Discrepancies In Medication Histories Research Articles

Interprofessional survey on medication reconciliation activities in the US Department of Veterans’ Affairs: development and validation of an Implementation Readiness Questionnaire

BackgroundMedication reconciliation (MR) can detect medication history discrepancies at interfaces-in-care and help avoid downstream adverse drug events. However, organisations have struggled to implement high-quality MR programmes. The literature has identified...

Impact of a Clinical Pharmacist Telehealth Service in a Geriatrics Assessment Clinic.

Objective Evaluate the impact of a telepharmacy service at a geriatrics assessment clinic. Design Retrospective, single-center, nonblinded cohort study. Setting Geriatrics assessment clinic. Patients The intervention/pharmacist and the control/no-pharmacist (provider) group included patients new to the clinic 50 years of age or older from over the span of 4 months. Patients who the pharmacist was unable to reach and those who missed appointments with the provider were excluded. Interventions The pharmacist phoned new patients approximately one week prior and one week after their first appointments with a provider. Main Outcome Measure Primary outcome: number of drug-related problems (DRPs) detected by the pharmacist compared with the provider. Secondary outcomes: number of medication history discrepancies, accepted medication-related recommendations, potentially inappropriate medications (PIMs) deprescribed, and adverse drug reactions (ADRs) detected. Results In the intervention/pharmacist (n = 204) vs control/no pharmacist (n = 200) groups, the number of DRPs was significantly greater (338 vs 218; P = 0.031) and driven by unnecessary drug therapies, doses too high, ADRs, and drug-drug interactions (230 vs 147, P = 0.045; 37 vs 7, P = 0.010; 36 vs 17, P = 0.023; 32 vs 1, P = 0.003, respectively). The difference in number of recommendations made by the pharmacist vs medication changes made by the provider was significant: 457 vs 319, P < 0.001, respectively. Conclusions The addition of a clinical pharmacist conducting telepharmacy at a geriatrics assessment clinic had a positive impact on patient care as it relates to DRPs, deprescribing PIMs, and optimizing medication adherence.

The impact of an in-department pharmacist on the prevention of drug iatrogenesis in a rheumatology department.

The primary objective was to evaluate the impact of an in-department pharmacist on the prevention of drug iatrogenesis in a rheumatology department. Secondary objectives were to determine (i) if medication history discrepancies were detected more frequently in the elderly or not, and (ii) if the mean number of treatments at admission had an impact on the number of medication history discrepancies. Implementation of a clinical-pharmacy program based on medication reconciliation and medication review of prescription for all patients admitted to a rheumatology department between January and June 2017. The analytical approach was mainly descriptive and data were expressed as mean ± standard deviation (i.e., number of treatments at admission, number of medication reconciliations) and as proportions (i.e., acceptance rate, impact). Chi-squared tests and Student's test were performed to determine if there was a significant difference in outcomes. Three hundred twelve patients were included in the study, 517 medication history discrepancies in 243 (77.8%) patients and 196 pharmaceutical interventions in 133 (42.6%) patients. A significant difference was found in the number of medication history discrepancies and pharmaceutical interventions between the two age groups and in the mean number of treatments at admission between patients with or without medication history discrepancies. 15.4% of study patients had major medication history discrepancies and major pharmaceutical interventions. All patients and practitioners reported the usefulness of an in-department pharmacist. This program was found effective in terms of safety and improvement in the continuity of care. Key Points • This clinical-pharmacy program with an in-department pharmacist had a positive impact on the prevention of drug iatrogenesis in one rheumatology department. • 15.4% (n = 48) of study patients had major medication history discrepancies and major pharmaceutical interventions. • All practitioners and patients were satisfied with this clinical-pharmacy program.

Value of pharmacy services in an outpatient, preoperative, anesthesia clinic

ObjectiveThis pilot study assessed the expansion of pharmacy services to a preoperative, anesthesia clinic. SettingTertiary care academic medical center. Practice descriptionMedication histories were routinely obtained by clinic nurses, and pharmacy services were not available. Practice innovationA prospective, single-center, pilot study enrolled English-speaking patients aged 65 years or older in a preoperative clinic before a scheduled surgery. Patient attributes including health literacy and preparatory activities were measured using verbal and written questionnaires. Home medication lists were obtained by both clinic nurses (routine care) and a pharmacist (research), and the 2 lists were compared to identify medication discrepancies for each patient. Discrepancies were categorized by type and severity. EvaluationThis study evaluated the potential impact of medication histories obtained by pharmacists compared with those obtained by clinic nurses during geriatric preoperative clinic visits. ResultsOf the 44 patients who gave their consent and were included in this pilot study, 25% (n = 11) had limited/marginal written and verbal health literacy, and 20% (n = 9) had limited/marginal numerical health literacy. Of the 38 patients who completed the pharmacist medication history interview, only 21% (n = 8) brought a complete list of their current medications to the preoperative clinic, 95% (n = 36) had at least 1 medication discrepancy, and 61% (n = 23) had at least 1 clinically meaningful discrepancy. Clinically meaningful discrepancies were identified for 8% (35 of 459) of medications and occurred most commonly for blood pressure medications, nonsteroidal anti-inflammatory drugs, and beta blockers. ConclusionIn this study, medication history discrepancies identified by pharmacists suggest that the expansion of pharmacy services into the preoperative clinic is feasible and could potentially prevent meaningful medication errors among geriatric patients being admitted for a scheduled surgery.

Pharmacy collected medication histories in an observation unit.

Background:Clear processes to facilitate medication reconciliation in a hospital setting are still undefined. The observation unit allows for a high patient turnover rate, where obtaining accurate medication histories is critical.Objectives:The objective of this study was to assess the ability of pharmacists and student pharmacists to identify discrepancies in medication histories obtained at triage in observation patients.Methods:Pharmacists and student pharmacists obtained a medication history for each patient placed in observation status. Patients were excluded if they were unable to provide a medication history and family, caregiver, or community pharmacy was also unable to provide the history. A comparison was made between triage and pharmacy collected medication histories to identify discrepancies.Results:A total of 501 medications histories were collected, accounting for 3213 medication records. There were 1176 (37%) matched medication records and 1467 discrepancies identified, including 808 (55%) omissions, 296 (20.2%) wrong frequency, 278 (19%) wrong dose, 51 (3.5%) discontinued, and 34 (2.3%) wrong medication. There was an average of 2.9 discrepancies per patient profile. In all, 76 (15%) of the profiles were matched. The median time to obtain a medication history was 4 min (range: 1–48 min).Conclusion:Pharmacy collected medication histories in an observation unit identify discrepancies that can be reconciled by the interdisciplinary team.

Medication histories by pharmacy technicians and physicians in an emergency department.

Medication histories (MHs) obtained at the time of patients' admission to hospital are often incomplete, and lack of information about patients' actual medicine use can potentially lead to prescribing failures and serious adverse events. Uses of clinical pharmacists in obtaining MHs are beneficial, but due to limited economic resources clinical pharmacists cannot be present in every hospital ward, and therefore pharmacy technicians (PTs) could probably be trained in obtaining MHs. To compare discrepancies in MHs obtained by physicians and PTs in an emergency department. Second to evaluate, whether PTs could assist and/or replace physicians in obtaining MHs. The study was conducted in the emergency department at Svendborg Hospital, Denmark and patients treated with a minimum of three prescribed medicines were included. On patients' admission to hospital, physicians recorded the primary MHs, and within 48 h the secondary MHs were made by PTs. All MHs were conducted using standard guidelines. A clinical pharmacist reviewed the MHs, and based on these reviews, a final medication list was defined, and the MHs were compared to this. The discrepancies were registered with respect to type and therapeutic group (medicines). A total of 113 patients were included in this study, and data for 106 patients were analysed. On average, three discrepancies were detected for each patient in the primary MHs, and less than one discrepancy per patient in the secondary MHs. A total of 1075 prescriptions were registered, and for the physicians, 287 discrepancies (27 % of total prescriptions) were found, and for PTs the number was 28 (2 % of total prescriptions). The commonly detected discrepancy was "drug missing in the electronic patient record". The largest number of discrepancies was found for nervous system medications (ATC group N), medicines from ATC group A (alimentary tract and metabolism) and respiratory medicine (ATC group R). Fewer discrepancies in the MHs obtained by PTs than physicians were detected compared to standard medicine lists made by an experienced clinical pharmacist.

Comparison of a Pharmacist-Performed and Physician or Advanced Practice Provider-Performed Medication History in Pediatric Patients.

Background: In the adult population, a high rate of discrepancies exists between provider-performed and pharmacist-performed medication histories. Limited data exist regarding pharmacist-performed medication histories in hospitalized pediatric patients. Objective: Identify the incidence and severity of discrepancies in medication histories performed by practitioners compared with pharmacists in the pediatric population. Methods: After institutional review board approval, a retrospective analysis of pediatric patients admitted to inpatient pediatric units in a tertiary hospital was performed. The primary endpoint of the study was the percentage of provider-performed medication histories with any discrepancies compared with the pharmacist-performed medication history. Secondary endpoints included the number and type of discrepancies and the discrepancy's potential risk of patient harm. Results: A total of 101 subjects were included. Nineteen patients (18.8%) had at least one medication discrepancy. Missing medications accounted for the majority of the discrepancies. Advance practice providers performed a small number of the initial medication histories (5%) and had at least one discrepancy for each history performed. The percentages of Grades 1, 2, and 3 discrepancies were 57.2%, 17.1%, and 25.7%, respectively. Medications with the most frequent discrepancies included anticonvulsants, antihistamines, and histamine receptor antagonists. Limitations include the retrospective nature of the study and lower than expected discrepancy rate. Conclusion: In this study, 18.8% of pediatric patients had a discrepancy between medication histories. Missing medications accounted for the largest amount of discrepancies. A large percentage of discrepancies had the potential to cause patient harm.

Effect of Medication Reconciliation at Hospital Admission on Medication Discrepancies During Hospitalization and at Discharge for Geriatric Patients

Medication discrepancies have the potential to cause harm. Medication reconciliation by clinical pharmacists aims to prevent discrepancies and other drug-related problems. To determine how often discrepancies in the physician-acquired medication history result in discrepancies during hospitalization and at discharge. Secondary objectives were to determine the influence of clinical pharmacists' interventions on discrepancies and to investigate possible patient-related determinants for experiencing discrepancies. This was a retrospective, single-center, cohort study of patients who were admitted to the acute geriatric department of a Belgian university hospital and followed up by clinical pharmacists between September 2009 and April 2010. Patients were limited to those 65 years or older who were taking 1 or more prescription drug. Medication reconciliation at admission, during hospitalization, and at discharge was conducted by an independent pharmacist who gathered information via chart reviews. The reconciliation process at admission identified 681 discrepancies in 199 patients. Approximately 81.9% (163) of patients had at least 1 discrepancy in the physician-acquired medication history. The clinical pharmacists performed 386 interventions, which were accepted in 279 cases (72.3%). A quarter of the medication history discrepancies (165; 24.2%) resulted in discrepancies during hospitalization, mostly because the intervention was not accepted. At discharge, 278 medication history discrepancies (40.8%) resulted in discrepancies in the discharge letter, accounting for 50.2% of all 554 discrepancies identified in the discharge letters. The likelihood for experiencing discrepancies at admission increased by 47% for every additional drug listed in the medication history. Discrepancies in the physician-acquired medication history at admission do not always correlate with discrepancies during hospitalization because of clinical pharmacists' interventions; however, discrepancies at admission may be associated with at least half of the discrepancies at discharge. Clinical pharmacist-conducted medication reconciliation can reduce these discrepancies, provided the erroneous information in the physician-acquired medication history is corrected and each intentional change in the medication plan is well documented during hospitalization and at discharge.

Structured History Taking of Medication Use Reveals Iatrogenic Harm Due to Discrepancies in Medication Histories in Hospital and Pharmacy Records

Structured History Taking of Medication Use Reveals Iatrogenic Harm Due to Discrepancies in Medication Histories in Hospital and Pharmacy Records

Accuracy of the medication history at admission to hospital in Saudi Arabia

Objective Inaccurate medication history at admission to hospitals leads to preventable adverse drug events, which in turn increase mortality, morbidity, and health care costs. The objective of this study was to investigate the role of pharmacists in identifying discrepancies in medication histories at admission to a tertiary referral hospital in Saudi Arabia. Methods We performed a prospective observational study in a 1200 bed tertiary hospital in Riyadh, Saudi Arabia. Patients were included if they were aged 16 years or older, were taking 5 or more medications, and were able to communicate or were accompanied by a caregiver who could communicate. Over 2 months in 2009, a pharmacist interviewed patients to ascertain all medications used prior to hospitalization, then all discrepancies were discussed with the admitting physician and unintended discrepancies were reported as errors. Results A pharmacist interviewed 60 patients who were taking 564 medications total. Of these patients, 65% were male, and their mean age was 62. Patients were taking an average of 9.4 medications. Twenty-two (37%) patients had at least one discrepancy, with the most common being omissions of medications (35%) and dosage errors (35%). The mean age for patients with discrepancies was 64.6 years, and without discrepancies, 60.8 years ( P = 0.37). Conclusion Inaccurate medication history at admission to a hospital was common in Saudi Arabia. This has the potential to cause harm to patients if it remains undetected. Pharmacists could potentially play a major role in obtaining this medication history at the time of hospital admission.

A study of the use of medicine lists in medicines reconciliation: please remember this, a list is just a list

Medication history-taking is recognised as a potential source of medication errors and is the subject of the first National Patient Safety Agency/National Institute for Health and Clinical Excellence Patient Safety Guidance. Medication lists are suggested as a way of improving medicines reconciliation, but, anecdotally, can falsely reassure prescribers that they have an accurate list of medicines if used in isolation. Patients in possession of a medicines list on admission to hospital were approached as part of routine care. Data were collated regarding medication-history discrepancies, their source and whether a prescription amendment was made. One hundred and twenty patients were reviewed and the median time for pharmacists to complete medicines reconciliation was 15 min. Eighty-three patients (69.2%) had only one medication list, 31 (26%) had two, five (4%) had three and one patient (0.8%) had four lists. In total, 447 discrepancies were identified of which 49 (11.0%) were initiated by the patient, including 32 (65.3%) to adjust a dosage regimen or not to comply with a dosing regime. For the 279 (62.4%) discrepancies attributable to secondary care staff, 119 (42.6%) prescribed medicines were omitted unintentionally. For the 119 (26.6%) discrepancies attributable to the primary care medicines lists, 48 (40.3%) related to inadequate or inaccurate information regarding medicine doses, frequency, strength or form. Each patient required a mean of 1.6 amendments to their prescription despite bringing a list of medicines with them. Medication lists should be interpreted with caution and assessed in combination with other sources of information, particularly the patient or their carer. Strategies to improve medicines reconciliation on admission to hospital are still needed and a single electronic patient record encompassing primary and secondary care medication records would be a positive step forward.

Pharmacist elicited medication histories in the Emergency Department: Identifying patient groups at risk of medication misadventure

The Australian Pharmaceutical Advisory Committee guidelines call for a detailed medication history to be taken at the first point of admission to an Emergency Department (ED). The elderly, in particular those residing in Residential Aged Care Facilities and those with a non-English speaking background, have been identified as patient groups vulnerable to medication misadventure. to analyse the incidence of discrepancies in medication histories in these demographic groups when pharmacist elicited medication histories were compared with those taken by ED physicians. It also aimed to investigate the incidence of medication related ED presentations. The study was conducted over a six week period and included 100 patients over the age of 70, who take five or more regular medications, have three or more clinical co-morbidities and/or have been discharged from hospital in three months prior to the study. Twenty four participants were classified as 'language barrier'; 12 participants were from residential aged care facilities, and 64 participants were classified as 'general'. The number of correctly recorded medications was lowest in the 'language barrier' group (13.8%) compared with 18% and 19.6% of medications for 'general' patients and patients from residential aged care facilities respectively. Seven of the patients (29.2%) with 'language barrier'; 1 from a residential aged care facility (8.3%) and 13 of the (20.3%) patients from the 'general' category were suspected as having a medication related ED presentation. This study further highlights the positive contribution an ED pharmacist can make to enhancing medication management along the continuum of care. This study also confirms the vulnerability of patients with language barrier to medication misadventure and their need for interpreter services at all stages of their hospitalisation, in particular at the point of ED presentation.

Reconciliation of discrepancies in medication histories and admission orders of newly hospitalized patients

A 1999 Institute of Medicine report received national attention by highlighting system vulnerabilities within health care and indicating that medication errors are a leading cause of morbidity and mortality. One area of concern was the increased number of errors occurring in the prescribing phase of the medication-use process due to prescribers’ lack of essential drug knowledge and patient information at the time of ordering. Pharmacists’ participation in medical rounds has demonstrated a reduction in medication errors in the ordering stage. However, at most hospitals, pharmacists are not directly involved in obtaining medication histories, despite the findings of one study showing that over 70% of drug-related problems were recognized only through a patient interview and another study reporting a 51% reduction in medication errors when pharmacists were involved in obtaining medication histories. Medication errors and patient harm can result from inaccurate or incomplete histories that are subsequently used to generate medication KRISTINE M. GLEASON, B.S.PHARM., is Research Pharmacist Coordinator; JENNIFER M. GROSZEK, R.N., B.S.N., M.J., and CAROL SULLIVAN, R.N., M.B.A., are Research Nurse Coordinators, Patient Safety Team; DENISE ROONEY, R.N., B.S.N., O.C.N., is Manager, Patient Safety Team; and CYNTHIA BARNARD, M.B.A., M.S.J.S., C.P.H.Q., is Director, Quality Strategies and Patient Safety Team, Division of Quality and Operations, Northwestern Memorial Hospital (NMH), Chicago, IL. GARY A. NOSKIN, M.D., is Associate Professor of Medicine, Department of Medicine, Division of Infectious Diseases, Feinberg School of Medicine, Northwestern University, Chicago, and Medical Director, Healthcare Epidemiology and Quality, NMH. Address correspondence to Ms. Gleason at the Division of Quality and Operations, Northwestern Memorial Hospital, 676 North St. Clair Street, Suite 700, Chicago, IL 60611 (kmgleaso@nmh.org). The Patient Safety Team and Failure Mode and Effects Analysis team members at Northwestern Memorial Hospital are acknowledged for their active participation and support. Karen Nordstrom, B.S.Pharm., Michael Fotis, B.S.Pharm., and Desi Kotis, Pharm.D., provided invaluable assistance and insight into this project. The dedicated clinical staff pharmacists are acknowledged for enhancing patient safety by obtaining medication and allergy histories, reconciling discrepancies in medication histories and orders, and collecting data. Supported in part by an Excellence in Academic Medicine Grant from the State of Illinois Department of Public Aid and U.S. Public Health Service grant UR8/515081. Presented at the ASHP Midyear Clinical Meeting, Atlanta, GA, December 11, 2002; the 5th Annual National Patient Safety Foundation Patient Safety Congress, Washington, DC, March 12–14, 2003; and the Institute for Healthcare Improvement 15th Annual National Forum on Quality Improvement in Health Care, New Orleans, LA, December 4, 2003.