interventions for patients identified as having potential barriers to medication adherence (one or more medication change to their heart failure regimen). The clinic pharmacist called the patient within 2 business days of hospital discharge, and followed up with the patient within 7 days at a heart failure discharge office visit. As part of this intervention, the pharmacist assessed for adherence and reviewed all medications, dosages, indications, and side effects. Medication errors were defined as any discrepancy between discharge instructions in the electronic medical record and patient report of medication administration. Discrepancies were corrected by the clinic pharmacist after consultation with the prescribing clinician. Reasons for medication errors were annotated and grouped using grounded theory approaches, to identify potential interventions for improvement. Results: During the study period, 86 patients were identified as having potential barriers to medication adherence and received a pharmacist-led transitional care call. Of the identified patients, 69/86 (80%) were reached and assessed for medication errors. Of those reached, 38/69 (55%) had at least one medication error. All identified medication errors were reconciled. Four major themes emerged as reasons for medication errors: 1. the patient did not understand the medication instructions (24/69), 2. the patient did not receive a prescription at discharge (11/69), 3. the patient chose not to adhere to instructions (8/69), and 4. the patient could not afford the prescribed medication(s) (4/69). Conclusions: Pharmacist-led transitional care interventions reveal a remarkable number of medication errors post-discharge, which group into 4 major themes. These medication errors create inaccuracies in the plan of care, introduce inefficiencies in the post-hospital follow-up visit, and place patients at avoidable risk for rehospitalization. Qualitative approaches allow for root cause analysis, and identification of targets for process improvement. Ongoing process of care work will reveal whether improvements in root causes of medication error rate will ameliorate heart failure rehospitalizations.