Best Possible Medication History Research Articles

The effect of an extended-hours ED clinical pharmacy service on admission medication prescribing errors.

The aim of this study was to determine the effect of a 7-day extended-hours clinical pharmacy service in the ED on medication prescribing errors upon hospital admission and time to medication reconciliation. In this retrospective observational study, high-needs patients reviewed by ED pharmacists were compared against those not reviewed, to determine if the service was associated with reduction in admission medication errors. The primary outcome was the rate of medication errors. Errors were independently rated by two senior clinicians using a risk-probability matrix. Secondary outcomes included service's impact on time to best possible medication history (BPMH) and medication reconciliation. There were 242 patients who met the inclusion criteria: 105 intervention vs 137 control. In the intervention arm, 74 patients had at least 1 medication error compared with 113 in the control arm (total errors 206 vs 407). The error rate per 10 medications (interquartile range) was 1.4 (0, 2.9) in the intervention arm compared with 2.7 (1.2, 4.3) in the control arm (risk ratio 0.66 [95% confidence interval: 0.56-0.78]; P < 0.001). There were 33 moderate-risk and no high-risk errors (intervention), compared with 84 moderate-risk and 3 high-risk errors (control). Percent agreement was 98.98% (weighted kappa: 0.62). Time to BPMH and medication reconciliation were reduced from 40.5 and 45.0 h to 7.8 and 40.0 h, respectively. The 7-day extended-hours ED clinical pharmacy service was associated with a reduction in medication prescribing errors in high-needs patients and improved time to BPMH and medication reconciliation.

Redesigning Medication Management in the Emergency Department: The Impact of Partnered Pharmacist Medication Charting on the Time to Administer Pre-Admission Time-Critical Medicines, Medication Order Completeness, and Venous Thromboembolism Risk Assessment.

In order to enhance interdisciplinary collaboration and promote better medication management, a partnered pharmacist medication charting (PPMC) model was piloted in the emergency department (ED) of an Australian referral hospital. The primary objective of this study was to evaluate the impact of PPMC on the timeliness of time-critical medicines (TCMs), completeness of medication orders, and assessment of venous thromboembolism (VTE) risk. This concurrent controlled retrospective pragmatic trial involved individuals aged 18 years and older presenting to the ED from 1 June 2020 to 17 May 2021. The study compared the PPMC approach (PPMC group) with traditional medical officer-led medication charting approaches in the ED, either an early best-possible medication history (BPMH) group or the usual care group. In the PPMC group, a BPMH was documented promptly soon after arrival in the ED, subsequent to which a collaborative discussion, co-planning, and co-charting of medications were undertaken by both a PPMC-credentialled pharmacist and a medical officer. In the early BPMH group, the BPMH was initially obtained in the ED before proceeding with the traditional approach of medication charting. Conversely, in the usual care group, the BPMH was obtained in the inpatient ward subsequent to the traditional approach of medication charting. Three outcome measures were assessed -the duration from ED presentation to the TCM's first dose administration (e.g., anti-Parkinson's drugs, hypoglycaemics and anti-coagulants), the completeness of medication orders, and the conduct of VTE risk assessments. The analysis included 321 TCMs, with 107 per group, and 1048 patients, with 230, 230, and 588 in the PPMC, early BPMH, and usual care groups, respectively. In the PPMC group, the median time from ED presentation to the TCM's first dose administration was 8.8 h (interquartile range: 6.3 to 16.3), compared to 17.5 h (interquartile range: 7.8 to 22.9) in the early BPMH group and 15.1 h (interquartile range: 8.2 to 21.1) in the usual care group (p < 0.001). Additionally, PPMC was associated with a higher proportion of patients having complete medication orders and receiving VTE risk assessments in the ED (both p < 0.001). The implementation of the PPMC model not only expedited the administration of TCMs but also improved the completeness of medication orders and the conduct of VTE risk assessments in the ED.

Medication discrepancies across care transitions and the role of pharmacy technicians: A retrospective chart review

BackgroundAfter hospitalization, older adults are increasingly discharged to postacute care facilities such as skilled nursing facilities (SNFs). Medication reconciliation and obtaining the best possible medication history (BPMH) are key components of medication management for care transitions and essential for preventing medication errors and adverse drug events. ObjectiveThis study aimed to assess medication discrepancies across care transitions after a Certified Pharmacy Technician (CPhT) obtains the BPMH on hospital admission. MethodsSingle-center, retrospective chart review and included adults ≥ 18 years admitted to the medicine service and discharged to a SNF between November 2016 and June 2017. Medication lists were evaluated for discrepancies across 3 transitions: hospital admission to hospital discharge (Time I), hospital discharge to SNF admission (Time II), and SNF admission to SNF discharge (Time III). Discrepancies were categorized by medication class, type of discrepancy, and whether it was potentially intentional or unintentional. ResultsIn 127 patients, the average age was 83.3 (SD 9.16), 61% (n = 77) were female, and 67% (n = 85) were white. Median hospital length of stay (LOS) was 6 days (interquartile range [IQR] 4-10) and SNF LOS 21 days (IQR 15-30). Across 381 transitions, 6322 medications were reviewed, and 2602 discrepancies identified. The total number of medication discrepancies was 1034 (Time I), 687 (Time II), and 881 (Time III), respectively. All patients had at least one medication discrepancy. The average number of potentially unintentional discrepancies per patient at each transition was 0.14, 0.2, and 0.16, respectively. The most common discrepancy type was omissions (39%), and the highest number of discrepancies in the potentially intentional and unintentional discrepancy groups was gastrointestinal (21%) and cardiovascular medications (24%), respectively. ConclusionMedication discrepancies are common across all care transitions. Future studies are needed to evaluate the role of CPhT in obtaining the BPMH on hospital admission for reducing medication discrepancies across the continuum of care.

Parkinson’s disease medications in hospital: A retrospective audit of prescribing and administration errors

Background: Managing Parkinson’s disease (PD) medications in the acute hospital setting is complex. Mismanagement of PD medications such as inaccurate medication administration time and prescribing errors is common which can lead to the worsening of PD symptoms. Aim and Objectives: The aim of the study was to identify the extent of PD medication prescribing and administration errors in adult inpatients and pharmacists’ impact across a Victorian metropolitan hospital. Materials and Methods: A retrospective review analyzed a sample of 30 patients admitted between January and April 2022. PD medication orders (PDMO) and medication administration records (MAR) were reviewed; charting errors were identified based on reconciliation of PDMO with the pharmacist-led best-possible medication history (p-BPMH). Administration errors were identified through a review of MAR and PDMO charted time or p-BPMH documented administration time for each PD medication. Results: A total of 60 PDMO and 469 administration instances were reviewed. About 83.3% (50) of PDMOs had at least one instance of delay or omission in administration. 45.0% (27) of PDMO charting errors led to delays or omissions in administration. The timing of administration was the most common charting error accounting for 18.3% (11) of PDMOs. Documentation of p-BPMH within 24 h of admission led to a reduction of charting errors (52.9% vs. 76.9%, respectively). PD medications that were administered on time compared to p-BPMH documented time and PDMO charted time were 48.6% (228/469) and 53.7% (252/469), respectively. Conclusion: This study identified a high degree of PDMO charting and administration errors for patients with PD. Strategies to improve PD medication management are warranted.

Clinical and economic impact of partnered pharmacist medication charting in the emergency department.

Introduction: Partnered pharmacist medication charting (PPMC), a process redesign hypothesised to improve medication safety and interdisciplinary collaboration, was trialed in a tertiary hospital's emergency department (ED). Objective: To evaluate the health-related impact and economic benefit of PPMC. Methods: A pragmatic, controlled study compared PPMC to usual care in the ED. PPMC included a pharmacist-documented best-possible medication history (BPMH), followed by a clinical conversation between a pharmacist and a medical officer to jointly develop a treatment plan and chart medications. Usual care included medical officer-led traditional medication charting in the ED, without a pharmacist-obtained BPMH or clinical conversation. Outcome measures, assessed after propensity score matching, were length of hospital or ED stay, relative stay index (RSI), in-hospital mortality, 30-day hospital readmissions or ED revisits, and cost. Results: A total of 309 matched pairs were analysed. The median RSI was reduced by 15.4% with PPMC (p = 0.029). There were no significant differences between the groups in the median length of ED stay (8 vs. 10h, p = 0.52), in-hospital mortality (1.3% vs. 1.3%, p > 0.99), 30-day readmission rates (21% vs. 17%; p = 0.35) and 30-day ED revisit rates (21% vs. 19%; p = 0.68). The hospital spent approximately $138.4 for the cost of PPMC care per patient to avert at least one medication error bearing high/extreme risk. PPMC saved approximately $1269 on the average cost of each admission. Conclusion: Implementing the ED-based PPMC model was associated with a significantly reduced RSI and admission costs, but did not affect clinical outcomes, noting that there was an additional focus on medication reconciliation in the usual care group relative to current practice at our study site.

The impact of partnered pharmacist medication charting in the emergency department on the use of potentially inappropriate medications in older people.

Introduction: A process redesign, partnered pharmacist medication charting (PPMC), was recently piloted in the emergency department (ED) of a tertiary hospital. The PPMC model was intended to improve medication safety and interdisciplinary collaboration by having pharmacists work closely with medical officers to review and chart medications for patients. This study, therefore, aimed to evaluate the impact of PPMC on potentially inappropriate medication (PIM) use. Methods: A pragmatic concurrent controlled study compared a PPMC group to both early best-possible medication history (BPMH) and usual care groups. In the PPMC group, pharmacists initially documented the BPMH and collaborated with medical officers to co-develop treatment plans and chart medications in ED. The early BPMH group included early BPMH documentation by pharmacists, followed by traditional medication charting by medical officers in ED. The usual care group followed the traditional charting approach by medical officers, without a pharmacist-collected BPMH or collaborative discussion in ED. Included were older people (≥65 years) presenting to the ED with at least one regular medication with subsequent admission to an acute medical unit. PIM outcomes (use of at least one PIM, PIMs per patient and PIMs per medication prescribed) were assessed at ED presentation, ED departure and hospital discharge using Beers criteria. Results: Use of at least one PIM on ED departure was significantly lower for the PPMC group than for the comparison groups (χ2, p = 0.040). However, PIM outcomes at hospital discharge were not statistically different between groups. PIM outcomes on ED departure or hospital discharge did not differ from baseline within the comparison groups. Discussion: In conclusion, PIM use on leaving ED, but not at hospital discharge, was reduced with PPMC. Close interprofessional collaboration, as in ED, needs to continue on the wards.

Best Possible Medication History Collection by Clinical Pharmacist in a Preoperative Setting: An Observational Prospective Study.

A Best Possible Medication History (BPMH) collected by clinical pharmacists is crucial for effective medication review, but, in Italy, it is often left to the nursing staff. This study aims to compare the quality and accuracy of a clinical pharmacist-documented BPMH with the current standard practice of ward staff-collected BPMH in an Italian preoperative surgical setting. A 20-week prospective observational non-profit study was conducted in a major university hospital. The study comprised three phases: a feasibility, an observational, and an interventional phase. During the feasibility phase, 10 items for obtaining a correct BPMH were identified. The control group consisted of retrospectively analyzed BPMHs collected by the ward staff during the observational phase, while interventions included BPMHs collected by the clinical pharmacist during the third phase. Omissions between the two groups were compared. 14 (2.0%) omissions were found in the intervention group, compared with 400 (57.4%) found in the controls (p < 0.05); data collection was more complete when collected by pharmacists compared to the current modality (98.0% of completed information for the intervention versus 42.6%; p < 0.05). The involvement of a pharmacist significantly reduced the number of omissions in preoperative surgical-collected BPMHs. This intervention holds the potential to decrease the risk of medication errors associated with inaccurate or incomplete BPMHs prior to surgical hospitalization.

Accuracy of medication labels on community pharmacy-prepared dose administration aids: An observational study

BackgroundHospital prescribers often use the labels on multicompartment compliance aids or monitored dosage systems, known in Australia as dose administration aids (DAAs), as a trusted source of information about patients' medication regimens taken in the community. AimThe primary aim was to explore the prevalence and nature of labelling incidents on community pharmacy-prepared DAAs. MethodsA convenience sample of 100 adult patients admitted to a metropolitan teaching hospital who used a community pharmacy-prepared DAA at home was recruited. Patients were excluded if their DAAs were not brought to hospital. As part of usual care, a pharmacist took a best possible medication history (BPMH) using multiple information sources. This ‘gold standard’ BPMH was compared to the regimen listed on the DAA summary label and the DAA contents. The primary outcome was the percentage of patients whose DAA summary label(s) had one or more incidents for DAA packed medications. DAA label incident was defined as incorrect, missing or illegible/ambiguous medication name, strength, dose or dose-form when compared to the BPMH and DAA contents. Secondary outcomes were compliance with best-practice guidelines for labelling DAAs; and percentage of patients with a DAA packing error. ResultsThe 100 patients used 110 DAAs, packed by 75 community pharmacies. Four (4.0%) patients had no medication summary label on their DAAs. Of the 96 patients whose DAA(s) had a summary label, 82 (85.4%) had one or more summary label incidents. The most prevalent incidents were ‘illegible, ambiguous or missing medication details’, ‘truncated medication name’ and ‘omission of a medication’. The most prevalent guideline non-compliance was not including generic medication names (68% DAA-packed medications). Two DAA packing errors were identified. ConclusionA high prevalence of DAA labelling incidents was identified. Improved DAA labelling software functionality, more robust pharmacy procedures and pharmacy staff education are required.

Obtaining medication histories via telepharmacy: an observational study

BackgroundMedication reconciliation is an effective strategy to reduce medication errors upon hospital admission. The process involves obtaining a best possible medication history (BPMH), which can be both time-consuming and resource-intensive. During the COVID-19 pandemic, telepharmacy was used to reduce the risk of viral transmission. Telepharmacy is the remote provision of pharmacy-led clinical services, such as obtaining BPMHs, using telecommunications. However, the accuracy of telephone-obtained BPMHs has not yet been evaluated. Therefore, the primary aim of this study was to evaluate the proportion of patients who have an accurate BPMH from the telephone-obtained BPMH compared to an in-person obtained BPMH.MethodsThis prospective, observational study took place in a large tertiary hospital. Recruited patients or carers had their BPMH obtained by a pharmacist over the telephone. The same patients or carers then had their BPMH conducted in-person to identify any deviations between the telephone-obtained and in-person obtained BPMH. All telephone-obtained BPMHs were timed with a stopwatch. Any deviations were categorised according to their potential consequence. An accurate BPMH was defined as having no deviations. Descriptive statistics were used to report all quantitative variables. A multivariable logistic regression was conducted to identify risk factors for patients and medications for having medication deviations.ResultsIn total, 116 patients were recruited to receive both a telephone-obtained and in-person obtained BPMH. Of these, 91 patients (78%) had an accurate BPMH with no deviations. Of the 1104 medications documented across all the BPMHs, 1064 (96%) had no deviation. Of the 40 (4%) medication deviations, 38 were deemed low-risk (3%) and 2 high-risk (1%). A patient was more likely to have a deviation if they are taking more medications (aOR: 1.11; 95% CI: 1.01–1.22; p < 0.05). A medication was more likely to have a deviation if it was regular non-prescription medication (aOR: 4.82; 95% CI: 2.14–10.82; p < 0.001) or ‘when required’ non-prescription medication (aOR: 3.12; 95% CI: 1.20–8.11; p = 0.02) or a topical medication (aOR: 12.53; 95% CI: 4.34–42.17; p < 0.001).ConclusionsTelepharmacy represents a reliable and time-efficient alternative to in-person BPMHs.

Implementation of medication reconciliation in outpatient cancer care

BackgroundMedication reconciliation (MedRec) is a process where providers work with patients to document and communicate comprehensive medication information by creating a complete medication list (best possible medication history (BPMH)) then...

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...

Impact of Partnered Pharmacist Medication Charting (PPMC) on Medication Discrepancies and Errors: A Pragmatic Evaluation of an Emergency Department-Based Process Redesign.

Medication errors are more prevalent in settings with acutely ill patients and heavy workloads, such as in an emergency department (ED). A pragmatic, controlled study compared partnered pharmacist medication charting (PPMC) (pharmacist-documented best-possible medication history [BPMH] followed by clinical discussion between a pharmacist and medical officer to co-develop a treatment plan and chart medications) with early BPMH (pharmacist-documented BPMH followed by medical officer-led traditional medication charting) and usual care (traditional medication charting approach without a pharmacist-collected BPMH in ED). Medication discrepancies were undocumented differences between medication charts and medication reconciliation. An expert panel assessed the discrepancies' clinical significance, with 'unintentional' discrepancies deemed 'errors'. Fewer patients in the PPMC group had at least one error (3.5%; 95% confidence interval [CI]: 1.1% to 5.8%) than in the early BPMH (49.4%; 95% CI: 42.5% to 56.3%) and usual care group (61.4%; 95% CI: 56.3% to 66.7%). The number of patients who need to be treated with PPMC to prevent at least one high/extreme error was 4.6 (95% CI: 3.4 to 6.9) and 4.0 (95% CI: 3.1 to 5.3) compared to the early BPMH and usual care group, respectively. PPMC within ED, incorporating interdisciplinary discussion, reduced clinically significant errors compared to early BPMH or usual care.

Improving the Efficiency of Medication Reconciliation in Two Taiwanese Hospitals by Using the Taiwan National Health Insurance PharmaCloud Medication System

Medication reconciliation (MedRec) is a process to ensure complete and accurate communication of patient medication information throughout care transitions to prevent medication errors. Hospitals in Taiwan have stride to implement a universal protocol for MedRec. To establish a feasible protocol indigenously, the World Health Organization (WHO) protocol was incorporated with the Taiwan National Health Insurance (NHI) PharmaCloud patient medication profile. The efficiency and error detection capability of this modified protocol was evaluated in two hospitals. A prospective, non-randomized, unblinded, multicenter cohort study was conducted. Subjects were recruited among patients admitted for colorectal or orthopedic surgery with at least 4 or more chronic drugs. To obtain the best possible medication history (BPMH), the control group was conducted according to the WHO protocol, and the experimental group used the modified WHO protocol with the medication data from the PharmaCloud system. The time spent on the two protocols was recorded. Admission and discharge orders were reconciled against the BPMH to identify any discrepancies. Discrepancies were evaluated by appropriateness, prescribing intentions, and types of inappropriateness. The levels of potential harm were classified for inappropriate discrepancies. The mean time to obtain BPMH in the control group was 34.3±10.8 minutes and in the experimental group 27.5±11.5 minutes (P = 0.01). The experimental group had more subjects with discrepancies (87.9%) than the control (58.3%) (p < 0.001). The discrepancies in both admission and discharge orders for the experimental group (84.5 and 67.2%) were higher than those of the control (47.9 and 37.5%). Many inappropriate discrepancies were classified as the potential harm of level 2 (77.8%). Through the establishment of BPMH with the medication data from the Taiwan NHI PharmaCloud, MedRec could be achieved with greater efficiency and error detection capability in both the admission and discharge order validation processes.

165 PHARMACIST-LED MEDICINES RECONCILIATION: AN OBSERVATIONAL STUDY TO EVALUATE INFORMATION SOURCES AS A QUALITY INDICATOR OF THE SERVICE

Abstract Background Medicines Reconciliation (MR) involves obtaining a Best-Possible Medication History (BPMH) and is essential for reducing medication errors and adverse events. Recommendations on how best to undertake MR range from utilising the patient alone to using ≥2 sources (in addition to the patient). Few studies evaluate the use of &amp;gt;1 source as a measure of MR quality. Methods This observational study was undertaken in a major teaching hospital that provides a dedicated pharmacist-led MR service. Eligible patients (aged ≥65 years, admitted through the Emergency Department) were randomly recruited. MRs were compiled using 2 sources and compared to individual 1-source MRs (both in addition to patient/carer interview). Additional Medication Discrepancies (AMDs), or differences between 1-source and 2-source MR, were assessed and potential predictors analysed. Results A total of 114 patients were included. Community pharmacy was the most frequently used and most accurate source (full agreement in 97.4% of BPMHs). Two-thirds of MRs would not differ if either of the two sources were used in isolation, alongside patient/carer interview. The remaining MRs identified a total of 85 AMDs (1–6 per MR). The majority were drug omissions (49.4%). Most were deemed “low” potential clinical significance (59%). Higher patient/carer reliability was associated with lower incidence (p=0.001) and fewer AMDs (p=0.001). Conclusion Contrary to some international guidelines, using &amp;gt;1 source (in addition to patient/carer interview) does not add value to the BPMH in the majority of cases.

Pharmacotherapy Problems in Best Possible Medication History of Hospital Admission in the Elderly.

Transfer of care is a sensitive process, especially for the elderly. Polypharmacy, potentially inappropriate medications (PIMs), drug-drug interactions (DDIs), and renal risk drugs (RRDs) are important issues in the elderly. The aim of the study was to expand the use of the Best Possible Medication History (BPMH) and to evaluate polypharmacy, PIMs, DDIs, and inappropriately prescribed RRDs on hospital admission, as well as to determine their mutual relationship and association with patients’ characteristics. An observational prospective study was conducted at the Internal Medicine Clinic of Clinical Hospital Dubrava. The study included 383 elderly patients. Overall, 49.9% of patients used 5–9 prescription medications and 31.8% used 10 or more medications. EU(7)-PIMs occurred in 80.7% (n = 309) of the participants. In total, 90.6% of participants had ≥1 potential DDI. In total, 43.6% of patients were found to have estimated glomerular filtration rate < 60 mL/min/1.73 m2, of which 64.7% of patients had one or more inappropriately prescribed RRDs. The clinical pharmacist detected a high incidence of polypharmacy, PIMs, DDIs, and inappropriately prescribed RRDs on hospital admission. This study highlights the importance of early detection of pharmacotherapy problems by using the BPMH in order to prevent their circulation during a hospital stay. The positive correlations between polypharmacy, PIMs, DDIs, and inappropriately prescribed RRDs indicate that they are not independent, but rather occur simultaneously.

Drug Reconciliation Program as a Patient Safety Initiative in a Specialty Hospital in the Southeastern Region of Brazil: A Study Protocol

A common problem observed in patient safety is the lack of accurate and complete information about medications in regular use during transfers of care between different health facilities. In view of this, medication reconciliation is postulated as a barrier to reducing medication discrepancies and consequently medication errors. This project aims to evaluate the implementation of safe clinical practices conducted by clinical pharmacists. To this end, we will conduct a standardized process to obtain the best possible medication history (BPMH); assessment of the patient's level of understanding of pre-admission therapy; quantification, classification and analysis of discrepancies of unintentional drugs at hospital admission; effect of interventions conducted by clinical pharmacists and impact on patient safety. This prospective, pilot, descriptive, interventional and single-center study will be carried out in the Clinical Pharmacy Department of a large hospital in the state of São Paulo. In order to standardize the process of data collection and reconciliation of prescription drugs, the interview with the patient will be carried out using an adapted and modified form. After collecting information in the structured interview, clinical pharmacists will identify, analyze and classify possible discrepancies. All unintentional discrepancies found without any clinical justification will be considered medication errors. Finally, the degree of impact of each drug discrepancy will be defined as: clinically insignificant; clinically significant; serious and life-threatening.

Simulated Home Visit to Promote Chronic Disease Management Competencies in Prelicensure Nursing Students.

Conducting a best possible medication history (BPMH), while using effective patient communication skills, falls within the nursing scope of practice and is recommended at all care levels. Nursing students should be taught these skills before entering clinical practice, but evidence about effective teaching strategies is limited. A standardized patient-facilitated home visit simulation was utilized in a prelicensure nursing program to practice a BPMH while using effective patient communication skills. All students correctly identified medications listed on the patient history, and most identified omitted medications (90.1%), transposed medications (91.6%), and incorrect medication usage (91.6%). All students demonstrated effective patient communication skills-using open-ended questions and inquiring about medication usage. Incorporating a standardized patient-facilitated home visit BPMH simulation allows students the opportunity to practice and achieve BPMH competency essential for nurses.

Development and Delphi validation of a Best Possible Medication History form

ObjectiveTo develop and validate a standardized Best Possible Medication History (BPMH) form that could be used by clinical pharmacists.MethodsThe draft version was presented to a focus group and was adapted...

Evaluation of a Web-Based Medication Reconciliation Application Within a Primary Care Setting: Cluster-Randomized Controlled Trial.

BackgroundDespite routine review of medication lists during patient encounters, patients’ medication lists are often incomplete and not reflective of actual medication use. Contributing to this situation is the challenge of reconciling medication information from existing health records, along with external locations (eg, pharmacies, other provider/hospital records, and care facilities) and patient-reported use. Advances in the interoperability and digital collection of information provides a foundation for integration of these once disparate information sources.ObjectiveWe aim to evaluate the effectiveness of and satisfaction with an electronic health record (EHR)-integrated web-based medication reconciliation application, MedTrue (MT).MethodsWe conducted a cluster-randomized controlled trial of MT in 6 primary care clinics within an integrated health care delivery system. Our primary outcome was medication list accuracy, as determined by a pharmacist-collected best-possible medication history (BPMH). Patient and staff perspectives were evaluated through surveys and semistructured interviews.ResultsOverall, 224 patients were recruited and underwent a BPMH with the pharmacist (n=118 [52.7%] usual care [UC], n=106 [47.3%] MT). For our primary outcome of medication list accuracy, 8 (7.5%) patients in the MT arm and 9 (7.6%) in the UC arm had 0 discrepancies (odds ratio=1.01, 95% CI 0.38-2.72, P=.98). The most common discrepancy identified was patients reporting no longer taking a medication (UC mean 2.48 vs MT mean 2.58, P=.21). Patients found MT easy to use and on average would highly recommend MT (average net promoter score=8/10). Staff found MT beneficial but difficult to implement.ConclusionsThe use of a web-based application integrated into the EHR which combines EHR, patient-reported data, and pharmacy-dispensed data did not improve medication list accuracy among a population of primary care patients compared to UC but was well received by patients. Future studies should address the limitations of the current application and assess whether improved implementation strategies would impact the effectiveness of the application.

Sources of medication omissions among hospitalized older adults with polypharmacy.

Hospitalized older adults have a high prevalence of polypharmacy and medication inaccuracies. Gathering the best possible medication history (BPMH) is necessary to accurately identify each medication for multimorbid older adults. The objective was to describe a multipronged approach to obtaining the BPMH for hospitalized older adults, quantify the medication discrepancies identified through these sources, and explore factors associated with these discrepancies. Cross-sectional analysis of 372 hospitalized older adults (age ≥ 50) transitioning to post-acute care as part of a randomized controlled trial to reduce medication burden. We used four information sources to yield a BPMH. Medication discrepancies at hospital admission were categorized as omissions, additions, and dose discrepancies after comparing alternate sources with the electronic medical record (EMR). Multivariate regression analysis, including patient factors (e.g., age, prehospital medication count, number of pharmacies), was performed to identify factors associated with the total count of medication discrepancies. Ninety percent of participants had at least one medication discrepancy and 46% used more than one pharmacy. The majority of discrepancies were omissions. Among the entire cohort, there was a median of two omitted medications per patient across two alternate sources-pharmacy refill history and bedside interview. Lower age, greater total number of prehospital medications, and admission from assisted living or skilled nursing facility were significantly associated with greater medication discrepancies. A multipronged and consistent approach to obtain a BPMH during hospitalization for multimorbid older adults revealed medication discrepancies that should be addressed prior to hospital discharge to support safe prescribing practices.