Medication Discrepancies Research Articles

Study to assess the impact of analytics software on operating room controlled substance management and drug diversion.

This study investigated the impact of an advanced analytics software solution in the operating room (OR) on tracking and evaluating controlled substance discrepancies. The authors hypothesized that the software would increase identification of these discrepancies and improve the efficiency of the preexisting manual process. In this evaluation comparing data from before to after implementation of the software, data were collected using the preexisting manual process for 50 days before implementation, followed by a 25-day period for acclimation to the new software, and ending with a 49-day postimplementation review period. Data collected included the total number of medication discrepancies, time required for discrepancy review and reconciliation by an OR analyst, types of discrepancies, and number of discrepancies leading to provider audits. Before implementation of the analytics software, there were 7,635 OR cases with a total of 674 charting discrepancies (8.83 discrepancies per 100 total OR cases) discovered across 439 OR cases. After implementation, there were 7,454 OR cases with a total of 930 charting discrepancies (12.48 discrepancies per 100 total OR cases; P < 0.0001) discovered across 680 OR cases. While discrepancies increased by 38%, the median review time for the OR analyst per case decreased (P < 0.0001) and the percentage of incidents resolved by the OR analyst increased by 14% while the number of cases requiring additional documentation by the provider decreased by 10%. Implementation of advanced analytics software in the OR significantly increased the number of controlled substance charting discrepancies identified compared to the preimplementation review process while increasing the efficiency of the OR analyst.

Exploring the Roles of Nurses in Medication Reconciliation for Older Adults at Hospital Discharge: A Narrative Approach.

Medication reconciliation (MR) is the process of comparing a patient's medication orders to all of the medications that the patient has been taking in order to identify and resolve medication discrepancies. It is an effective means of risk management to avoid medication errors (eg, omissions, duplication, dosage errors, or drug interactions). Some guidelines explicitly state that MR is a pharmacist-led transition of care; however, there is a shortage of qualified pharmacists to meet the increasing clinical needs, and clinical nurses' roles have not been clearly described. This paper aimed to enable nurses to gain confidence in contributing to MR at discharge and to make the industry aware of the potential risks if nurses do not actively intervene in this area. A narrative approach was used to introduce experiences in identifying discrepancies and medication errors through MR at discharge in a geriatric ward of an academic medical center hospital in China. The nurses' main roles in MR involve chasing, checking, and education. Clinical nurses, an untapped hospital resource, can actively engage in MR at discharge if they receive effective training and motivation. Multidisciplinary collaboration at discharge allowed many discrepancies to be reconciled before harming older patients. It is worth conducting further research in MR when discharging older adults, such as the cost-effectiveness of nurses' efforts, the value of electronic tools and the impact of MR-targeted education and training for nursing students and nursing staff.

An Overview of Pharmaceutical Reconciliation

During the move between healthcare settings and changes in the medical status of patients, it is very important to update the correct drug regimen according to the clinical conditions to avoid the possibility of medical errors. Nearly half of medication errors occur during initial admission, transfer between hospital departments, and before discharge. Among these errors, about 30% of cases have the potential of seriously harming the patient. Some risk factors, such as old age and the number of drugs used, are associated with an increased risk of medication discrepancies. The medication reconciliation process can significantly reduce the risk of potential errors. It includes obtaining, verifying, and documenting a list of the patient's current medications and comparing it to the patient's medication orders and condition to identify and resolve any discrepancies. Comparing what is being prescribed in one setting with what is being taken in another will prevent errors of drug-drug interactions, omission, and other discrepancies. Pharmaceutical reconciliation is an important element of patient safety and rational drug use, and it can significantly contribute to the health economy.

Intervention for a correct medication list and medication use in older adults: a non-randomised feasibility study among inpatients and residents during care transitions

BackgroundMedication discrepancies in care transitions and medication non-adherence are problematic. Few interventions consider the entire process, from the hospital to the patient’s medication use at home.AimIn preparation for randomised controlled trials (RCTs), this study aimed (1) to investigate the feasibility of recruitment and retention of patients, and data collection to reduce medication discrepancies at discharge and improve medication adherence, and (2) to explore the outcomes of the interventions.MethodParticipants were recruited from a hospital and a residential area. Hospital patients participated in a pharmacist-led intervention to establish a correct medication list upon discharge and a follow-up interview two weeks post-discharge. All participants received a person-centred adherence intervention for three to six months. Discrepancies in the medication lists, the Beliefs about Medicines Questionnaire (BMQ-S), and the Medication Adherence Report Scale (MARS-5) were assessed.ResultsOf 87 asked to participate, 35 were included, and 12 completed the study. Identifying discrepancies, discussing discrepancies with physicians, and performing follow-up interviews were possible. Conducting the adherence intervention was also possible using individual health plans for medication use. Among the seven hospital patients, 24 discrepancies were found. Discharging physicians agreed that all discrepancies were errors, but only ten were corrected in the discharge information. Ten participants decreased their total BMQ-S concern scores, and seven increased their total MARS-5 scores.ConclusionBased on this study, conducting the two RCTs separately may increase the inclusion rate. Data collection was feasible. Both interventions were feasible in many aspects but need to be optimised in upcoming RCTs.

Effectiveness of Standardized Medication Reconciliation Education on Provider's Compliance and Medication Discrepancies in an Ambulatory Clinic Caring for Post-Allo HSCT Patients. a Quality Improvement Project.

Effectiveness of Standardized Medication Reconciliation Education on Provider's Compliance and Medication Discrepancies in an Ambulatory Clinic Caring for Post-Allo HSCT Patients. a Quality Improvement Project.

Impact of Clinical Pharmacist-conducted Medication Reconciliation at Admission and Discharge on Medication Safety in Patients Hospitalized with Acute Decompensated Heart Failure.

Most studies have focused on the impact of medication reconciliation on one of the points of hospital admission or discharge. In this study, we aimed to investigate the impact of medication reconciliation at both admission and discharge on medication safety in patients hospitalized with acute decompensated heart failure. This was a prospective, single-center, cohort study conducted in a tertiary care cardiovascular hospital from October 2022 to March 2023 on patients hospitalized with acute decompensated heart failure. Patients were considered eligible if they were taking at least five chronic medications prior to hospital admission. Medication reconciliation was carried out for the study patients by a clinical pharmacy team both at admission and discharge. Further, the study patients also received comprehensive discharge counseling as well as post-discharge follow-up and monitoring. Medication reconciliation was applied for 129 patients at admission and 118 of them at discharge. The mean time needed for medication reconciliation presses was 32 min per patient on admission and 22min per patient on discharge. Unintentional medication discrepancies were relatively common both at admission and discharge in the study participants, but compared to admission, discrepancies were less frequent at discharge (178 versus 72). Based on the consensus review, about 30% of identified errors detected at both admission and discharge were judged to have the potential to cause moderate to severe harm to the patient, and most of the clinical pharmacists' recommendations on unintended discrepancies were accepted by physicians and resulted in changes in medication orders (more than 80%). Further, the majority of the participants were 'very satisfied' or 'satisfied' with the clinical pharmacy services provided to them during hospitalization and after hospital discharge (89.90%). Our results demonstrated that heart failure patients are vulnerable to medication discrepancies both at admission and discharge and implementing a comprehensive medication reconciliation by clinical pharmacists could be helpful in improving medication safety in these patients.

Assessment of medication discrepancy, medication appropriateness, and cost analysis among patients with pediatric nephrotic syndrome: An ambispective cohort observational study

BackgroundNephrotic syndrome (NS) is a commonly encountered chronic kidney disease in pediatric populations, with South Asian children being at high risk and requiring long-term pharmacological management. Thus, identifying medication discrepancies and evaluating the appropriateness of therapy and its economic burden are vital for inpatient management. The aim of the study was to assess medication reconciliation, medication appropriateness, and cost analysis in NS cases. MethodsAn ambispective cohort observational study was carried out with 150 NS patients where medication discrepancies were identified retrospectively and prospectively using the best possible medication history and following up patients correspondingly. Further, the Medication Appropriateness Index and cost variation analysis were used to assess the prescribed therapy and cost analysis, respectively. ResultsOut of 150 patients with NS included, 67.3% were male and the mean age was 7.2 years. In total, 36.7% medication discrepancies were found at baseline and 6% discrepancies at follow-up. The majority of discrepancies were unintentional and due to dosing error both at baseline and follow-up. Further, in only 2% of the patients was there inappropriately prescribed medication, and the majority of patients spent between INR (Indian Rupees) 500 and 1000. ConclusionChronic conditions like NS require continuous monitoring by the specialist pediatric clinical pharmacist, who can contribute significantly by minimizing the medication discrepancies, by assessing the appropriateness of therapy, and lessening the economic burden.

From Inaccuracy to Insight: Identifying Medication Discrepancies through Observational Reconciliation at a Tertiary Care Hospital, Bhimavaram of Andhra Pradesh

Background: Medication reconciliation is the process of examining the patient's entire medication regimen at the time of admission, transfer, and discharge and comparing it with the regimen being considered for the new setting of care. This helps to prevent unintentional inconsistencies across transitions in medical care. Medication reconciliation protects patients from medication side effects while ensuring that they receive standard care. It serves as the baseline from which therapeutic interventions are developed, drug treatment is continued upon admission, and self-care is continued upon release. Objectives: Determining the frequency and kinds of discrepancies discovered during medication reconciliation was the main goal of this study. Determining the effect of medication reconciliation to assess the possible seriousness of medication inconsistencies and ascertain the drug's role in medication errors was the secondary goal. Methodology: In the inpatient units of a tertiary care hospital in the West Godavari District, a prospective, observational study on medication reconciliation was conducted for six months. Results: Of the 385 patients that made up this study, 224 (58.18%) were males and 161 (41.8%) were females. In 169 (43.89%) of the patients, medication discrepancies were detected. There were inconsistencies discovered at several transition points: 50 disparities were detected at admission, 50 during the transfer phase, and 17 on the discharge. Conclusion: A multi-centric assessment including parameters like the percentage of inpatients encountering at least one major medication error would be intriguing. This may support the idea that drug reconciliation is crucial for patient safety.

Effectiveness of Clinical Pharmacists-Led Medication Reconciliation to Prevent Medication Discrepancies in Hospitalized Patients: A Non-Randomized Controlled Trial.

Medication discrepancies are a major safety concern for hospitalized patients and healthcare professionals. Medication Reconciliation (MR) is a widely used tool in different practice settings to ensure the proper use of medications. This study aimed to assess the effectiveness of the clinical pharmacists-led MR process in identifying, preventing, and resolving medication discrepancies among hospitalized patients. This was a prospective study with an observational and interventional part, conducted at the Internal Medicine Department of a tertiary Hospital in Sudan from January to September 2023. The enrolled patients were divided into two groups, the observation group, in which the routine MR process was performed by doctors (usual care), and the intervention group, in which clinical pharmacists led the MR process. Compared to the usual care, the clinical pharmacists were more efficient in identifying and preventing medication discrepancies (P=0.001). From a total of 1012 medications, clinical pharmacists' interventions contributed to the detection of (39%) equivalent to 2.2 discrepancies per patient, resolving 325 (83%) and preventing (55%) clinically significant discrepancies. Dose discrepancy (43%) was the most common type of identified discrepancies. These interventions were accepted by (98%) of doctors and implemented in (86%) of the total cases. The main predictors of medication discrepancies (P ≤0.05) for patients were the length of hospital stay, patient-hospital transfer, high number of medication histories, and increased number of medications used during hospitalization. Through the implementation of the MR process, the clinical pharmacist's interventions substantially contributed to the detection and resolution of medication discrepancies among hospitalized patients. It is recommended that this intervention be disseminated in more hospitals in Sudan to encourage the implementation of appropriate practices.

Medication Discrepancies in Hospitalised Medical Patients – Status After a Decade With Targeted Medication Reconciliation Measures, a Cross-sectional Multicenter Study

Several targeted medication reconciliation (MR) initiatives have been introduced to reduce the number of medication discrepancies (MDs). The real-life quality of medication lists at hospital admission has however not been comprehensively investigated in the last decade. We aimed to examine the frequency and potential clinical relevance of MDs at hospital admission and investigate whether certain characteristics are associated with MDs. Patients ⩾18 years old admitted to medical wards at 4 hospitals in Norway were included. MR was performed, and discrepancies between the reconciled medication list and the medication chart were identified. The potential clinical relevance was assessed in a short-term and long-term perspective. We included 250 patients and 201 (80%) had 1 or more MDs, mean 3.2 (SD 2.9) per patient. Out of 824 identified MDs, 171 (20.8%) and 362 (43.9%) were of moderate, major, or extreme potential clinical relevance in short- and long-term perspective, respectively. The risk of MDs increased with increasing age, increasing number of medications, and the use of multidose drug dispensing. Although several targeted MR initiatives have been launched, the frequency of MDs upon hospital admission is still high. However, the potential clinical relevance of the MDs seems less severe, which indicates an improvement.

Optimizing Subsequent CARdiovascular Medication Reintroduction in the Intensive Care Unit.

Hospital admission for a critical illness episode creates communication breakpoints and can lead to medication discrepancies during hospital stays. Due to the patient's underlying condition and the care setting, chronic medications such as cardiovascular medication are often held, discontinued, or changed to alternative administration routes. Unfortunately, data on the optimal timing of cardiovascular drug reinitiation among intensive care unit (ICU) survivors are lacking. The primary objective of this study was to describe the prevalence of chronic cardiovascular medication taken before hospital admission and discontinued at ICU discharge and hospital discharge for critically ill patients. A secondary objective was to assess factors associated with medication discontinuation. We conducted a multicentered retrospective cohort study at 2 tertiary academic hospitals in Canada. All adult patients taking cardiovascular medication before ICU admission and surviving to hospital discharge between April 1, 2016, and April 1, 2017, were eligible. The main outcome of the study was the discontinuation of cardiovascular medication prescribed before ICU admission. The outcome was assessed through participants' chart review. We included 352 patients with a median age of 71.0 years. A total of 155 patients (44.03%) had at least 1 cardiovascular medication discontinued during their stay. Our adjusted model uncovered 3 factors associated with cardiovascular medication discontinuation: male sex (odds ratio [OR] = 0.564, 95% confidence interval [CI] = 0.346-0.919), number of cardiovascular medications taken preadmission (OR = 1.669, 95% CI = 1.003-2.777 for 2 medications and OR = 3.170, 95% CI = 1.325-7.583), and the use of vasopressors (OR = 1.770, 95% CI = 1.045-2.997). Our study uncovered that cardiovascular medication discontinuation for ICU patients is frequent, especially for renin-angiotensin system (RAS) blockers. Data from our study could be used to reinforce site-specific protocols of medication reconciliation and optimization, as well as inform future protocols aimed at RAS blocker reinitiation follow-up.

Implementation of pharmacy-led preoperative medication reconciliation in surgical oncology patients

BackgroundPharmacy-led medication history collection and reconciliation have demonstrated decreased medication errors, increased patient safety, and improved cost-savings. However, literature lacks documented efforts to implement such services in the preoperative space, where having accurate medication lists following complex procedures with high postoperative admission rates is critical. ObjectivesThe purpose of this study was to describe the implementation of a telephonic pharmacy student and pharmacist-led preoperative medication reconciliation program. Practice descriptionThe service was piloted using third- and fourth-year pharmacy students to conduct telephonic medication histories for urologic surgical oncology patients. Weekly reports identified eligible patients with scheduled procedures within 2 weeks’ time. Using standardized methods for patient communication and documentation, students authored telephone encounter notes that were reviewed and signed by pharmacist preceptors. Pharmacist preceptors also reconciled home medication lists based on students’ findings. Practice innovationA standardized preoperative medication reconciliation process was developed and implemented utilizing third- and fourth-year pharmacy students. Resulting notes were available for surgical staff on the day of patients’ procedures and upon potential postoperative admission. Evaluation methodsA retrospective chart review was conducted to evaluate successfully documented medication histories collected by pharmacy students within the pharmacy-led preoperative medication reconciliation program. ResultsForty-six medication reconciliation notes were identified between August 2021 and February 2022, and 39 met inclusion criteria. Amongst the 177 medication additions, deletions, and edits, deletions were the most common, and 95% of patients had at least 1 medication discrepancy identified. A total of 33 medication classes were represented by the identified discrepancies, and each encounter took an average of 33 minutes to complete. ConclusionPreoperative medication reconciliation services can be successfully accomplished through a telephonic pharmacy student and pharmacist-led workflow. Accurate medication histories aid in minimizing medication errors and increasing patient safety.

Medication reconciliation by community pharmacists: an essential contribution to ensure continuity of care with regard to medications at hospital discharge.

Background: Collaboration and communication between hospital and ambulatory care is crucial to ensure continuity of care with regard to medications. However, electronic platforms to facilitate seamless care are often deficient and/or insufficiently integrated. Different Belgian chronic care projects (i.e. regional projects with support of the National Institute for Health and Disability Insurance to enhance integrated care) have therefore decided to implement the ‘green envelope’ as a way to transfer the therapy plan of the patient at discharge to the community pharmacy. The green envelope also contains the prescriptions for the patient, as well as an information letter for the pharmacist, including a QR-code to an online platform where the characteristics of the medication reconciliation, as performed by the community pharmacist, can be registered. The aim of this study was to analyze the findings registered by the pharmacists, as to have a clear idea on their contribution to continuity of care with regard to medications.&#x0D; Methods: A descriptive analysis was performed on the data registered by the community pharmacist during / after medication reconciliation.&#x0D; Results: In total, 1807 online surveys were completed by community pharmacists. The mean duration of the patient encounter in the pharmacy, which in more than three quarter of the cases took place on the day of discharge or the day thereafter, was 12,8 minutes (SD 6,933). Over 63% of patients discharged from hospital were aged +75; 52.4% was female. In about 68% of cases, another person than the patient presented him/herself at the pharmacy.&#x0D; About 74% of the patients had not visited the GP before presenting at the pharmacy; only 24% of patients had a planned appointment with the GP.&#x0D; In about 19% of the cases, the pharmacist discovered at least one medication discrepancy. Most frequently it concerned omitted medication, i.e. medication that was taken by the patient before admission, and for which it was unclear for the patient and pharmacist whether it had been stopped intentionally or not.&#x0D; The pharmacist noted in about 11% of cases at least one drug-related problem, mostly related to the choice or use of the drug. With regard to the choice of drug, it mostly concerned a lack of re-substitution to the molecule used by the patient at home; problems related to the use of the drug mostly referred to incorrect dosing or frequency, or incorrect way of administration.&#x0D; In about 15% of cases, the pharmacist contacted another HCP, mostly the GP. On the level of the patient, the intervention mostly consisted of extensive counselling.&#x0D; The final therapy plan was in less than 60% shared with other HCPs. Problems with the platforms used, and lack of collaboration, were mentioned as the most important reasons for not sharing.&#x0D; Conclusion: Our results show that pharmacists discover a relatively high number of medication discrepancies and drug related problems while performing medication reconciliation at discharge. Their alertness, engagement to contact other HCPs and talk to the patients and their relatives undoubtedly contribute to a safe transfer of patients from the hospital to home.&#x0D;

Beyond the Hospital: Redefining the Role of Pharmacists in Transitions of Care

Unjustifiable medication discrepancies or inconsistency are responsible for more than half of medication errors occurring at transitions in care and up to one-third could have the potential to cause harm. Studies have shown that pharmacist-led medication reconciliation programmes are effective at improving post-hospital healthcare utilisation. In Singapore, the Hospital-to-Home (H2H) programme in Changi General Hospital (CGH) focuses on providing care to vulnerable patients transitioning from different settings, who are exposed to gaps in care and lapses in quality and safety. The Home Medical Service by Pharmacists was pioneered in CGH and Singapore in October 2020 to enhance provision of pharmacy-related services by certified collaborative prescribing pharmacists in the home setting. The purpose of this quality improvement project is to identify provider and patient characteristics that are predictive of the response towards this new pharmacy service, which in turn influences the referrals to the service.&#x0D; A fishbone diagram was used to analyse and categorise the problems into different factors – pharmacist-, nursing-, physician-, patient-, and process-related. Pharmacist-, nursing- and physician-related factors include poor awareness of the potential value-added roles of pharmacists due to the lack of prescribing experience in the home setting. Patient-related factors include difficulty in establishing the appropriate criteria to identify patients who need pharmacist’s intervention. Process-related factors include potential additional cost to patients.&#x0D; Based on the Model of Improvement, several changes were implemented in two Plan-Do-Study-Act (PDSA) cycles. The first cycle was to perform roadshows to the H2H team comprising of physicians and nurses, to raise awareness of the new pharmacy service and pharmacist's roles (more in-depth medication reconciliation, drug information, and prescribing). After three months, the second cycle was initiated by conducting regular monthly case audits with the H2H team to monitor progress, identify lapses, and receive feedback to further improve processes and explore potential areas that pharmacists can contribute.&#x0D; After implementing PDSA cycle 1, the average number of unique home visits by pharmacists per month increased from 1 visit to 4 visits, and subsequently increased to 8 visits after implementing PDSA cycle 2. A survey was also conducted to determine if the changes implemented were satisfactory to the team. Overall, 80% of responses were satisfied with the Home Medical Service by Pharmacists in managing patients under the H2H programme.&#x0D; This project had enabled us to achieve improvements in several processes which facilitated the refinement of pharmacist’s roles in the H2H programme to complement the team’s current roles and increased awareness of these roles within the team. Lastly, we will continue to further improve other problem areas yet be addressed and together with the H2H team, close the gaps in care for patients undergoing transitions of care.

The impact of clinical pharmacists’ medication reconciliation upon patients’ admission to reduce medication discrepancies in the emergency department: a prospective quasi-interventional study

BackgroundThe role of the clinical pharmacist in medication reconciliation is well established. Upon patients’ admission, the reconciliation service mainly focuses on achieving an accurate and full drug history. This will achieve the best treatment plan and reduce medication discrepancies.Upon the recent implementation of clinical pharmacy services in the emergency department at Alexandria Main University Hospital, medication reconciliation was one of the most important duties that needed to be focused on.We hypothesized that clinical pharmacists are able to achieve patients’ drug history lists with higher accuracy than emergency physicians.ResultsA total number of 161 patients were included. Age was 58.59 ± (13.78) years, number of comorbidities was 2.39 ± (1.22) and number of home medications was 4.51 ± (2.72). Clinical pharmacists’ fulfillment of patients’ drug history was significantly more accurate than the emergency physicians (75.16% and 50.3% of the total number of revised patients’ profiles respectively). The clinical pharmacists could put a written copy of the accurate patients’ drug history list in only 50.93% of the revised patients’ profiles. Five hundred eighty-five medication discrepancies were detected which represent an average of 3.63 discrepancies/medication sheet. Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for medication reconciliation and the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) index were used to categorize discrepancies. Categories A, B, and C represented (66.5%), while categories D, E, and F represented (33.5%) of the total discrepancies. There was a significant direct relationship between the total number of discrepancies and both the number of comorbidities and the number of drugs administered before hospital admission.ConclusionThe clinical pharmacists are the main members of the emergency health care team. One of their fundamental services is medication reconciliation. The establishment of a complete drug history list and physicians’ discussion about the current treatment plan can obviously detect and reduce medication errors.Trial registrationNCT04395443. Registered 16 May 2020.

Effect of educational intervention on medication reconciliation practice of hospital pharmacists in a developing country – A non-randomised controlled trial

BackgroundMedication reconciliation is an evidence-based practice that reduces medication-related harm to patients. This study evaluated the effect of educational intervention on medication reconciliation practice of pharmacists among ambulatory diabetes and hypertensive patients.MethodsA non-randomized clinical trial on medication reconciliation practice was carried out among 85 and 61 pharmacists at the intervention site and control site, respectively. Medication reconciliation was carried out among 334 (intervention-183; control-151) diabetes and/or hypertensive patients by the principal investigator to indirectly evaluate pharmacists’ baseline medication reconciliation practice at both sites. A general educational intervention was carried out among intervention pharmacists. Medication reconciliation was carried out by the principal investigator among another cohort of 96 (intervention-46; control-50) and 90 (intervention-44; control-46) patients at three and six months postintervention, respectively, to indirectly assess pharmacists’ postintervention medication reconciliation practice. Thereafter, a focused educational intervention was carried out among 15 of the intervention pharmacists. Three experts in clinical pharmacy analysed the medication reconciliation form filled by the 15 pharmacists after carrying out medication reconciliation on another cohort of 140 patients, after the focused intervention. Data was summarized with descriptive (frequency, percentage, mean ± standard deviation) and inferential (Pearson product-moment correlations analysis, independent-samples t-test and one-way ANOVA) statistics with level of significance set at p<0.05.Key findingsBaseline medication reconciliation practice was poor at both sites. Post-general educational intervention, medication discrepancy was significantly reduced by 42.8% at the intervention site (p<0.001). At the intervention site, a significant increase of 54.3% was observed in patients bringing their medication packs for clinic appointments making medication reconciliation easier (p=0.003), at 6-months postintervention. Thirty-five, 66 and 48 drug therapy problems were detected by 31 (43.1%), 33 (66.0%) and 32 (71.1%) intervention pharmacists at 1-, 3- and 6-month post-general educational intervention, respectively. Post-focused educational intervention, out of a total of 695 medications prescribed, 75 (10.8%) medication discrepancies were detected and resolved among 42 (30%) patients by the 15 pharmacists.ConclusionsThe educational interventions improved pharmacists’ medication reconciliation practice at the intervention site. It is expected that this research would help create awareness on medication reconciliation among pharmacists in developing countries, with a view to reducing medication-related patient harm.

Identifying older inpatients at high risk of unintentional medication discrepancies: a classification tree analysis

Identifying older inpatients at high risk of unintentional medication discrepancies: a classification tree analysis

Medication Reconciliation during Transitions of Care Across Institutions: A Quantitative Analysis of Challenges and Opportunities.

Medication discrepancies between clinical systems may pose a patient safety hazard. In this paper, we identify challenges and quantify medication discrepancies across transitions of care. We used structured clinical data and free-text hospital discharge summaries to compare active medications' lists at four time points: preadmission (outpatient), at-admission (inpatient), at-discharge (inpatient), and postdischarge (outpatient). Medication lists were normalized to RxNorm. RxNorm identifiers were further processed using the RxNav API to identify the ingredient. The specific drugs and ingredients from inpatient and outpatient medication lists were compared. Using RxNorm drugs, the median percentage intersection when comparing active medication lists within the same electronic health record system ranged between 94.1 and 100% indicating substantial overlap. Similarly, when using RxNorm ingredients the median percentage intersection was 94.1 to 100%. In contrast, the median percentage intersection when comparing active medication lists across EHR systems was significantly lower (RxNorm drugs: 6.1-7.1%; RxNorm ingredients: 29.4-35.0%) indicating that the active medication lists were significantly less similar (p < 0.05).Medication lists in the same EHR system are more similar to each other (fewer discrepancies) than medication lists in different EHR systems when comparing specific RxNorm drug and the more general RxNorm ingredients at transitions of care. Transitions of care that require interoperability between two EHR systems are associated with more discrepancies than transitions where medication changes are expected (e.g., at-admission vs. at-discharge). Challenges included lack of access to structured, standardized medication data across systems, and difficulty distinguishing medications from orderable supplies such as lancets and diabetic test strips. Despite the challenges to medication normalization, there are opportunities to identify and assist with medication reconciliation across transitions of care between institutions.

Medication Bias During the Hospital-to-Family Transition Among Young and Middle-Aged Chinese Patients with Type 2 Diabetes: A Qualitative Study.

This study aimed to examine the prevalence of medication non-adherence among young and middle-aged Chinese individuals diagnosed with type 2 diabetes, and to explore the underlying causes of such deviations. The Medication Discrepancy Tool (MDT) was used to assess medication deviations in a cohort of 100 patients who had been discharged from the hospital. Furthermore, 15 subjects were interviewed to gain a better understanding of their medication non-adherence experiences. The rate of medication deviation in the studied cohort was 79.5%, with the most frequent deviation being a reduction in the types of drugs taken. The primary cause of this deviation was found to be patient-derived, with the most common reason being symptom improvement. Iatrogenic medication deviation was most often caused by incomplete or inaccurate medication education for medical staff at discharge, resulting in patients having to guess their own medication. Internal and extrinsic motivating factors were identified as the primary causes of medication deviation behavior. This study has demonstrated that medication non-adherence is a major issue among young and middle-aged Chinese individuals diagnosed with type 2 diabetes. Therefore, it is essential for nurses to be aware of the importance of medication adherence management and working.

A Multi-method Exploratory Evaluation of a Service Designed to Improve Medication Safety for Patients with Monitored Dosage Systems Following Hospital Discharge.

Medication safety problems are common post-hospital discharge, and an important global healthcare improvement target. The Transfers of Care Around Medicines (TCAM) service was launched by a National Health Service Trust in the North-West of England, initially focusing on patients with new or existing Monitored Dosage Systems(MDS). The TCAM service is designed to enable the prompt transfer of medication information, with referrals made by hospitals at discharge to a named community pharmacy. This study aimed to explore the utilisation and impact of the TCAM service on medication safety. The evaluation included a descriptive analysis of 3033 anonymised patient referrals to 71 community pharmacies over a 1-year period alongside an assessment of the impact of the TCAM service on unintentional medication discrepancies and adverse drug events using a retrospective before-and-after study design. Impact data were collected across 18 general practices by 16 trained clinical pharmacists. Most patient referrals (70%, 2126/3033) were marked as 'completed' by community pharmacies, with 15% of completed referrals delayed beyond 30 days. Screening of 411 patient records by clinical pharmacists yielded no statistically significant difference in unintentional medication discrepancies or adverse drug event ratesfollowing TCAM implementation using a multivariable regression analysis (unintentional medication discrepancies adjusted odds ratio = 0.79 [95% confidence interval 0.44-1.44, p = 0.46]; and adverse drug events adjusted odds ratio = 1.19 [95% confidence interval 0.57-2.45, p = 0.63]), although there remained considerable uncertainty. The TCAM service facilitated a number of community pharmacy services offered to patients with monitored dosage systems; but the impact of the intervention on unintentional medication discrepancies and adverse drug event rates post-hospital discharge for this patient group was uncertain. The results of this exploratory study can inform the ongoing implementation of the TCAM service at hospital discharge and highlight the need to understand service implementation in different contexts, which may influence its impact on medication safety.