Admission Medication Reconciliation Research Articles

Pharmacy‐led optimization of transitions of care in patients with heart failure

AbstractIntroductionEffective transitional care for patients with heart failure is essential to ensure optimal utilization of guideline‐directed medical therapy. Clinical pharmacists and specially trained pharmacy technicians have unique skillsets that enable them to improve care transitions.ObjectivesTo evaluate the implementation of a comprehensive pharmacy transitions of care program in an acute heart failure population.MethodsA retrospective, single center, single‐arm study evaluating pharmacy‐delivered transitions of care services (admission and discharge medication reconciliation, medication cost assessment, medication counseling, bedside delivery of discharge medications, and post‐discharge phone calls) for patients discharged from the heart failure service. The primary outcome was the completion rate of transitions of care services. Secondary outcomes included the medication intervention rate and types of interventions made, medication classes assessed for cost, discharge medication prescription captured, and 30‐day all‐cause readmissions.ResultsFive hundred and ninety‐five patients were eligible for the transitions of care program. Admission and discharge medication reconciliations were completed in 68.1% and 92.1% of patients, respectively. Medication cost assessments were completed for 39.8% of patients. Heart failure medication counseling prior to discharge was completed for 83.9% of patients. Discharge prescription capture rate was 56.5% and bedside prescription delivery was provided for 27.8% of patients. The discharge medication reconciliation intervention rate was 37.4%, with the most common intervention being dose adjustment. Post‐discharge outreach was conducted for 229 patients, with education provided for 69.4% and an intervention rate of 43.7%. The 30‐day all‐cause readmission rate was lower for patients on the heart failure service compared with the institution (10.1% vs 16.5%).ConclusionHigh rates of completion and utilization were identified after the implementation of a comprehensive pharmacy transitions of care program. Utilization of clinical pharmacists and pharmacy technicians during transitions of care improved medication access, patient education, and reduced medication‐related problems.

Effectiveness of pharmacist-led medication reconciliation on medication errors at hospital discharge and healthcare utilization in the next 30 days: a pragmatic clinical trial.

Transitions of care often lead to medication errors and unnecessary healthcare utilization. Medication reconciliation has been repeatedly shown to reduce this risk. However, the great majority of evidence is limited to the provision of medication reconciliation within clinical trials and countries with well-established clinical pharmacy. Thus, this pragmatic, prospective, controlled trial evaluated the effectiveness of routine pharmacist-led medication reconciliation compared to standard care on medication errors and unplanned healthcare utilization in adult general medical patients hospitalized in a teaching hospital in Slovenia. All patients hospitalized in a ward where medication reconciliation was integrated into routine clinical practice were included in the intervention group and received admission and discharge medication reconciliation, coupled with patient counselling. The control group consisted of randomly selected patients from the remaining medical wards. The primary study outcome was unplanned healthcare utilization within 30 days of discharge, and the secondary outcomes were clinically important medication errors at hospital discharge and serious unplanned healthcare utilization within 30 days of discharge. Overall, 414 patients (53.4% male, median 71 years) were included-225 in the intervention group and 189 in the control group. In the intervention group, the number of patients with clinically important medication errors at discharge was significantly lower (intervention vs control group: 9.3% vs 61.9%). Multiple logistic regression revealed that medication reconciliation reduced the likelihood of a clinically important medication error by 20-fold, while a higher number of medications on admission was associated with an increased likelihood. However, no significant differences were noted in any and serious unplanned healthcare utilization (intervention vs control group: 33.9% vs 27.8% and 20.3% vs 14.6%, respectively). The likelihood of serious healthcare utilization increased with the age of the patient, the number of medications on admission and being hospitalized for an acute medical condition. Our pragmatic trial confirmed that medication reconciliation, even when performed as part of routine clinical practice, led to a substantial reduction in the risk of clinically important medication errors at hospital discharge but not to a reduction in healthcare utilization. Medication reconciliation is a fundamental, albeit not sufficient, element to ensure patient safety after hospital discharge. Clinical Trial Registration: https://clinicaltrials.gov/search?id=NCT06207500, identifier NCT06207500.

Admission Medication Reconciliation Discrepancies in Trauma Patients: Consistent Nursing Care May Not Be the Answer.

Inadvertent medication reconciliation discrepancies are common among trauma patient populations. We conducted a prospective study at a level 1 trauma center to assess incidence of inadvertent medication reconciliation discrepancies following decreased reliance on short-term nursing staff. Patients and independent sources were interviewed for home medication lists and compared to admission medication reconciliation (AMR) lists. Of the 108 patients included, 37 patients (34%) never received an AMR. Of the 71 patients that had a completed AMR, 42 patients (59%) had one or more errors, with total 154 errors across all patients, for a rate of 3.7 per patient with any discrepancy. Patients taking ≥ 5 medications were significantly more likely to have an incomplete or inaccurate AMR than those taking <5 medications (89% vs 41%, P < .0001). Decreased reliance on short-term nursing staff did not decrease inadvertent admission medication reconciliation discrepancies. Additional interventions to decrease risk of medication administration errors are needed.

Guidance on using Medicaid web portals and other electronic prescriptions claims data to improve admission medication reconciliation in critical access hospitals.

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Improving Equity and Accuracy in Admission Medication Reconciliation.

Improving Equity and Accuracy in Admission Medication Reconciliation.

Defining quality indicators, pharmaceutical care bundles and outcomes of clinical pharmacy service delivery using a Delphi consensus approach.

Clinical pharmacy quality indicators are often non-uniform and measure individual activities not linked to outcomes. To define a consensus agreed pharmaceutical care bundle and patient outcome measures across an entire state health service. A four-round modified-Delphi approach with state Directors of Pharmacy was performed (n = 25). They were asked to rate on a 5-point Likert scale the relevance and measurability of 32 inpatient clinical pharmacy quality indicators and outcome measures. They also ranked clinical pharmacy activities in order from perceived most to least beneficial. Based upon these results, pharmaceutical care bundles consisting of multiple clinical pharmacy activities were formed, and relevance and measurability assessed. Response rate ranged from 40 to 60%. Twenty-six individual clinical pharmacy quality indicators reached consensus. The top ranked clinical pharmacy quality indicator was 'proportion of patients where a pharmacist documents an accurate list of medicines during admission'. There were nine pharmaceutical care bundles formed consisting between 3 and 7 activities. Only one pharmaceutical care bundle reached consensus: medication history, adverse drug reaction/allergy documentation, admission and discharge medication reconciliation, medication review, provision of medicines education and provision of a medication list on discharge. Sixteen outcome measures reached consensus. The top ranked were hospital acquired complications, readmission due to medication misadventure and unplanned readmission within 10 days. Consensus has been reached on one pharmaceutical care bundle and sixteen outcomes to monitor clinical pharmacy service delivery. The next step is to measure the extent of pharmaceutical care bundle delivery and the link to patient outcomes.

Impact of pharmacist-led admission medication reconciliation on patient outcomes in a large health system

Objective Performing accurate medication history and reconciliation is recognized to reduce medication discrepancies and errors resulting in improved patient safety. This quality improvement project retrospectively evaluated the impact of a newly implemented pharmacy-led admission medication reconciliation program for several hospitals. Methods In 2020, a pharmacy-led admission medication reconciliation program was implemented in 16 hospitals across a large health system. The program targeted high-risk, complex inpatients admitted through the emergency department and directly to the hospital. Medication history technicians captured the best possible medication list and medication reconciliation pharmacists reviewed the list, collaborating with providers to complete reconciliation, and intervening to optimize drug therapy. A retrospective, pre-post analysis was performed comparing the preimplementation time period of June to November 2019 to the postimplementation time period of June to November 2020. Outcomes evaluated included pharmacy staff productivity, adverse drug events (ADEs), complications, and healthcare professional satisfaction. Results A total of 311,473 patients were admitted to the 16 hospitals during the pre- and postimplementation time periods. During the six-month postimplementation period, nearly 80,000 medication histories and reconciliations were completed, with 39.9% of those histories requiring medication clarification. Both the ADE rate and complication rate decreased significantly after program implementation, 12% decrease ( p &lt; 0.017) and 14% decrease ( p &lt; 0.001), respectively. Healthcare professional survey results from nurse, physician, and pharmacist respondents indicated a statistically significant improvement in satisfaction. Conclusion After implementation of pharmacy-led admission medication reconciliation, patient ADEs and complications decreased during hospitalization, and physician, nurse, and pharmacist satisfaction significantly improved.

Clinical Pharmacist Transition of Care Model Improves Hospital System Practice by Reducing Readmissions.

A primary cause of hospital readmission is medication-related problems (MRPs). Polypharmacy patients taking multiple medications concurrently experience an increased likelihood of MRPs and high occurrence of readmissions to the hospital within 30 days. This study assessed the ability of a pharmacist-led transition of care program to decrease readmissions in polypharmacy patients by evaluating and rectifying MRPs. Over 16 months, patients admitted onto the medicine ward service with ≥10 home medications ( n = 536) received medication management interventions from a clinical pharmacist including admission interview, medication reconciliation and consultation, and postdischarge phone follow-up. Admitted patients taking fewer than 10 home medications during the same time served as the control group and received routine standard of care ( n = 2317). The polypharmacy group who received the pharmacist-led intervention had a statistically significantly lower 30-day readmission rate (8.8%) compared with patients in the control group (12.4%; X 2 = 5.63, p = .01). Patients receiving pharmacist intervention were 33% less likely to be readmitted within 30 days of discharge compared with the control group (odds ratio = 0.67, 95% CI = 0.49-0.94). All patients had at least one medication-related discrepancy. This pharmacy-led transition of care program can effectively reduce readmission rates through resolution of medication-related problems.

What guidelines?: Attitudes and behaviors for prescribing prophylactic hepatic encephalopathy medications.

What guidelines?: Attitudes and behaviors for prescribing prophylactic hepatic encephalopathy medications.

Effect of a Pharmacist-Led Discharge Counseling Service at a Children's Hospital.

To evaluate the effect of a pharmacist-led discharge counseling service at a pediatric hospital. This was a prospective observational cohort study. Patients in the pre-implementation phase were identified by the pharmacist at the time of admission medication reconciliation, whereas patients in the pos-timplementation phase were identified at the time of pharmacist discharge medication counselling. Caregivers were contacted within 2 weeks of the patients' discharge date to complete a 7-question telephone survey. The primary objective was to measure the effect of the pharmacist-led service on caregiver satisfaction, using a pre- and post- implementation telephone survey. The secondary objectives were to evaluate the effect of the service on 90-day medication-related readmissions and determine the change in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey response (Question 25) regarding discharge medications following implementation of the new service. A total of 32 caregivers were included in both the pre- and post-implementation groups. The most common reason for inclusion was high-risk medications (84%) in the pre-implementation group and device teaching (62.5%) in the post-implementation group. The primary outcome, the average composite score on the telephone survey, was 30.94 ± 3.50 (average ± SD) in the pre-implementation group and 32.5 ± 2.26 in the post-implementation group (p = 0.038). There were no medication-related readmissions within 90 days in either group. The score on HCAHPS Question 25 was not different between groups (p = 0.761). Implementation of a pharmacist-led discharge counseling service in pediatric patients improved caregiver satisfaction and understanding as shown by a postdischarge telephone survey.

What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study

BackgroundThe 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...

Aortic thrombus with contraceptive vaginal ring use

AbstractBackgroundCombination hormonal contraceptives are widely used and are available in various dosage forms. Thromboembolism is an established risk factor associated with the use of these agents, with increased rates of arterial thrombosis and venous thromboembolism reported. Arterial thromboembolism occurs much less frequently and is associated with more serious short‐term and long‐term consequences.AimWe report a case of aortic thrombus occurring secondary to NuvaRing use with concomitant smoking. There are no other reports of aortic thrombus resulting from contraceptive vaginal ring (CVR) use reported in the literature.Clinical DetailsThis case describes a 35‐year‐old female patient with disabling claudication, severe aortoiliac stenosis, and end organ damage resulting from a nearly occlusive aortic thrombus with no identifiable source of emboli. The patient's past medical history was significant for tachycardia and tobacco use disorder. Her scheduled medicines most notably included NuvaRing for contraception. Oral anticoagulation was initiated, and the patient agreed to pursue tobacco cessation. Haematology consultation and workup was negative. Months later, an open infrarenal abdominal aorta thromboendarterectomy and bovine patch angioplasty were completed. The clinical pharmacist conducting intensive care unit admission medication reconciliation postoperatively identified continued NuvaRing use, in addition to smoking. NuvaRing was promptly discontinued. Repeat hypercoagulable workup has remained negative.OutcomeFollowing NuvaRing and smoking cessation, no thrombotic symptoms have recurred.ConclusionNuvaRing should be considered as potential aetiology for venous and arterial thromboembolism.

Effect of the population health inpatient Medicare Advantage pharmacist intervention on hospital readmissions: A quasi-experimental controlled study

BACKGROUND: The population health inpatient Medicare Advantage pharmacist (PHIMAP) intervention is a pharmacist-led, transitions-of-care intervention that aims to reduce hospital readmissions among Medicare Advantage beneficiaries. PHIMAP includes inpatient pharmacist participation in interdisciplinary rounds, admission and discharge medication reconciliation, pharmacy staff delivery of discharge medications to the bedside, personalized discharge medication lists and counseling, and communication with outpatient pharmacists through an electronic health record. OBJECTIVE: To evaluate the effect of the PHIMAP intervention on unplanned 30-day same-hospital readmissions among Medicare Advantage patients. METHODS: Those included were patients admitted to a large urban academic medical center between May 2018 and March 2020 who had a Medicare Advantage plan and were aged at least 18 years. A 2-group, quasi-experimental design was utilized. Control patients received the usual care, which included a best possible medication history and a postdischarge phone call. A multivariable logistic regression model was estimated to predict unplanned 30-day same-hospital readmissions. This study was a Hypothesis Evaluating Treatment Effectiveness study. RESULTS: In total, 884 patients were included. The majority were White (59.0%), non-Hispanic (87.7%), English speaking (90.5%), and older adults (median age, 75 years; interquartile range, 70-83 years). We detected no statistically significant association between the PHIMAP intervention and unplanned 30-day same-hospital readmissions (odds ratio [OR] = 0.91, 95% CI = 0.56-1.52). After adjusting for patient demographics and clinical covariates, significant predictors of 30-day readmissions included the number of emergency department/inpatient visits within 180 days prior to index admission (OR = 1.40, 95% CI = 1.11-1.77); discharge to a post-acute care facility, such as an inpatient rehabilitation facility, long-term acute care facility, or skilled nursing facility (OR = 1.69, 95% CI = 1.06-2.66); hospital length of stay in days (OR = 1.04, 95% CI=1.01-1.07); and the Agency for Healthcare Research and Quality Elixhauser Comorbidity Index score (OR = 1.01, 95% CI = 1.01-1.02). CONCLUSIONS: Significant predictors of readmissions among Medicare Advantage beneficiaries were consistent with greater illness severity, including a recent history of prior hospital utilization, a discharge to post-acute care facility (vs home), a longer length of hospital stay, and a higher comorbidity burden. Although we detected no statistically significant association between PHIMAP and unplanned 30-day same-hospital readmissions, differences in study group assignment based on the day of hospital discharge (weekend vs weekday) was a noted limitation of this study. Future studies of inpatient pharmacist-led interventions should plan to minimize the risk of selection bias due to differences in the time of patient discharge. DISCLOSURES: This study was supported in part by the National Institute on Aging under award number R01AG058911 (to Pevnick) and the UCLA Clinical Translational Science Institute (UL1 TR001881). The sponsor had no role in the design and conduct of the study, nor the writing of this report.

Incidence and Severity of Medication Reconciliation Discrepancies in Trauma Patients.

Trauma patients are especially vulnerable to inadvertent medication reconciliation discrepancies. We conducted a prospective study to evaluate the USA Health University Hospital's incidence and type of inadvertent medication reconciliation discrepancies among trauma patients. Patients were interviewed for accuracy of their admission medication reconciliation (AMR). Eighty-nine patients were included in this study. Twenty-six patients (29%) never received an AMR. There were 107 inadvertent medication reconciliation errors identified from 30 separate patients (48%), for a rate of 3.6 errors per patient with any error. There was a significant difference in the frequency of inadvertent medication reconciliation discrepancies for patients with >5 medication compared to those with fewer (P = .00029). In conclusion, trauma centers must be adequately staffed to provide timely, accurate, and available medication lists so that patients can be appropriately cared for.

Use of complete medication history to identify and correct transitions-of-care medication errors at psychiatric hospital admission.

Methods for categorizing the scale and severity of medication errors corrected by pharmacy staff during admission medication reconciliation using complete medication history continue to evolve. We established a rating scale that is effective for generating error reports to health system quality leadership. These reports are needed to quantify the value of investment in transitions-of-care pharmacy staff. All medication errors that were reported by pharmacy staff in the admission medication reconciliation process during a period of 6 months were eligible for inclusion. Complete medication history data source was utilized by admitting providers and all pharmacist staff and a novel medication error scoring methodology was developed. This methodology included: medication error category, medication error type, potential medication error severity, and medication non-adherence. We determined that 82 medication errors were detected from 72 patients and assessed that 74 of these errors may have harmed patients if they were not corrected through pharmacist intervention. Most of these errors were dosage discrepancies and omissions. With hospital system budgets continually becoming leaner, it is important to measure the effectiveness and value of staff resources to optimize patient care. Pharmacists performing admission medication reconciliation can detect subtle medication discrepancies that may be overlooked by other clinician types. This methodology can serve as a foundation for error reporting and predicting the severity of adverse drug events.

Effect of a Pharmacist Admission Medication Reconciliation Service at a Children's Hospital.

To evaluate the clinical effect and estimate cost avoidance attributed to a pharmacist-led admission medication reconciliation service at a children's hospital. This was a prospective observational cohort study that measured pharmacist interventions for pediatric patients over a 90-day period. Pharmacists logged all interventions identified during medication reconciliation in real time. Patient demographic data were collected retrospectively. Cost avoidance from prevented adverse drug events (ADEs) was estimated based on previously published literature. Pharmacists completed 283 admission medication reconciliations during the study period. Of those, 69% of medication reconciliations required intervention. Interventions affected care during the hospital admission in 21.9% of patients and 8 medication reconciliations resulted in prevention of a major ADE. This pharmacist-led service resulted in an estimated cost avoidance of $46,746.65 in the 3-month period. Implementation of a pharmacist-led admission medication reconciliation service for pediatric patients improved medication safety and resulted in significant cost avoidance, which justifies investment in these pharmacist resources.

Evaluation of Pharmacy Resident-Driven Medication Reconciliation on Patients at High Risk of Hospital Readmission.

Purpose: Pharmacists play a key role in preventing medication errors during transitions of care and preventing hospital readmissions through medication reconciliation (MR) programs. This study retrospectively evaluated the implementation of a standardized pharmacy residentdriven MR program for patients at high risk for readmission as defined by the Hospital Readmissions Reduction Program (HRRP). Methods: This was a single-center, retrospective cross sectional study of a pharmacy resident-driven MR program including patients at high risk of readmission defined by HRRP. The primary objective was to determine the number of inpatient regimen interventions identified during the MR. Secondary objectives include severity of interventions, number of medication discrepancies identified, types of interventions and discrepancies identified, and all-cause hospital readmission rates within 30 days of discharge.. Results: Fifty-three high-risk patients were included in the study. Pharmacy intervention recommendations were accepted by prescribers for nine patients (9/53; 17.0%) with a total of 13 accepted inpatient regimen interventions. The two most commonly identified medication classes for interventions were anticonvulsants (3/13; 23.1%) and antidepressants (6/13; 46.2%). Discrepancies on the admission MR were identified for 46 (46/53; 86.8%) patients with a median of three discrepancies per patient (interquartile range 2-4). The most common type of discrepancy was an incorrect or unnecessary drug. The 30-day all-cause readmission rate was 35.8% (19/53) for the total patient Conclusion: A pharmacy-resident driven MR program provided value in clarifying prior to admission medications and may help prevent drugrelated adverse events.

Melatonin Versus Trazodone for the Treatment of New Onset Insomnia in Hospitalized Adult Patients.

Background: New-onset insomnia and other sleep disturbances occur more frequently in the inpatient setting due to a variety of physical and psychological factors. Studies have found that non-pharmacologic interventions can be effective in treating insomnia in the inpatient setting, particularly in the ICU, to prevent adverse outcomes, but further research is needed to identify optimal pharmacologic interventions. Objective: To compare treatment outcomes of patients initiated on melatonin and trazodone to treat new-onset insomnia in non-ICU hospitalized patients based on the need for an additional sleep aid therapy during hospitalization and to compare the rate of adverse events of each agent. Methods: A retrospective chart review was conducted for adult patients admitted to a non-ICU general medicine or surgical floor at a community teaching hospital between July 1, 2020 and June 30, 2021. Patients were included if they were initiated on scheduled melatonin or trazodone for the treatment of new onset insomnia during their hospitalization. Patients were excluded if they had a previous diagnosis of insomnia, were prescribed 2 sleep aids simultaneously, or if their admission medication reconciliation included pharmacologic treatment for insomnia. Clinical data collected included non-pharmacologic interventions, sleep aid dose, number of doses of sleep aid administered, and total number of nights an additional sleep aid was needed. The primary outcome was the percentage of patients needing additional therapy defined as, administering an additional sleep aid between 2100-0600 or utilizing more than 1 sleep aid agent during hospitalization compared between melatonin and trazodone. Secondary outcomes of this study included the rate of adverse events such as difficulty awakening, daytime sleepiness, serotonin syndrome, falls, and development of in hospital delirium. Results: Of 158 included patients, 132 received melatonin and 26 received trazodone. Male sex (53.8% [melatonin] vs. 53.8% [trazodone]; P = 1), hospital length of stay (7.7 vs 7.7 days; P = .68), and administration of drugs that could cause insomnia (34.1% vs 23.1%vs; P = .27) were similar between sleep aids. Percentage of patients needing an additional sleep aid during hospitalization (19.7% vs 34.6%; P = .09), and patients prescribed a sleep aid at discharge (39.4% vs 46.2%; P = .52) were similar between sleep aids, respectively. Rates of adverse events were similar between sleep aids. Conclusions: There was no significant difference between the 2 agents in terms of the primary outcome, even though a higher rate of patients treated with trazodone for new-onset insomnia during hospitalization required an additional sleep aid compared to those treated with melatonin. No difference in adverse events was observed.

Hospital admission medication reconciliation in high-risk prescription opioid users

No studies have assessed the clinical significance of medication reconciliation in surgical patients using high-risk extended-release/long-acting (ER/LA) opioid medications.We assessed differences in the perioperative use of opioid analgesics in patients who underwent medication reconciliation upon hospital admission compared to patients who did not and identified predictors of perioperative use of opioids.Retrospective observational quasi-experimental study including adult non-cancer patients who underwent elective surgery at UCSF Medical Center in the period January 2017 through December 2019 and received at least one opioid analgesic during surgical hospitalization. The primary study outcome was perioperative use of opioids measured in daily oral morphine equivalents (OME). Secondary outcomes were predictors of perioperative use of opioids after adjusting for baseline differences between groups.We identified 402 patients. Of them, 59.5% were female. The mean patient age was 58.5 years. Most patients underwent neurological or orthopedic surgery (each 40.8%). Over 94.3% of our patients underwent medication reconciliation upon hospital admission, with 78.4% completed by a pharmacy staff. Medication reconciliation evidenced that 5.5% patients were not taking the ER/LA opioids on their medication history list. Inactive ER/LA opioids were discontinued during hospitalization. None of the patients with inactive ER/LA opioids had those opioids restarted at hospital discharge. In addition, patients (26.9%) were successfully converted from ER/LA to SA opioids. After adjusting for patients' demographic and clinical characteristics, surgical procedure type and post-operative pain, opioid formulation conversion was the main predictor of perioperative use of opioids per hospitalization day. Switching patients from ER/LA to SA opioids reduced the mean daily use of OME by 66.03 units (p < 0.02) without adversely impacting postoperative pain.Medication reconciliation upon hospital admission reduced unnecessary exposure to opioids in hospitalized surgical patients.

OP0169 INPATIENT DISCONTINUATION OF ALLOPURINOL – A QUALITATIVE IMPROVEMENT (QI) INITIATIVE

BackgroundGout is a chronic inflammatory arthritis induced by hyperuricemia and manifested by recurrent acute flares of debilitating joint pain, when left untreated. Allopurinol is often used as long-term urate lowering therapy. Discontinuation of allopurinol leads to worsening flares, disability, poor quality of life, and frequent use of acute care facilities. Recent data revealed that 56% of hospitalized patients had allopurinol discontinued during an episode of acute gout flare, suggesting an unmet need for ongoing provider education (1). Gout flares are 14 times more likely to develop in patients who have allopurinol discontinued upon admission to the hospital (2).ObjectivesWe performed a qualitative analysis of the current rate of discontinuation of allopurinol during hospitalizations at an academic hospital in order to develop a continuous improvement model.MethodsWe leveraged our electronic health records (EHR) to obtain data on gout patients admitted to the university hospital from 2019-2020, with IRB approval. Patients on allopurinol as an active home medication that was discontinued during hospitalization and/or after hospital discharge were included to calculate the rate of discontinuation. Lean thinking methodology with A3 process mapping for root cause analysis (RCA) was utilized. We first identified stakeholders involved in medication reconciliation – nurses and various providers, including trainees, and invited them to participate in an anonymous survey to understand the rationale behind allopurinol discontinuation during hospitalization. Next, we created countermeasures and actionable recommendations that could be implemented at an institutional level.ResultsA total of 2138 patients who were hospitalized had allopurinol listed as an active home medication. Of these, 364 (17%) did not receive allopurinol during hospitalization. Based on the survey data, providers chose to discontinue allopurinol due to the following factors – acute gout flare, renal impairment, gastrointestinal issues, cytopenia, drug interactions, NPO status, and always discontinued the medication. The RCA revealed layers of reasoning at various levels of the medication reconciliation process which impacted the decision-making algorithm. This in turn led to discontinuation during the admission and subsequent omission of allopurinol on the discharge medication list. Several actionable and high-impact recommendations emerged as countermeasures, including – a) pharmacy involvement at admission medication reconciliation, b) creation of a clinical practice guideline, and c) automated routing by EHR to standardized guidelines when allopurinol was discontinued on admission (Figure 1).Figure 1.Countermeasures and Implementation PlanConclusionThere is evidence of inappropriate discontinuation of allopurinol that leads to gout flares in the outpatient setting and unnecessary resource utilization. We developed an implementation plan to mitigate this systematically at an institutional level. Testing these recommendations next to devise a standardized protocol as a continuous improvement strategy may help improve gout care and patient outcomes.