Discharge Medication List Research Articles

Pharmacist-led Transitions of Care: A Cohort Study on Admission Medication History Factors and Adjustments to the Discharge Medication List.

Background:Patients are at risk of experiencing medication errors during each transition of care (TOC), which can result in adverse drug events and readmissions. Implementing a pharmacist-led TOC service can optimize medication safety and patient outcomes by identifying and correcting medication discrepancies prior to hospital discharge. A pharmacist-led TOC service at a tertiary care center expanded services to review medications at discharge for all enrolled hospitalized patients, but data collection and review had yet to be performed. Objective: The purpose of this study was to evaluate the number of patients with a medication discrepancy identified at hospital discharge in a pharmacist-led TOC service. Methods: This was a single center, retrospective cohort study conducted at a tertiary care facility. Admission medication histories were completed by pharmacists in the emergency department and inpatient units. TOC discharge medication reconciliations were completed by pharmacists prior to hospital discharge. The study included hospitalized adult patients with a pharmacist-completed admission medication history and discharge medication reconciliation between July 1, 2021, to September 30, 2021. Patients readmitted within the study period were included more than once if study criteria were met. Patients who left against medical advice, discharged to hospice, or expired were excluded from the study. Results: A total of 213 patients met inclusion criteria for this study, with 214 patient encounters included in the analysis after accounting for readmissions. More patients had a TOC medication discrepancy identified at discharge when admission medication histories were completed less than or equal to 24 hours after hospital admission versus greater than 24 hours after hospital admission (28.2% vs 23.6%, OR: 1.269, 95% CI: 0.658, 2.448). Fewer patients had a TOC discrepancy at discharge when fewer PTA medications were changed versus more PTA medications were changed during the admission medication history (0-1 medication changes vs ≥10 medication changes: 19% vs 29.4%, OR: 1.780, 95% CI: 0.730, 4.339). Fewer patients had a TOC discrepancy at discharge when admission medication histories were completed in the emergency department versus on the inpatient units (22.4% vs 28.6%, OR: 0.721, 95% CI: 0.366, 1.420). A similar number of patients had a TOC discrepancy at discharge regardless of the number of unit transitions throughout their hospital stay (1-2 transitions vs ≥4 transitions: 25.9% vs 25.5%, OR: 0.977, 95% CI: 0.456, 2.096). Conclusions: One in four patients enrolled in the pharmacist-led TOC service had a medication discrepancy identified at discharge. This was irrespective of when the admission medication history was completed, how many changes were made, or how many times the patient transitioned units. Therefore, medication reconciliation at discharge should be a service provided to all admitted patients.

Quantitative evaluation of clinical pharmacy activities following implementation of an enhanced weekend service at a teaching hospital

Abstract Introduction Improving equity of staffing across seven-days is a strategic priority for the National Health Service (NHS).1 Development of enhanced weekend clinical pharmacy services presents opportunity to improve admission and discharge medicines reconciliation (MR), reduce medication error and increase patient counselling.2 At the study site, an enhanced weekend clinical pharmacy service was implemented in October 2021. The service was delivered 9am-5pm to all clinical specialities across 54 wards. Defined minimum staffing was 13 pharmacists and 2 medicines management pharmacy technicians (MMPT). Service specification included: clinical screen and order of medications; admission MR, review of high-risk patients (critical care patients and those prioritised by the weekday team); and discharge activities including patient counselling. Aim To evaluate provision of the enhanced weekend clinical pharmacy service post-implementation by quantification of shift fill and clinical pharmacy professional activities. Methods A quantitative study was conducted over two separate weekends one month and six months post-implementation (13th-14th November 2021 and 9-10th April 2022). Pharmacy professionals collected data using a paper activity tool validated for use at the study site. Interventions included rectification of medication error, medicines optimisation or consult. Data were collated in Microsoft Excel immediately after each study weekend. Simple descriptive statistics were performed in Microsoft Excel. The study was registered with KCH Pharmacy Research and Audit Group (07/2021), deemed service evaluation and ethics approval waived. Results Pharmacy professionals reviewed 1,056 patients over 3,645 occupied bed-days. Services were delivered by 13 pharmacists and 1 MMPT on weekend 1, 12 pharmacists and 1 MMPT on weekend 2. Data were collected for all wards on weekend 1; on weekend 2 activity data was not collected for five surgical wards (Saturday and Sunday), four post-acute medical wards (Saturday) and the acute medical unit (Sunday). Admission MR was conducted for 77% (317/412) of newly-admitted patients. Pharmacists recommended prescription amendment for 68% (217/317) of patients receiving admissions MR; affecting 517 medicines. The recorded intervention rate per patient reviewed was 0.64 (680/1056). Pharmacy professionals responded to 211 queries from healthcare professionals (HCPs), undertook 90 incidences of pro-active HCP education and counselled 92 patients/carers. Pharmacists prepared discharge medication lists or clinically screened discharge prescriptions for 205 patients. A total of 952 non-stock medicines were ordered and 313 patients own medicines checked for suitability for reuse. Discussion / Conclusion These findings add to existing evidence for seven-day clinical pharmacy services. Defined minimum staffing was not fulfilled with 90% shift fill rate. Clear benefit was demonstrated in terms of admission MR and resultant intervention, HCP education, discharge and counselling activities. The percentage of patients with a recommended prescription amendment following admission MR matched findings from a separate service evaluation during February 2021 of an enhanced weekend service introduced at our study site during the COVID-19 pandemic (68%).3 The intervention rate for reviewed patients was also comparable (0.64 compared with 0.57 during COVID-19).3 Limitations include the relatively short period of data collection at a single-site which limits generalisability of findings. There were some gaps in data collection and acceptance rate of interventions was not collected.

Measuring the impact of pharmaceutical care bundle delivery on patient outcomes: an observational study.

Clinical pharmacists perform activities to optimise medicines use and prevent patient harm. Historically, clinical pharmacy quality indicators have measured individual activities not linked to patient outcomes. To determine the proportion of patients who receive a pharmaceutical care bundle (PCB) (consisting of a medication history, medication review, discharge medication list and medicines information on the discharge summary) as well as investigate the relationship between delivery of this PCB and patient outcomes. Pharmaceutical care bundle activities were defined within state-wide (Queensland, Australia)clinical information systems and datasets were linked. An observational study using routinely recorded data was performed at ten participating sites for adult patients who had a non-same day hospital stay. The association between extent of PCB delivery and three patient outcomes were investigated: length of stay (LOS), unplanned readmission, and mortality. In total 283,813 patient hospital stays were evaluated. The delivery of the PCB occurred in 26.9% of patients at the ten participating hospital sites, ranging from 0.6 to 61.2% across sites. Patients with a longer LOS were more likely to receive delivery of the complete PCB (P < 0.001). There was no correlation between PCB and hospital standardised mortality ratio (r = 0.03, p = 0.93). Higher rates of delivery of the PCB were associated with lower rates of unplanned readmission within 30 days (r = - 0.993, p < 0.001). A complete PCB was delivered to 26.9% of patients and was associated with a significantly lower rate of unplanned readmission within 30 days.

Which patients with coronary artery disease should include oral nitrates on their discharge medication list?

Background Which patients with coronary artery disease (CAD) should have oral nitrates on their discharge medication list after coronary angiography (CAG)? To assess the relationship between oral nitrates included in the discharge medication list and major adverse cardiovascular events (MACEs) among CAD patients, we designed this retrospective cohort study. Methods A total of 2979 CAD patients hospitalised in the Department of Cardiology, Affiliated Hospital of Jining Medical University from May 2013 to October 2015 were enrolled, grouped according to whether oral nitrates were included at discharge after CAG, and followed up for MACEs for a mean of 4.42 years after discharge. The primary endpoint was MACEs. Multivariate Cox proportional hazards models were used to analyses potential confounding factors. Stratified analysis was used to observe the relationship between oral nitrates and MACEs by different covariates. Results The median follow-up time was 4.61 years, and 296 (9.94%) patients experienced MACEs. Multivariate Cox proportional hazards model analysis showed no association between oral nitrates on the discharge medication list and the occurrence of MACEs among patients with CAD (p > 0.05) after adjusting for some covariates, such as SYNTAX score (hazard ratio (HR): 1.18, 95% confidence interval (CI): 0.90–1.55, p = 0.2420). Stratified analysis revealed a higher incidence of MACEs among hypertensive patients prescribed oral nitrates at discharge (HR: 1.67, 95% confidence CI: 1.13–2.46, p = 0.0046). However, prescribing nitrates at discharge for patients with low uric acid levels increased the incidence of MACEs, which showed a possible trend towards significance (HR: 1.44, 95% CI: 0.99–2.09, p = 0.0525) Conclusion There was no association between oral nitrates included in the discharge medication list and the development of MACEs among patients with CAD after adjusting for some covariates, such as SYNTAX score. Oral nitrates after discharge for CAD patients combined with hypertension increased the occurrence of MACEs. Oral nitrates after discharge for CAD patients combined with low uric acid levels may increase theoccurrence of MACEs, and close monitoring for any adverse events is recommended.

COVID-19 Patients' Medication Management during Transition of Care from Hospital to Virtual Care: A Cross-Sectional Survey and Audit.

Virtual models of care were implemented to ease hospital bed pressure during COVID-19. We evaluated the medication management of COVID-19 patients transferred to virtual models of care. A retrospective audit of COVID-19 patients transferred from inpatient units to virtual care during January 2022 and surveys from patients transferred during December 2021-February 2022 was carried out. One hundred patients were randomly selected: mean age 59 years (SD: 19.8), mean number of medicines at admission 4.3 (SD: 4.03), mean length of virtual ward stay 4.4 days (SD: 2.1). Pharmacists reviewed 43% (43/100) of patients' medications during their hospital stay and provided 29% (29/100) with discharge medicine lists at transfer. Ninety-two (92%) patients were prescribed at least one new high-risk medicine whilst in hospital, but this was not a factor considered to receive a pharmacist medication review. Forty patients (40%) were discharged on newly commenced high-risk medicines, and this was also not a factor in receiving a pharmacist discharge medication list. In total, 25% of patient surveys (96/378) were returned: 70% (66/96) reported adequate medicine information at transfer and 55% (52/96) during the virtual model period. Patient survey data show overall positive experiences of medication management and support. Audit data highlight gaps in medication management during the transfer to a virtual model, highlighting the need for patient prioritisation.

Impact of pharmacist‐led discharge medication reconciliation at an Academic Medical Center

AbstractPrior studies evaluating the impact of pharmacist‐led discharge medication reconciliation have demonstrated higher rates of medication discrepancy detection and intervention with variable effects on hospital readmission. The purpose of this study was to evaluate the impact of a newly developed pharmacist‐led hospital discharge medication reconciliation process implemented with an interdisciplinary Internal Medicine Service. This was a retrospective, single‐center, pre‐post observational cohort study. Institutional review board approval was obtained. The primary end point was quantification and categorization of medication discrepancies identified on the hospital discharge medication list. Secondary end points included characterization of interventions made during the discharge medication reconciliation process, and 30‐day hospital readmission rates that were adjusted using a multivariable logistic regression model. A total of 144 patients were included in the pharmacist‐led discharge medication reconciliation intervention group and 144 patients were included in the historical control. There was a statistically significant four‐fold reduction in the number of medication discrepancies identified on discharge medication lists in the intervention group (77 vs. 18 in the historical control vs. intervention groups, respectively; p &lt; 0.0001). When adjusted for length of stay (L), acuity of the admission (A), comorbidity of the patient (C), and emergency department use in the last 6 months (E) (LACE) index and age, the adjusted odds ratio (aOR) for 30‐day readmission was 0.51 (95% confidence interval: 0.27–0.95) in the intervention versus the historical control group. Implementation of an interdisciplinary pharmacist‐led discharge medication reconciliation program was associated with a significant reduction in medication discrepancies on the discharge medication list, as well as a reduction in the adjusted odds of 30‐day hospital readmission.

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.

Patterns of Prescribing Postoperative Analgesic Medication After Thyroid Surgery: A Retrospective Cohort Study.

Mild-to-moderate postoperative pain is common after surgical procedures of the thyroid. Opioid analgesics have been commonly prescribed in such cases, but their use has been debated owing to concerns regarding the addictive nature of opioids. Recently, experts from the Endocrine Surgery Section of the American Head and Neck Society released a consensus document to limit the use of opioids as the first-line pain control medication after head and neck or endocrine procedures. However, differences in pain management prescriptions have been noted in many settings. This study aims to assess the post-thyroid surgery pain control medication prescription practices of head and neck and endocrine surgeons. This study retrospectively reviewed the charts of 105 adult patients who underwent thyroid surgery (total thyroidectomy, thyroid lobectomy, or subtotal thyroidectomy) by head and neck or endocrine surgeons. The type of prescribed pain medication at hospital discharge postoperatively was then retrieved from each patient's discharge medication list. Descriptive statistics mean, standard deviations, frequencies, and percentages were computed, while the Chi-square test was applied to measure the significant differences among variables at a 5.00% significant level. An outpatient oral opioid, in the form combining paracetamol and codeine, was prescribed for 62 (59%) patients, whereas 43 (41%) were discharged on paracetamol only. The use of opioids is the practice pattern for pain management among some head and neck or endocrine surgeons despite emerging evidence that supports the use of non-opioid and other alternative analgesic strategies in outpatient thyroid and parathyroid surgery. Further research and quality improvement interventions should be geared towards leading all health professionals to appropriate prescription practices to improve patient safety and reduce unnecessary opioid prescriptions.

The Carer Assessment of medicaTion management guidanCe for people living with dementia at Hospital discharge (CATCH): Preliminary analysis for a national cross-sectional survey.

Medication therapy management for people living with dementia is a major contributing factor to adverse events after discharge from hospital. Carers play an important role in overseeing medication management for the person with dementia. We aimed to evaluate medication management guidance provided to carers of people with dementia at hospital discharge. This was a cross-sectional survey disseminated across Australia. Data was captured using the Carer Assessment of medicaTion management guidanCe for people with dementia at Hospital discharge (CATCH) tool. The CATCH tool included 30 items and was developed using a multi-method approach involving content validation and pretesting with carers of people with dementia. The tool utilized a 5-point Likert scale, and multiple-choice responses. We included carers responsible for managing the medications of the person with dementia, and the person with dementia has had at least one discharge from the hospital. Electronic and hardcopy distribution of the survey occurred Australia wide through advertisement. Data collection started on April 24th , 2022, and is currently ongoing. Quantitative data was descriptively analyzed. To date, 30 participants completed the survey with a median age 66 (IQR 16.5) and 28 were female. Most participants (n = 21) were provided guidance on the day of discharge by the doctor (n = 12) or nurse (n = 7) in written form. Most (n = 18) found that discharge summary and medication list was easy to understand. The most common medication information provided related to administration instructions (n = 13), medication purpose (n = 11) and possible benefits of medications (n = 8). However, some participants reported that they were not given information about possible side effects (n = 8), medications that might increase confusion (n = 7) and how long the medication should be used for (n = 12). Some (n = 12) reported that they were not asked if the person with dementia had any problems taking their medications.. Most (n = 20) stated that medication management guidance could be improved. Our preliminary findings suggest that there are opportunities to improve guidance in medication therapy management provided to carers at discharge. Targets for interventions around comprehensive guidance on all aspects of medication use tailored specifically for the people with dementia are needed.

An audit of discharge medicines counselling on an acute elderly admissions unit

Abstract Introduction Poor discharge communication is a major contributor to medication-related errors during care transfers. The World Health Organisation 2019 Medication Safety report1 acknowledged this and recommended prioritising collaboration with patients/families/carers, communicating medication changes, and interdisciplinary working. The Care Quality Commission 2020 National Patient Inpatient Survey found that only 28% of participants received information regarding side-effects, 55% given explanations on medicines-use, 48% provided written information and 12% no information.2. Health information systems including Medicines a Patient Profile Summary (MaPPs) provide easy-read leaflets which may improve patient awareness and understanding of their medicines.3 This study explored patients’ experience of DMC at one hospital Trust. Aim To measure patient satisfaction and understanding of DMC offered at Mid Yorkshire Hospitals Trust and establish whether the Trust standards were met of all patients with medication changes (new/stopped/changed) receiving verbal DMC and being offered a MaPPs leaflets/charts documenting the changes. Method Ethics approval was not required for this service evaluation. Baseline data was collected from the Trust Medicines Information department to establish which ward had the most discharge enquiries in October 2021. Inpatients from this ward were included if they were elderly, had a previous admission within the last 2 months, usually lived at home and managed their own medications or had help from relatives/friends. Inpatients were excluded if they were care-homes residents, had carers who visited to administer medicines, used a compliance aid or had no medication changes. A 13-item questionnaire was designed for qualitative/quantitative data collection over a 4-week period in December 2021. Questions concerned discharge medicines information provided (written/verbal), patient/relative satisfaction and patient/relative understanding of medicines indicated and changes. Quantitative data underwent descriptive statistical analysis, whilst qualitative data were grouped by similarity and frequency counted. Results A total of 20 elderly patients/relatives were included: 11 were female and 9 were male. Eight respondents (40%) reported not receiving written information. Twelve respondents (60%) reported received a SystmOne discharge letter, of whom 7 received additional written information that included a discharge medication list. This was provided by nurses on all occasions. No respondents reported being offered a MaPPs leaflet/chart, but 17 respondents indicated that they thought that a MaPPs leaflets/chart would have been beneficial. Eleven respondents reported receiving verbal DMC, of whom 4 rated themselves as being “not very satisfied” with it. Key themes were: ‘rushed discharges’, ‘limited patient/relative involvement’. No respondents reported being informed about side-effects. Eleven and 14 respondents respectively reported partially/not fully understanding why medications were indicated or changes made. Discussion/Conclusion Overall, DMC was below the Trust standards. Poor explanation of changes and no information on side-effects was common practice. The findings are limited by the small sample size and limited generalisability to ethnic minorities. Future study plans include involving underrepresented patient groups in a larger sample. Nevertheless, the following recommendations were made: Offer all patients MaPPs leaflets/reminder charts and verbal DMC; Offer all elderly ward nurses pharmacy-led MaPPs training; add monthly reminders during morning handovers to use MaPPs; Document on the electronic prescribing system when MaPPs leaflets are provided.

Characteristics of Lymphoma Patients Experiencing Unplanned Readmissions at a Large Academic Medical Center

Background: Patients with lymphoma frequently experience hospital readmissions. Yet, limited data exist describing hospital readmissions in the lymphoma population. In this study, we sought to identify additional patient-specific characteristics associated with unplanned readmissions in patients with lymphoma at our institution. Methods: We conducted a retrospective, single-center study of patients with lymphoma who were age >18 and discharged from medical oncology wards from January-December 2019 (index admission). We categorized patients as having high-risk medications per the Institute for Safe Medication Practices, potentially inappropriate medications (PIMs) for older patients (age 65+) per the American Geriatric Society Beers Criteria, and polypharmacy and major polypharmacy as 5 or more and 10 or more scheduled medications on the discharge medication list, respectively. We performed univariate logistic regression to assess the association of with having an unplanned readmission within 30 days of discharge from index admission. The following factors, selected for clinical relevance, were assessed: age; gender; race; marital status; Charlson comorbidity score; lymphoma diagnosis and related parameters (stage, LDH, prior treatment ECOG PS); index hospitalization reason, duration, discharge disposition and prior healthcare utilization; activities of daily living (ADL) status; Morse fall score; laboratory values at time of discharge; discharge medication list; 30-day readmission status and readmission reason if applicable. Results: We included 207 patients (mean age 63.9 years, 38.6% female, 83.1% white race, 56.8% partnered), 65 (31.4%) of whom experienced a 30-day unplanned readmission. Patients experiencing a 30-day unplanned readmission were more likely to have ECOG PS >2 (36.9% vs 14.2%, p<0.001), higher age-adjusted IPI score (score 0, 3.3% vs 7.8%; score 1, 23.3% vs 35.7%; score 2, 55.0% vs 47.8%; score > 3, 18.3% vs 8.7%; p=0.012), received CAR T-cell therapy (9.2% vs 2.1%, p=0.032), index length of stay >5 days (55.4% vs 33.1%, p=0.003), been discharged to a skilled nursing facility (12.3% vs 3.5%, p=0.023), albumin <3.5 g/dL (78.5% vs 52.1%, p<0.001), and sodium <135 mEq/L (18.5% vs 8.5%, p=0.041). Patients discharged home were less likely to have a 30-day unplanned readmission (56.9% vs 76.8%, p=0.004). Age, sex, marital status, Charlson comorbidity score, aggressive versus non-aggressive lymphoma diagnosis, prior lymphoma treatment, discharge home with services or to inpatient rehabilitation, Morse fall score, bowel and/or bladder continence, independence in feeding or bathing, neutropenia (ANC<1.5 k/mcL), and Hgb <10 g/dL were not significantly associated with increased likelihood for unplanned readmission. Among medication-related factors, we found that patients with major polypharmacy on the index admission discharge medication list had a higher likelihood for unplanned readmission (56.9% vs 37.3%, p=0.009). Patients with discharge medication lists with polypharmacy (90.8% vs 81.7%, 00, long-acting opiates (10.8% vs 4.2%, p=0.082), and/or anticoagulants (26.2% vs 15.5%, p=0.071) had a higher likelihood for unplanned readmissions, but these differences did not reach statistical significance. Presence of PIMs was not associated with readmission. Conclusions: In this relatively large cohort of patients with lymphoma, we identified several risk factors for unplanned hospital readmissions. We found associations among unplanned readmissions and impaired performance status, receipt of prior CAR T therapy, higher age-adjusted IPI score, discharge location (home, skilled nursing facility, etc), lower albumin and sodium levels, as well as major polypharmacy on the discharge medication list. Future directions include further efforts to identify lymphoma patients at high risk for hospital readmissions and developing readmission prevention strategies in those patients. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Impact of a clinical pharmacist on medication safety in mental health Hospital-in-the-Home: a retrospective analysis

Background Integration of clinical pharmacists into multidisciplinary Mental Health Hospital-in-the-Home teams is increasing but little is known about the medication safety contribution these pharmacists make.AimTo evaluate whether clinical pharmacist involvement in a Mental Health Hospital-in-the-Home service improved medication safety key performance indicators.Method Medical records were retrospectively reviewed of all patients admitted to 2 Western Australian Mental Health Hospital-in-the-Home services from September to November 2015.Site 1 was a 16-bed service incorporating a clinical pharmacist as part of its multidisciplinary team.Site 2was a similarly structured 18-bed service but without clinical pharmacist involvement. The primary outcome measure was completion of medication safety key performance indicators obtained from the Western Australian Government Pharmaceutical Review Policy and mental health-specific best practice guidelines. ResultsKey performance indicators from Site 1 (n = 75 records), which incorporated a clinical pharmacist, demonstrated significantly (p < 0.001) higher rates of completion of medication reconciliation [65 (87%) versus 17 (29%)], accurate adverse drug reaction list [73 (97%) versus 34 (58%)], accurate discharge medication list [51 (74%) versus 18 (45%)], accurate medication profile [74 (99%) versus 40 (68%)] and medication chart review [74 (99%) versus 0 (0%)] than Site 2 (n = 59). ConclusionIntegrating a clinical pharmacist into a Mental Health Hospital-in-the-Home program significantly improved achievement of medication safety key performance indicators.

Medication reconciliation – Responsibilities and barriers facing physicians, pharmacists, and nurses in Saudi Arabia

Background: Patient safety can be adversely affected by medication errors. The medication reconciliation process plays a critical role in the prevention of medication discrepancies and adverse drug events. Aims: This study aimed to investigate the perceptions of Saudi Arabian physicians, pharmacists, and nurses regarding their functions in the medication reconciliation process and to elucidate the barriers to implementing this process. Materials and Methods: A cross-sectional survey was performed for 4 months targeting pharmacists, physicians, and nurses who work at various hospitals in Saudi Arabia. An online survey was used to collect all data. Data gathered were statistically analyzed using SPSS24. Results: In all, 447 participants completed the survey. Physicians considered their profession to be the primary health-care providers responsible for every step of the medication reconciliation process. Pharmacists believed that their profession was the main one among health-care providers responsible for all steps in the process, apart from interviewing patients during admission and taking a correct medication history. They assigned those tasks to physicians by a margin of 53.3%. Nurses viewed themselves as responsible for more roles than physicians, except for two steps, in which they considered pharmacists to be the responsible person: reconciling medications while transferring a patient to the next level of care (54.1%) and sending the patient's discharge medication list to his or her next provider (56.5%). Conclusions: Participants revealed the insufficiency of a clear understanding of the functions of health-care providers in every step of the medication reconciliation process.

Pharmacy-Led Medication Reconciliation Program Reduces Adverse Drug Events and Improves Satisfaction in a Community Hospital.

Pharmacy-led medication reconciliation identifies and corrects medication errors that can potentially cause moderate to severe harm. This research sought to identify the impact of pharmacy-led medication reconciliation on patient outcomes and describe the changes in healthcare workers' perceptions of the program. A pharmacy-led admission medication reconciliation program pilot started in July 2019, and a discharge medication reconciliation proof of concept was tested in September 2020 at a 432-bed hospital. The following periods were compared: August 2018 to February 2019 (pre-program implementation) and August 2019 to February 2020 (post-program implementation). Endpoints included patient outcomes, workforce productivity and interdisciplinary healthcare team satisfaction through program surveys. Patient outcomes were assessed with chisquared tests. Survey responses were assessed using the Likert scale. Descriptive statistics were used for productivity outcomes and the number of discharge medication reconciliations completed. Approximately 18,000 admissions were recorded for each period. The adverse drug event (ADE) rate decreased 49% (p < 0.001), and the complication rate decreased 29.7% (p = 0.001). During post-pilot implementation, 6,530 medication histories were completed, and 70,050 medications were reviewed. Of medication histories completed, 22.6% of patient allergies/adverse drug reactions were updated, 52.3% of medications were clarified, and 54.7% of preferred outpatient pharmacies were updated. Pharmacy services completed medication histories in 38.8% of inpatients. In the proof of concept, 168 discharge medication lists were drafted. Survey results showed statistically significant improvement in healthcare team satisfaction. A pharmacy-led medication reconciliation program involving designated pharmacists and pharmacy technicians has shown to decrease ADEs and complications while improving interdisciplinary healthcare team satisfaction.

Retrospective cohort study of new-onset atrial fibrillation in acute pulmonary embolism on prognosis

ObjectivesTo investigate the characteristics of new-onset atrial fibrillation (AF) and its impact on prognosis in acute pulmonary embolism (aPE).DesignA retrospective cohort studySettingThe study cohort included patients diagnosed with aPE who...

Quantifying Discharge Medication Reconciliation Errors at 2 Pediatric Hospitals.

Introduction:Medication reconciliation errors (MREs) are common and can lead to significant patient harm. Quality improvement efforts to identify and reduce these errors typically rely on resource-intensive chart reviews or adverse event reporting. Quantifying these errors hospital-wide is complicated and rarely done. The purpose of this study is to define a set of 6 MREs that can be easily identified across an entire healthcare organization and report their prevalence at 2 pediatric hospitals.Methods:An algorithmic analysis of discharge medication lists and confirmation by clinician reviewers was used to find the prevalence of the 6 discharge MREs at 2 pediatric hospitals. These errors represent deviations from the standards for medication instruction completeness, clarity, and safety. The 6 error types are Duplication, Missing Route, Missing Dose, Missing Frequency, Unlisted Medication, and See Instructions errors.Results:This study analyzed 67,339 discharge medications and detected MREs commonly at both hospitals. For Institution A, a total of 4,234 errors were identified, with 29.9% of discharges containing at least one error and an average of 0.7 errors per discharge. For Institution B, a total of 5,942 errors were identified, with 42.2% of discharges containing at least 1 error and an average of 1.6 errors per discharge. The most common error types were Duplication and See Instructions errors.Conclusion:The presented method shows these MREs to be a common finding in pediatric care. This work offers a tool to strengthen hospital-wide quality improvement efforts to reduce pediatric medication errors.

Medication Education Pilot Program for Heart Transplant Patients

Purpose As a high volume solid organ transplant center, we implemented a medication education didactic (MED) pilot program as a quality improvement initiative to enhance patient knowledge, increase patient and provider engagement, reduce medication errors, and identify target patient populations for more intense education interventions. Methods After reviewing our current practice of medication education, we initiated a MED program incorporating auditory, visual and kinesthetic teaching materials and enrolled 31 patients. Pharmacist-led educational interventions included a sample discharge medication list, medication flashcards, and a pre and post teaching assessment. Provider interventions included implementation of virtual rounding, coordinated discharge medication handoff between multidisciplinary staff, and creation of patient education videos. Results Our primary outcome analyzed patients’ pre and post education assessment scores, with a mean pretest score of 55.11 + 15.523 and a mean posttest score of 90.46 + 10.167. Post test scores comparing English versus non-native English speakers were 93.32% and 75.94%, respectively. To assess patient and provider engagement, we administered surveys to staff and a cohort of patients. After MED program, 93.33% of patients reported feeling moderately to extremely knowledgeable about their medications. 70% of staff observed a positive change in provider engagement and 90% reported that new virtual rounding has been at least moderately beneficial. Chart reviews for each patient demonstrated no recorded medication errors in their first 30-days post discharge. Conclusion Our study suggests intensive teaching from a dedicated pharmacist greatly increases patient medication knowledge. We identified non-native English-speakers would benefit from more intensive education sessions prior to discharge and are developing additional translated written materials and videos. Our initial data also suggests the MED program to be a highly effective method for improving patient outcomes and quality of care. Further research is ongoing to fully characterize the benefits of MED program implementation. Due to the overwhelming success of this pilot study, MED program initiatives have expanded across our institution's solid organ transplant programs.

Improving 30-day readmissions: Student pharmacists’ role in transitions of care

BackgroundPharmacists have reduced 30-day hospital readmissions when involved with transitions of care (TOC). The impact of student pharmacists on readmissions is more limited. ObjectiveThe goal of this study was to describe student pharmacists’ role in a new TOC service and determine their impact on 30-day hospital readmissions. MethodsWe designed a 3-step TOC service spanning inpatient, discharge, and follow-up led by student pharmacists and involving both inpatient and ambulatory care pharmacy preceptors. The student pharmacists followed inpatient care and discussed medications with the patients. Discharge orders were reviewed, and the student pharmacists provided discharge education. On discharge, the student pharmacists wrote a handoff to the ambulatory care pharmacist describing inpatient care, discharge medication list, follow-up, and unresolved medication issues. Finally, the student pharmacists participated in the outpatient follow-up at the primary care provider office with the provider and an ambulatory care pharmacist. Readmissions were compared between this process and a standard-of-care historical control group using chi-square analysis. ResultsThe student pharmacist–led TOC service reduced 30-day hospital readmissions by 13.1% (P = 0.018) compared with standard of care. ConclusionStudent pharmacists are effective members of the health care team in reducing readmissions. Student pharmacists are cost-effective, appropriately trained, and well positioned to assist with these services.

Association between admission medication reconciliation by pharmacists on the accuracy of hospital discharge medication lists

AbstractIntroductionMedication errors upon hospital discharge can lead to patient harm. Medication reconciliation during the admission process can potentially impact discharge medication lists. This study aimed to determine the extent to which a pharmacist medication reconciliation on hospital admission affects the accuracy of discharge medication lists.MethodsA prospective observational study was conducted in a major metropolitan tertiary hospital in Sydney, Australia. Patients in the hospital discharge lounge were recruited to evaluate the accuracy of their medication list in the discharge letter. Patients were categorized into two groups: (a) those who received a pharmacist admission medication history (PHARM) and (b) those who did not (non‐PHARM). The primary outcomes were the proportion of patients with medication errors in their discharge letter.ResultsThere were 102 patients included in the study (51 in each group). Patients in the PHARM group were less likely to have one or more medication errors in the discharge letter compared to the no‐PHARM group (70.6% [n = 36/51] versus 92.2% [n = 47/51] [P = .010]). When restricted to prescription only errors (i.e. excluding over the counter [OTC] or herbal medications) the proportion with errors was 51.0% (n = 26/51) in the PHARM group versus 84.3% (n = 43/51) in the no‐PHARM group (P = .001). Patients in the PHARM group were less likely to have errors that were of moderate or greater risk (31.4% [n = 16/51] versus 68.6% [n = 35/51] [P &lt; .001]). After adjusting for confounders in the Poisson regression analysis, patients in the PHARM group had a lower error rate compared to the non‐PHARM group (incidence rate ratio 0.51, 95% confidence interval 0.38–0.69, P &lt; .001).ConclusionA pharmacist‐completed medication history and reconciliation on hospital admission improves the accuracy of discharge medication lists. This study highlights that medication errors during the admission process may be propagated to hospital discharge.

Patient satisfaction with a pharmacist-led best possible medication discharge plan via tele-robot in a remote and rural community hospital.

Medication reconciliation (MedRec) reduces the risk of preventable medication-related adverse events (ADEs). A best possible medication discharge plan (BPMDP) is a revised list of medications a patient will take when discharged from hospital; a pharmacist review ensures accuracy. For many hospitals, on-site pharmacists are non-existent. Extension of a visual presence via a mobile robotic platform with real-time audiovisual communication by pharmacists to conduct MedRec remains unstudied. This study explored patient perceptions of a pharmacist-led BPMDP using a telepresence robot. Time requirements, unintentional discharge medication discrepancies (UMD), programme inefficiencies/barriers and facilitators involved in pharmacist review of the discharge medication list and patient interviews were also described. This prospective cohort study enrolled adult patients admitted to a 12-bed community hospital at high risk of an ADE. Remote pharmacists reviewed the discharge prescription list, identified/resolved UMDs, and interviewed/counselled patients using a telepresence robot. Thereafter, patients completed an anonymous satisfaction questionnaire. Prescriber discharge UMDs were classified, and barriers/inefficiencies and facilitators were documented. Nine patients completed an interview, with a 75% interview agreement rate. All patients were comfortable with the robot and 76% felt their care was better. With a median of 11 discharge medications/patient, the UMD rate was 78%; 71% had omitted medications, 43% involved a cardiovascular medication, 88% were due to a hospital system cause, and 43% were specifically due to an inaccurate best possible admission medication history. Median times for interview preparation, interview and UMD/drug therapy problem resolution were 45, 15 and 10 min, respectively. Using a telepresence robot to provide pharmacist-led BPMDPs is acceptable to patients and an innovative, effective solution to identify/resolve UMDs.