Discharge Medication Reconciliation Research Articles

Development and implementation of ambulatory care pharmacy services at an internal medicine clinic.

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. This report describes the step-by-step process that led to expansion of ambulatory care pharmacy services at a newly established internal medicine clinic within a patient-centered medical home in North Carolina. Implementation of clinical pharmacist services at the clinic was led by a postgraduate year 2 (PGY2) pharmacy resident and guided by the 9 steps described in the book Building a Successful Ambulatory Care Practice: A Complete Guide for Pharmacists. After a needs assessment and review of the demographics and insurance status of the clinic's target population, it was determined that pharmacist services would focus on quality measures including diabetes nephropathy screening, diabetes eye examination, blood glucose control in diabetes, discharge medication reconciliation, annual wellness visits, and medication adherence in diabetes, hypercholesterolemia, and hypertension. Clinic appointments were conducted under 3 models: a pharmacist-physician covisit model, a "floor model" of pharmacist consultation on drug information or medication management issues during medical resident sign-out sessions with supervising physicians (medical residents could also see patients along with the pharmacist at a covisit appointment), and a covisit model of stacked physician and pharmacist appointments. The pharmacist's services were expanded from 2 half-day clinic sessions per week initially to 5 or 6 half-day clinic sessions by the end of the residency year. By the fourth quarter of the first PGY2 residency year in which ambulatory care pharmacy services were provided in the clinic, the clinical and financial impact of those services justified the addition of a second full-time pharmacist to the clinic team.

Improving medication prescribing-related outcomes for vulnerable elderly in transitions on high-risk medications (IMPROVE-IT HRM): a pilot randomized trial protocol.

Seniors with recurrent hospitalizations who are taking multiple medications including high-risk medications are at particular risk for serious adverse medication events. We will assess whether an expert Clinical Pharmacology and Toxicology (CPT) medication management intervention during hospitalization with follow-up post-discharge and communication with circle of care is feasible and can decrease drug therapy problems amongst this group. The design is a pragmatic pilot randomized trial with 1:1 patient-level concealed randomization with blinded outcome assessment and data analysis. Participants will be adults 65 years and older admitted to internal medicine services for more than 2 days, who have had at least one other hospitalization in the prior year, taking five or more chronic medications including at least one high-risk medication. The CPT intervention identifies medication targets; completes consult, including priorities for improving prescribing negotiated with the patient; starts the care plan; ensures a detailed discharge medication reconciliation and circle-of-care communication; and sees the patient at least twice after hospital discharge via virtual visits to consolidate the care plan in the community. Control group receives usual care. Primary outcomes are feasibility - recruitment, retention, costs, and clinical - number of drug therapy problems improved, with secondary outcomes examining coordination of transitions in care, quality of life, and healthcare utilization and costs. Follow-up is to 3-month posthospital discharge. If results support feasibility of ramp-up and promising clinical outcomes, a follow-up definitive trial will be organized using a developing national platform and medication appropriateness network. Since the intervention allows a very scarce medical specialty expertise to be offered via virtual care, there is potential to improve the safety, outcomes, and cost of care widely. ClinicalTrials.gov identifier: NCT04077281.

Reducing Discharge Medication Reconciliation Errors at a Pediatric Neurology Inpatient Unit.

Medication reconciliation errors are a common problem in health care, particularly during transitions of care. Discharge medication reconciliation (DMR) errors in a pediatric setting can range from 26% to 42.2%. We conducted a quality improvement project to decrease DMR error rate at Dayton Children's Hospital in Dayton, Ohio. We conducted 2 interventions, each with 3 Plan-Do-Study-Act cycles from September 2021 through February 2023. The first intervention focused on using current specialty neurology nurses as scribes and creating a template note to include the plan of care and review of DMR before discharge. Our second intervention consisted of standardizing the seizure rescue medication order by creating an order panel within our electronic medical record system for all the rescue medications presently available. Medication errors were documented by the specialty neurology nurse during a phone conversation on the next business day post discharge. DMR error rates were calculated for each week using a control chart. Medication errors and patient harm were classified according to the National Coordinating Council for Medication Error Reporting and Prevention Index. One hundred six errors were noted. Of these, 98 (92%) occurred in patients with seizure and 64 (60%) were related to prescription of seizure rescue medication specifically. The baseline error rate was calculated at 15.7% or 7 errors per month (January 2021 through June 2021). The average error rate dropped from 15.7% to 5.3% (2 errors per month) after initiation of our first intervention (September 2021). Twelve weeks after initiation of the second intervention, a 2.9% (1 error per month) was noted. Afterward, there was a ten-week period of 0% errors. Sustainable reduction of DMR errors in pediatric patients with epilepsy was achieved by using specialty neurology nurses to scribe the care plan and creating order panels to facilitate accuracy of discharge medication orders without additional cost to the hospital.

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.

Development of a Discharge Counseling and Medication Reconciliation Process for Pediatric Patients Within a Large, Academic Health System

OBJECTIVE This study aims to characterize the impact of a pharmacist-driven discharge medication reconciliation and counseling program targeting high-risk pediatric patients to mitigate barriers in transitions of care. METHODS This was a single-center quality improvement initiative including high-risk pediatric patients within a large academic medical center. Pharmacy, medical, and information technology team members developed a scoring system to identify patients at high risk of hospital readmission that resulted in a trigger tool built within the electronic medical record (EMR). Pharmacy workflow, the EMR documentation, and staff training were implemented. The primary end point was the number of high-risk patients with complete medication reconciliation and/or discharge counseling performed during the first 2 months after implementation. The secondary end points included quantification and qualification of the interventions conducted by a pharmacist. RESULTS Pediatric clinical pharmacists conducted discharge medication reconciliation and/or counseling for 60 patients during the first 2 months after implementation. There were 65 interventions performed, including 60 discharge medication reconciliations and 5 discharge counseling sessions. Of these interventions, 22 were recommendations on appropriate medication dosing and frequency (37%), 12 on duration of therapy (20%), and 8 were medication additions (13%). There were 6 interventions on adherence assistance (10%), 6 involved selection of medication formulation (10%), 3 involved medication discontinuation (5%), 2 involved appropriate therapy selection (3%), and 1 involved medication stability (1%). All interventions were accepted and implemented by the prescribing providers. CONCLUSIONS Pharmacist-driven discharge medication reconciliation and counseling programs targeting pediatric high-risk population might be an effective tool to mitigate gaps in transitions of care.

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.

Optimizing the Hospital Discharge Process: Perspectives of the Health Care Team.

Prior research capturing pharmacists' perspectives on the discharge process has shown that their involvement is essential. Given the multidisciplinary nature of the hospital environment, it is important to understand the perspectives of nonpharmacist health care providers. To explore the perspectives of nonpharmacist health care providers concerning current discharge practices, components of an effective discharge plan, and perceived barriers to an optimal discharge, and to explore their expectations of pharmacists at discharge. This qualitative study used key informant interviews of allied health professionals and prescribers at Vancouver General Hospital and North Island Hospital Comox Valley (British Columbia). Participants primarily working on general medicine, family practice, or hospitalist wards were invited to participate. A total of 16 health care providers participated, consisting of 12 allied health professionals and 4 prescribers. Thematic analysis of the interview transcripts revealed 5 themes for each group. The following 3 themes were common to both groups: systems-related barriers to an optimal discharge; patient- and community-related barriers to an optimal discharge; and patient involvement and education. For allied health professionals, themes of prioritization of patients for discharge and direct communication/teamwork were also key for an optimal discharge. Prescriber-specific themes were limitations related to technology infrastructure and inefficiency of existing collaborative processes. Key responsibilities expected of the pharmacist at discharge included preparing the discharge medication reconciliation and prescriptions, addressing medication-related cost concerns, organizing adherence aids/tools, and providing medication counselling. Further studies are warranted to investigate optimization of the discharge process through implementation of standardized discharge protocols and electronic health record-related tools. The primary responsibilities of the pharmacist at discharge, as perceived by study participants, were consistent with previous literature.

A cross-sectional study of hospital pharmacists communicating medication changes at discharge

Abstract Introduction Medication discrepancies can happen at transitions of care and there are recognised problems with the content of discharge letters.1 We introduced a discharge medication reconciliation process that was shown to improve the quality of medication information in discharge summaries.2 This involves pharmacists recording any changes to patient’s medication in the electronic prescribing system during the inpatient stay and summarising these changes on discharge in a discharge medication reconciliation (DMR) note. Though this is part of routine clinical pharmacy practice we have not directly quantified these notes in comparison to standards for the clinical structure and content of patient records,3 nor have we examined which medication classes are commented upon by our pharmacists. Aim To characterise the type of medication changes that pharmacists describe and the classes of medication that warrants such attention. Methods A retrospective study of a purposive sample of 100 patient episodes where a DMR note was recorded at a 750-bed teaching district general hospital in England. We classified the text of the DMR note using the four categories (added, amended, on hold, and discontinued) in the eDischarge Summary Standard,3 plus four further categories. The actual medication named was categorised according to the main BNF therapeutic chapters. Data were collated and analysed using Microsoft Excel. As this project falls under the definition of a service evaluation, according to UK NHS Research Ethics Committees, formal ethical approval was not required. This project was registered on the hospital’s clinical audit database. Results Data were extracted for 100 discharges from early 2023. The mean age was 70 years (range 12 to 96), and 40% were male. In total, 352 medicines were named in the DMR notes with 184 (52%) recorded as added, 41 (12%) amended, 32 (9%) on hold, and 42 (12%) discontinued. For 32 (9%) instances the DMR note specifically referred to continuation of medication; in 12 (3%) instances to monitoring required; and 22 (6%) instances fell into other category. For 33 (33%) of episodes there was a note indicating that no changes had been made to other pre-admission medication during the hospital stay. Of the medication attracting a DMR note, the main chapters were cardiovascular 162 (46%), gastrointestinal 45 (13%), central nervous system 40 (11%), and 28 (8%) each for infection and for blood and nutrition. Discussion/Conclusion For this sample of patients who undergo a DMR process, the pharmacy team clarified medication changes at a mean rate of 3.5 changes per patient. Addition of medication was the most common event. The most frequent class of medication attracting a DMR note may be a reflection of the cardiovascular morbidities of patients as well as perceived adverse effects as 27/32 ‘on hold’ notes were for cardiovascular medication. Limitations of this study include the patient sample being collected in one hospital, hence results may not be generalizable. There was no attempt to ascertain if the DMR notes added value to primary care medicines reconciliation process.

Prevented harm and cost avoidance with pharmacist intervention while utilizing a discharge medication reconciliation tool.

The aim of this study was to determine prevented harm and cost avoidance following pharmacist intervention utilizing a discharge medication reconciliation tool. A retrospective chart review was conducted to identify patients with pharmacist-initiated, provider-accepted discharge medication reconciliation interventions completed at a community teaching hospital in January 2021. Investigators assigned the discrepancies targeted for intervention a National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) category, probability of harm, and calculated cost avoidance. The primary endpoint was the total cost avoidance associated with discharge medication reconciliation. Pharmacists intervened 190 times in January 2021, avoiding an estimated $46,958 to $231,032 in cost. High-risk medications were associated with $33,920 to $147,203 in cost avoidance. The 3 high-risk therapeutic classes associated with the highest cost avoidance were insulin ($16,738-$70,793), antithrombotics ($13,884-$60,016), and opioids ($2,638-$11,834). Targeted pharmacist discharge medication reconciliation and related interventions avoid significant cost and patient harm.

A Quality Improvement Initiative to Improve Pediatric Discharge Medication Safety and Efficiency.

This QI project occurred between August 2020 and July 2021 on 2 subspecialty pediatric acute care inpatient units and respective outpatient clinics. An interdisciplinary team developed and implemented interventions, including integration of MAP within EHR; the team tracked and analyzed outcomes for discharge medication matching, and efficacy and safety MAP integration occurred with a go-live date of February 1, 2021. Statistical process control charts tracked progress. Following the implementation of the QI interventions, there was an increase from 0% to 73% in the utilization of the integrated MAP in the EHR across the acute care cardiology unit-cardiovascular surgery/blood and marrow transplant units. The average user hours per patient (outcome measure) decreased 70% from the centerline of 0.89 hours during the baseline period to 0.27 hours. In addition, the medication matching between Cerner inpatient and MAP inpatient increased significantly from baseline to postintervention by 25.6% (P < 0.001). MAP integration into the EHR was associated with improved inpatient discharge medication reconciliation safety and provider efficiency.

Improving inpatient discharge workflows through pharmacist pending discharge medication orders.

Hospital discharge represents a difficult care transition for patients, with the potential for medication-related problems (MRPs) and adverse events. Medication reconciliation is widely accepted as a best practice to minimize MRPs at the time of discharge. Pharmacists can play a key role in identification and resolution of MRPs, although pharmacist reconciliation usually occurs after provider medication reconciliation. This workflow is often inefficient and results in duplication of work within the care team. A prospective pharmacist-led pilot program with preparation of discharge medication orders for provider review, also known as pended medication orders, was investigated to determine its impact on MRPs and discharge processing time. Patient discharges from February through April 2022 were compared for 2 hospital medicine services at a large academic medical center. One group participated in the pilot workflow, while the other used standard discharge workflows. The pilot group had a significant decrease in the average number of clinical interventions made by a pharmacist after provider orders were placed (52.4% decrease; P = 0.03) and a nonsignificant reduction in the time from provider order entry to completion of the final pharmacist medication reconciliation (47.6% reduction; P = 0.18) compared to the group using standard workflows. Pharmacist-led, prospective discharge medication reconciliation with pending of medication orders for provider review increases overall discharge efficiency. Data from this project and previous studies support an expanded pharmacist role in the discharge process and continued high-level collaboration between pharmacists and providers.

1047-P: Evaluating Discharge Prescription Errors and the Clinical Impacts in Patients with Insulin-Treated Diabetes Mellitus in a Community Hospital

Introduction: Transitioning patients with insulin treated diabetes (ITDM) at time of hospital discharge is identified as a source of error in how information for home management is provided that can contribute to significant adverse health outcomes. To address this, we conducted a quality improvement project investigating the safety of current discharge procedures in our hospital and the impact on glycemic control at 3 months and diabetes related readmissions at 3 and 6 months. Methods: We retrospectively analyzed discharge prescription errors in patients with ITDM in a community hospital between January 2020 and December 2021. Errors were defined as being discharged on the wrong form of insulin (pen vs vial), and/or not being provided appropriate insulin administration devices (i.e., pen needles or syringes). Data was collected by reviewing discharge summaries, discharge medication reconciliations and pharmacy records. Results: Among 75 patients with ITDM (62 (82%) T2DM, 12 (16%) T1DM, 1 (1%) ketosis-prone DM), errors were noted in 73 (97%) patients. 46 (63%) were discharged on wrong form of insulin and 67 (91%) were discharged without appropriate insulin administration devices. Among those 73 patients, 19 (26%) patients had an increase in HbA1c at 3 months (8.7 vs 10.03, p=0.001); 5 (25%) and 8 (24%) had 30-day and 90-day diabetes-related hospital readmissions, respectively. In 2 patients with appropriate discharge, there were no 30-day or 90-day hospital readmissions. Conclusion: Prescription errors in patients with ITDM at discharge are common and potentially remediable and lead to hospital readmissions and poor glycemic control. These results demonstrate the need for increased awareness among providers through adoption of standardized discharge insulin order sets in EMR system including the form of insulin, insulin administration devices and supplies as well as for early post-discharge follow up with endocrinology. Disclosure A.N.Keskinkilic: None. M.T.Korytkowski: None. S.Mon: None.

Clinical pharmacist intervention to improve medication safety for hip fracture patients through secondary and primary care settings: a nonrandomised controlled trial

BackgroundHip fracture patients face a patient safety threat due to medication discrepancies and adverse drug reactions when they have a combination of high age, polypharmacy and several care transitions. Consequently, optimised pharmacotherapy through medication reviews and seamless communication of medication information between care settings is necessary. The primary aim of this study was to investigate the impact on medication management and pharmacotherapy. The secondary aim was to evaluate implementation of the novel Patient Pathway Pharmacist intervention for hip fracture patients.MethodsHip fracture patients were included in this nonrandomised controlled trial, comparing a prospective intervention group (n = 58) with pre-intervention controls who received standard care (n = 50). The Patient Pathway Pharmacist intervention consisted of the steps: (A) medication reconciliation at admission to hospital, (B) medication review during hospitalisation, (C) recommendation for the medication information in the hospital discharge summary, (D) medication reconciliation at admission to rehabilitation, and (E) medication reconciliation and (F) review after hospital discharge. The primary outcome measure was quality score of the medication information in the discharge summary (range 0–14). Secondary outcomes were potentially inappropriate medications (PIMs) at discharge, proportion receiving pharmacotherapy according to guidelines (e.g. prophylactic laxatives and osteoporosis pharmacotherapy), and all-cause readmission and mortality.ResultsThe quality score of the discharge summaries was significantly higher for the intervention patients (12.3 vs. 7.2, p < 0.001). The intervention group had significantly less PIMs at discharge (− 0.44 (95% confidence interval − 0.72, − 0.15), p = 0.003), and a higher proportion received prophylactic laxative (72 vs. 35%, p < 0.001) and osteoporosis pharmacotherapy (96 vs. 16%, p < 0.001). There were no differences in readmission or mortality 30 and 90 days post-discharge. The intervention steps were delivered to all patients (step A, B, E, F = 100% of patients), except step (C) medication information at discharge (86% of patients) and step (D) medication reconciliation at admission to rehabilitation (98% of patients).ConclusionThe intervention steps were successfully implemented for hip fracture patients and contributed to patient safety through a higher quality medication information in the discharge summary, fewer PIMs and optimised pharmacotherapy.Trial registration: NCT03695081.

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.

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...

Results of a Pilot Study for a Pharmacy Discharge Review in Neurosurgical Patients: A Quality-Safety Initiative.

Objective A multidisciplinary collaboration between the neurosurgical team and the pharmacy was established to conduct a pilot study in which discharged neurosurgical patients from a community hospital would receive medication reconciliation services and counseling by a pharmacy specialist to determine the impact on patient safety, readmission rates, and medication compliance. Methods Pharmacists reviewed discharge medication reconciliations of neurosurgical patients to address any discrepancies with the nurse practitioners or physicians prior to discharge and provided discharge medication counseling to the patient/families at the bedside. The service was provided on weekdays during the eight-hour pharmacist shiftin addition to other daily responsibilities. Data were analyzed by type and the total number of pharmacy interventions encountered during the discharge medication reconciliation process, time to complete services, and readmission rates. Lastly, the discharged neurosurgical patients that were not seen by pharmacists during the one-month pilot study were reviewed retrospectively to determine potential interventions. Results A total of 48 neurosurgical patients were discharged during the one-month pilot study; 27 patients received discharge medication reconciliation services and counseling from the pharmacy specialists. Sixty-three pharmacy interventions were accepted with prevention of medication errors/adverse drug reactions (21%, n=21) and addition of missing medication (21%, n=21) being the most common intervention types. The mean time to complete the services was 27 minutes and there was one non-medication-related readmission of the 27 patients seen. Twenty-one neurosurgical patients who were discharged without receiving services were reviewed retrospectively. It was determined that there was a potential for another 64 pharmacy interventions in which clarification of indication (33%, n=21) was the most common intervention type, followed by prevention of medication errors/adverse drug reactions (25%, n=16) and addition of missing medication (22%, n=14). There was a total of one medication-related readmission of the 21 patients not seen by the pharmacist during the pilot study. Conclusion The collaboration of pharmacists in the discharge process benefits neurosurgical patients by reducing the number of discrepancies when transitioning home and provides an additional layer of safety to reduce medication errors and/or prevent adverse events.

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.

Prevalence and severity of discharge medication discrepancies resolved by pharmacists at a veterans affairs teaching hospital

AbstractIntroductionAlthough reassuring outcome data exist, not all pharmacist discharge efforts have been effective. This may be explained by heterogenous medication reconciliation definitions and processes. At a Veterans Affairs Teaching Hospital, Clinical Pharmacy Specialists (CPS) review the discharge medication reconciliation as part of a multidisciplinary process. The objective of this study is to describe CPS' role in resolving discharge medication reconciliation discrepancies and to evaluate potential patient harm avoided through pharmacist intervention.MethodsPatients discharged home on at least one medication between October 21, 2021 and February 16, 2022 were included in this prospective single cohort study at a Veterans Affairs Hospital. Medication discrepancies were recorded. A panel of independent pharmacists categorized the clinical impact of discrepancies based on the potential to cause patient discomfort or clinical deterioration had the discrepancy gone unresolved: unlikely (class I), moderate (class II), or severe (class III).ResultsA total of 300 discharges were evaluated and 546 discrepancies identified. A majority (n = 202, 67.3%) of discharges had a discrepancy, with an average of 1.8 (SD ± 2.4) discrepancies per discharge. Pharmacists provided education during 84.3% of discharges and spent an average of 21.7 (SD ± 16.7) minutes per discharge. Panelists identified 359 (65.8%) class I, 149 (27.3%) class II, and 38 (7%) class III discrepancies. Omitted medication and incorrect dosing discrepancies conferred highest risk for potential patient harm. An increase in the number of medication changes from admission to discharge was the only variable predictive of discrepancies at discharge.ConclusionPharmacists play a vital role at hospital discharge by resolving discrepancies and mitigating potential adverse outcomes. Designing discharge systems that prevent omitted medication and incorrect dosing discrepancies may be beneficial as these errors had the largest potential clinical impact; however, this hypothesis was unable to be tested in this study and deserves further research.

Improving the discharge medication reconciliation process for an inpatient hematologic malignancies service by utilizing a pharmacist-facilitated workflow

BackgroundThere is an opportunity for pharmacists to play a greater role during discharge medication reconciliation (MR), particularly in the oncology setting. ObjectivesThis initiative aims to decrease the number of medication discrepancies that occur during discharge MR and improve physician satisfaction with the discharge MR process for patients discharged from an inpatient adult hematologic malignancies (HM) service. Practice descriptionPatients on the HM service at Sibley Memorial Hospital, a community hospital located in Washington, DC, are co-managed by hospitalists and HM oncologists. The care team for the service also includes nursing staff and a clinical pharmacist. Practice innovationThe HM service piloted a pharmacist-facilitated workflow that involved the clinical pharmacist reconciling inpatient and outpatient medications prior to discharge, reviewing the discharge MR with the HM oncologist, and pending the discharge MR in the electronic medical record for the discharging hospitalist to review and sign. Evaluation methodsPrior to pilot implementation, discharge MRs of patients discharged from the HM service from November 2021 to December 2021 were analyzed by a pharmacist to identify medication discrepancies through retrospective chart review. This process was repeated to analyze pharmacist-facilitated discharge MRs for discrepancies for patients discharged between December 2021 to April 2022. Physician satisfaction with the process was assessed via survey pre and post-pilot. ResultsA total of 30 and 37 discharge MRs were analyzed pre- and post-pilot, respectively. There were 19 medications discrepancies identified in the pre-pilot group and 6 discrepancies noted in the post-pilot group (P=0.038). Median physician satisfaction with the process was found to be 3.3 pre-pilot, and 5 post-pilot (on a scale of 1-5, with 5 being very satisfied). ConclusionA pharmacist-facilitated workflow for discharge MR increased the accuracy of the discharge MR for patients on the HM service and improved physician satisfaction with the discharge MR process.

Pharmacist discharge summary: Impact of inpatient to community pharmacist handoff at hospital discharge

BackgroundCommunity pharmacists are often the initial health professionals whom patients encounter after hospital discharge but are rarely provided relevant discharge information. ObjectivesImplement a pharmacist-to-pharmacist discharge summary (P2PDS) to improve the safety of pharmacist care provision to patients transitioning home from the hospital. Practice descriptionInpatient pharmacists at an academic medical center conduct discharge medication reconciliation and release discharge electronic prescriptions to dispensing pharmacies. Practice innovationA multidisciplinary intersystem quality improvement project was conducted to demonstrate the impact of clinical information sharing via the P2PDS to community pharmacists. Evaluation methodsWith input from community pharmacists, the P2PDS was created and implemented on inpatient units throughout the health system. Outcomes assessed included identification of medication discrepancies, enrollment into reimbursable medication management services, and pharmacist confidence when filling discharge prescriptions. ResultsDuring the study period, community pharmacists identified a total of 388 medication discrepancies in 161 patients; 16% of discrepancies were considered “unintentional.” Twenty-five discharging patients were identified for enrollment in medication management services, with 20 of these patients enrolling in all 3 services (medication delivery, synchronization, and medication packaging). The P2PDS increased community pharmacist confidence in discharge medication filling (40% vs. 95%, P < 0.001) and increased the percent of patients receiving community pharmacist medication reconciliation (14%-76%, P < 0.001). ConclusionEnhancing pharmacist communication across practice settings with a P2PDS decreases care fragmentation through identification of medication discrepancies and improves pharmacist confidence in patient care provision.