Medication Omission Research Articles

The Impact of an Electronic Medication Management System on Medication Deviations on Admission and Discharge from Hospital.

Medication errors at transition of care remain a concerning issue. In recent times, the use of integrated electronic medication management systems (EMMS) has caused a reduction in medication errors, but its effectiveness in reducing medication deviations at transition of care has not been studied in hospital-wide settings in Australia. The aim of this study is to assess medication deviations, such as omissions and mismatches, pre-EMMS and post-EMMS implementation at transition of care across a hospital. In this study, patient records were reviewed retrospectively to identify medication deviations (medication omissions and medication mismatches) at admission and discharge from hospital. A total of 400 patient records were reviewed (200 patients in the pre-EMMS and 200 patients in the post-EMMS group). Out of 400 patients, 112 in the pre-EMMS group and 134 patients in post-EMMS group met the inclusion criteria and were included in the analysis. A total of 105 out of 246 patients (42.7%) had any medication deviations on their medications. In the pre-EMMS group, 59 out of 112 (52.7%) patients had any deviations on their medications compared to 46 out of 134 patients (34.3%) from the post-EMMS group (p = 0.004). The proportion of patients with medication omitted from inpatient orders was 36.6% in the pre-EMMS cohort vs. 22.4% in the post-EMMS cohort (p = 0.014). Additionally, the proportion of patients with mismatches in medications on the inpatient charts compared to their medication history was 4.5% in the pre-EMMS group compared to 0% in the post-EMMS group (p = 0.019). Similarly, the proportion of patients with medications omitted from their discharge summary was 23.2% in the pre-EMMS group vs. 12.7% in the post-EMMS group (p = 0.03). Our study demonstrates a reduction in medication deviations after the implementation of the EMMS in hospital settings.

Using xPIRT to Record Pharmacy Interventions: An Observational, Cross-Sectional and Retrospective Study.

Medication errors and omissions can potentially cause harm, prolong a hospital stay, lead to co-morbidities and even death. Pharmacy interventions (PI) ensure that these errors are identified and addressed, leading to improved patient safety and prescriber practice. Particularly in community hospitals, many only having general practitioners and not specialist doctors in their medical teams, PIs assume a strategic role. The PIs recorded throughout 8 months (between November 2021 and June 2022) in the community hospital wards in Powys, Wales, UK, using xPIRT (Pharmacy Intervention Recording Tool), a new pharmacy intervention record toolkit, were subjected to a retrospective analysis. The data were organised by location, drug, severity, acceptance, cost avoidance and intervention type. Significant prescribing errors were identified, which can potentially be different from those recorded in acute settings. Our results also informed on the need for integrated electronic prescribing systems paired with a PI recording tool to address effectively prescribing inaccuracies. Overall, this study was able to identify pharmacy teams as key to improve patient safety and care while contributing to significant cost-savings, through the recording of PI using xPIRT.

“Nobody wants to rock the boat”: a grounded theory study of taking medication to prevent a further heart attack

Abstract Introduction Following an acute myocardial infarction (AMI), patients are prescribed a daily regime of five medications to prevent secondary cardiovascular events, however medication adherence in this patient group has been measured at only 66%.1 Sub-optimal adherence leads to increased mortality, morbidity and healthcare system costs. Current interventions such as monitored dosage systems, phone message reminders and pharmacist consultations have made some improvements but are largely based on presumptions about adherence than formal evidence. Studying the experience of medication-taking following an AMI, and the personal requirement and adjustment that is required to enable adherence could arguably generate the evidence needed to support future interventions in this field. Aim The aim of this study was to use grounded theory methodology to create a model explaining the process of medication-taking in patients prescribed medication following an AMI. Methods Following ethical approval (UREC 18/36), semi-structured interviews were conducted with thirteen people (based in South-East England) taking medication following at least one AMI episode in the past. The interviews were conducted in person, online or via the telephone and audio-recorded. These recordings were transcribed verbatim and analysed according to constructed grounded theory.2 NVivo software was used to organise and display the coded data and produce a model of the medication-taking process. Results Patients took medication because they wanted to continue living their lives. They saw medication as offering them protection, alongside diet and exercise. Following hospital discharge, patients incorporated medication into their daily routines at home. They used mealtimes and bedtime as a prompt, and kept medication located close to these activities. Patients described rarely missing doses but recognised being away from routines was a cause of medication omission. In this stable stage, patients considered medication-taking unproblematic; they ‘just got on with it’. The professional trust established with the medical team was the basis for following medication directions, and patients conferred the authority to make decisions about their treatment, not wanting to initiate changes themselves; to not ‘rock the boat’. The main cause of change to medication-taking was experiencing adverse bodily effects, ascribed by patients to medication and described as side effects. Patients used small noticeable bodily changes as a prompt for further investigation and information- seeking, after which they presented evidence to the medical team, who instigated medication changes. There was a background dislike of taking medication, which was eased by knowledge of medication action and personal biomedical results. These patients were intentionally adherent to medication but were drawn to question their treatment when ‘side effects’ or misunderstanding arose. Discussion/Conclusion Medication-taking in this group is driven by a desire to live, so they accommodate medication routine to fit their lives, but ‘side effects’ can disturb their intention to continue the routine. This action is reinforced by trust relationships with medical professionals. Resistance to taking medication is alleviated by knowledge of medication action and biomedical results. Practitioners can use patient education, test results and shared decision-making as points to further the patient relationship and strengthen adherence behaviours.

Using missed care survey results to improve medication management.

In this study, 96 medical-surgical RNs completed the MISSCARE Survey with a response analysis indicating medication delays or omissions. A medication management improvement project to address administration or reassessment delays achieved improvements at 6 months.

Evaluation of Medication Incidents in a Long-term Care Facility Using Electronic Medication Administration Records and Barcode Technology.

Objective To describe the frequency, type, and severity of reported medication incidents that occurred at a long-term care facility (LTCF) despite electronic medication administration record and barcode-assisted medication administration (eMAR-BCMA) use. The study also contains analysis for the contribution of staff workarounds to reported medication administration errors (MAEs) using an established typology for BCMA workarounds, characterize if the eMAR-BCMA technology contributed to MAEs, and explore characteristics influencing incident severity. Design Retrospective incident report review. Setting A 239-bed LTCF in Alberta, Canada, that implemented eMAR-BCMA in 2013. Participants 270 paper-based, medication incident reports submitted voluntarily between June 2015 and October 2017. Interventions None. Results Most of the 264 resident-specific medication incidents occurred during the administration (71.9%, 190/264) or dispensing (28.4%, 75/264) phases, and 2.3% (6/264) resulted in temporary harm. Medication omission (43.7%, 83/190) and incorrect time (22.6%, 43/190) were the most common type of MAE. Workarounds occurred in 41.1% (78/190) of MAEs, most commonly documenting administration before the medication was administered (44.9%, 35/78). Of the non-workaround MAEs, 52.7% (59/112) were notassociated with the eMAR-BCMA technology, while 26.8% (30/112) involved system design shortcomings, most notably lack of a requirement to scan each medication pouch during administration. MAEs involving workarounds were less likely to reach the resident (74.4 vs 88.8%; relative risk = 0.84, 95% CI 0.72-0.97). Conclusion Administration and dispensing errors were the most reported medication incidents. eMAR-BCMA workarounds, and design shortcomings were involved in a large proportion of reported MAEs. Attention to optimal eMAR-BCMA use and design are required to facilitate medication safety in LTCFs.

An intelligent environment for preventing medication errors in home treatment

This article presents an assistance system based on home sensors, Ambient Intelligence, and Artificial Intelligence, which helps the elderly during their medical treatment at home to reduce medication errors. The sort of medication errors we address are those due to medication omission, wrong dosage or timing, drug–drug interactions. Since the patient may have some physical and/or cognitive disabilities, the proposed solution provides advanced features of self-adaptation and exploits the most cutting edge Artificial Intelligence technologies such as Reinforcement Learning, Deep Learning and Natural Language Processing (NLP) to remind and monitor adherence to the prescribed treatment. In particular, the system offers functions for (i) personalised reminds; i.e. an intelligent agent – called Tutor – self-learns (via Reinforcement Learning) the best way to communicate with the patient; (ii) feedback about the medication the patient is going to take; i.e., another intelligent agent – called Checker- identifies the pillbox that the patient is handling before taking the pill (via Deep Neural Network, Optical Character Recognition, and Barcode Reading); and, (iii) alerts in case of known drug–drug interactions; i.e., an intelligent service – called Advisor – searches for the active principles of the medication (via NLP and Unified Medical Language System (UMLS) RxNorm resources) identified by the Checker and known interactions with other medications of the treatment. The final objective is to remind effectively when and what medication is to be taken, to check that the patient is going to take the correct medication, and to alert if possible drug–drug interactions are identified, remotely reporting about the adherence to the therapy or anomalies to the caregivers and/or doctors. Experimental evaluations show encouraging results in terms of drug recognition and drug–drug interactions identification.

Sources of medication omissions among hospitalized older adults with polypharmacy.

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

Parkinson's Disease Medication Administration During a Care Transition: The Impact of Interprofessional Team Simulation on Student Competency, Comfort, and Knowledge.

This study investigated the impact of an interprofessional mock code on students' comfort and competency related to Parkinson's disease (PD) medication administration during care transitions. Patients with PD are at increased risk for medication errors during hospitalization. Individualization of PD medication creates vulnerability during care transitions. Four interprofessional groups took part in this study: baccalaureate degree senior nursing students (n = 113), master's level nurse anesthesia students (n = 35), doctor of osteopathic medicine fourth-year students (n = 32), and doctor of clinical psychology fourth-year students (n = 22). Groups participated in an unfolding case study simulation involving a mock code with a focus on the omission of time-sensitive PD medication. Pre- and postsimulation test results were compared. Findings indicated an increased understanding among three of the four groups relating to medication timing during care transitions. All groups improved with respect to perceived comfort and competency.

Evaluating Medical Decision-Making: Using the EHR to Assess and Structure Resident Autonomy.

Evaluating Medical Decision-Making: Using the EHR to Assess and Structure Resident Autonomy.

Medication discrepancies among hospitalized patients with hypertension: assessment of prevalence and risk factors

BackgroundMedication errors remained among the top 10 leading causes of death worldwide. Furthermore, a high percentage of medication errors are classified as medication discrepancies. This study aimed to identify and quantify the different types of unintentional medication discrepancies among hospitalized hypertensive patients; it also explored the predictors of unintentional medication discrepancies among this cohort of patients.MethodsThis was a prospective observational study undertaken in a large teaching hospital. A convenience sample of adult patients, taking ≥4 regular medications, with a prior history of treated hypertension admitted to a medical or surgical ward were recruited. The best possible medication histories were obtained by hospital pharmacists using at least two information sources. These histories were compared to the admission medication orders to identify any possible unintentional discrepancies. These discrepancies were classified based on their severity. Finally, the different predictors affecting unintentional discrepancies occurrence were recognized.ResultsA high rate of unintentional medication discrepancies has been found, with approximately 46.7% of the patients had at least one unintentional discrepancy. Regression analysis showed that for every one year of increased age, the number of unintentional discrepancies per patient increased by 0.172 (P = 0.007), and for every additional medication taken prior to hospital admission, the number of discrepancies increased by 0.258 (P= 0.003). While for every additional medication at hospital admission, the number of discrepancies decreased by 0.288 (P < 0.001). Cardiovascular medications, such as diuretics and beta-blockers, were associated with the highest rates of unintentional discrepancies in our study. Medication omission was the most common type of the identified discrepancies, with approximately 46.1% of the identified discrepancies were related to omission. Regarding the clinical significance of the identified discrepancies, around two-third of them were of moderate to high significance (n= 124, 64.2%), which had the potential to cause moderate or severe worsening of the patient´s medical condition.ConclusionsUnintentional medication discrepancies are highly prevalent among hypertensive patients. Medication omission was the most commonly encountered discrepancy type. Health institutions should implement appropriate and effective tools and strategies to reduce these medication discrepancies and enhance patient safety at different care transitions. Further studies are needed to assess whether such discrepancies might affect blood pressure control in hypertensive patients.

Interprofessional mock code simulation promotes collaboration and competency in Parkinson's medication safety during transition in care

An interprofessional mock code simulation was designed to educate students from four healthcare disciplines on the care of a patient with Parkinson's disease (PD) during a care transition. This interprofessional education initiative facilitated students learning about, from, and with each other. The simulation consisted of an unfolding patient with Parkinson's disease (PD) that involved an incomplete medication reconciliation and an omission of time-sensitive PD medication, resulting in a full code. The simulation explored quality improvement strategies for safe and timely medication administration and reconciliation during a care transition for a patient with PD. The simulation was conducted in the Learning Resource Simulation Center with small groups of students from two separate institutions and four separate schools or college programs rotating throughout the semester. The student participants consisted of the following: Baccalaureate Degree Senior Nursing Students; Master's level Senior Nurse Anesthesia Students; Fourth-Year Doctor of Osteopathic Medicine Students; and Fourth-Year Doctor of Psychology Students. The objectives of the interprofessional mock code simulation were as follows: 1) learners shall understand the roles and responsibilities of members of a healthcare team by participating in an interprofessional simulation of a patient with Parkinson's disease during a mock code scenario; 2) learners shall recognize the harm that occurs from incomplete medication reconciliation specific to Parkinson's disease during care transitions such as disorientation, garbled speech, severely limited breathing capacity and even death; and 3) learners from four different healthcare disciplines will evaluate their comfort and competence specific to working as part of an interprofessional healthcare team during a mock code simulation. The simulation demonstrated an increase in knowledge among all the interprofessional healthcare team members regarding PD medication safety. This PD unfolding case study simulation training also helped students and future professionals feel comfortable and competent while working together during a patient code situation in the acute care setting. This simulation holds great potential for dissemination among all faculty disciplines to improve the quality and safety of the PD population during care transitions. A complete copy of the IPE simulation is available upon request from the primary author.

Value of pharmacy services upon admission to an orthopedic surgery unit

BackgroundIn Lebanon, the role of the pharmacist remains underestimated in the medication reconciliation process, especially in surgical departments. This study aims to assess the impact of pharmacist-conducted medication reconciliation performed within 48 h of hospital admission to the orthopedic surgical department.MethodsThis was a prospective single-arm study conducted in a tertiary-care teaching hospital in Lebanon between October 2019 and April 2020. Participants were adult inpatients hospitalized for orthopedic surgeries with ≥ 1 outpatient medications. Properly trained pharmacy resident obtained the Best Possible Medication History (BPMH) and led the reconciliation process. The primary endpoint was the number of reconciliation errors (REs) identified. Descriptive statistics were used to report participants’ responses and relevant findings. Linear regression was performed with the number of REs as a continuous dependent variable using backward method. Results were assumed to be significant when p was < 0.05.ResultsThe study included 100 patients with a mean age of 73.8 years, admitted for elective (54%) or emergency (46%) surgeries. Half of the study population had ≥ 5 home medications. The mean time for taking BPMH was around 8 min. A total of 110 REs were identified in 74 patient cases. The most common discrepancies consisted of medication omission (89.1%) and the most common medications involved were antihyperlipidemic agents. Twenty-four REs were judged as clinically significant, and four as serious. The most common interventions included the addition of a medication (71.9%). Most of the relayed interventions (84.5%) were accepted. The number of home medications was the only variable significantly associated with the number of REs (β 0.492; p < 0.001).ConclusionPharmacy-led medication reconciliation upon admission to orthopedic surgery department can reduce reconciliation errors and improve medication safety.Trial registrationRetrospectively registered in the Lebanon Clinical Trials Registry (LBCTR2020124680).

Medication Errors Detected in Primary Health Care after Hospital Discharge

Background: Medication conciliation allows finding discrepancies and medication errors in healthcare transitions, but there are few studies performed after hospital discharge, in the context of primary health care. Therefore, the main aim of this research was to evaluate the process of medication conciliation in primary health care, after hospital discharge. We further sought to analyze some demographic aspects of the patients that could be associated with potential discrepancies. Methods: A cross-sectional study was performed using the database which contained the records generated by the medication reconciliations performed by the physicians of the Andalusian Public Health Service, in Spain. Results: A total of 6115 medication conciliations were analyzed, and discrepancies were found in 73.7% of them. A total of 50.6% were medication errors, the most frequent being medication omission. Medication errors were more prevalent in women of 65 years and older. Conclusions: After hospital discharge, most patients show medication discrepancies in their records, particularly older women. To prevent this, primary health care plays an essential role in the conciliation process, therefore more research is needed in this context.

Medication omissions in the first 48 hours after admission: failure in prescribed medicines reaching in-patients in paediatrics wards at the University Teaching Hospitals, Children’s Hospital in Lusaka, Zambia

Background: The first few days of in-patient care are possibly the most significant in a patient’s recovery and any omitted medications during this period may harm the patient or increase their hospital length of stay. Therefore, our study aimed at assessing the frequency of medication administration omission errors and their reasons for the omission in the paediatric wards after admission at University Teaching Children’s Hospital.Methods: This was a descriptive study in which 259 patient files and drug charts were reviewed. Admission prescription charts were studied in detail over a period of four weeks and all drugs prescribed but then not given in the first 48 hours were recorded as omitted medications, along with the reason given for their omission.Results: From the 259 drug charts, a total of 1598 doses of drugs were ordered within 48 hours of admission. However, from this, only a total of 1132 doses were administered with the remaining 466 doses omitted, which accounted for a frequency of 29.2%. When the frequency of medication omission errors was compared, parenteral drugs (70.8% vs. 25.3%, [p=0.0001]), afternoon shift (48.5% vs. 15.8%, [p=0.0001]), and anti-infective medications (69.1% vs. 39.4%, [p=0.0001]) were found to be the most frequently omitted medications. There were also considerably more medication omissions in patients prescribed with more medications (median number: 4, I QR [2, 6] vs. median number: 2, IQR [2, 4], [p=0. 0.001]). The most common reason for the omission was medication unavailability (89.3%), followed by work overload (71.4%), and the patient is off the ward (71.4%).Conclusions: This study revealed that medication omissions are a continuing problem and this may result in increased morbidity and mortality rates. There is a need to put in place specific strategies to reduce this problem.

Potential prescribing omissions of medications in older adults based on START version 2 criteria in a tertiary Jordanian teaching hospital

Potential prescribing omission (PPO) represents a failure in prescribing drugs when indicated due to lack of the evidence base. Published data are scarce on the prevalence of prescribing omissions in Jordan. This study aimed to assess the prevalence of prescribing omissions in elderly patients in a Jordanian teaching hospital. Screening Tool to Alert doctors to the Right Treatment (START) version 2 was used to identify the prescribing omissions in older adults admitted to a tertiary hospital in Jordan for 18 months. During the study period, data relating to the patients’ medical problems and prescribed medicines were collected by two clinical pharmacists via reviewing the clinical and prescription records of the included patients. Data were collected using a predefined data collection form and statistical analysis was conducted using Statistical Package of Social Sciences (SPPSS). One or more prescribing omissions were found in 40.5%, 41.0%, and 39.5% of the patients upon admission, during hospitalization, and on discharge, respectively. The most common prescribing omission was about START criterion I1 which was “seasonal trivalent influenza vaccine annually” in 54.8% upon admission, 51.5% during hospitalization, and 51.9% on discharge. Logistic regression found that the higher number of medical conditions was associated with an increased risk of PPO occurrence upon admission, during hospitalization, and on discharge (p value < 0.05). Acts of omission of appropriate medications were highly prevalent among older patients in our hospital setting. A validated screening tool (START) is one method of systematically identifying appropriate omitted medicines in clinical practice. Application of validated START criteria can help detect and prevent PPO occurrence among older patients

197 Perioperative Diabetic Medication Prescribing- Adherence to Local Guidelines

Abstract Aim Optimization of diabetic medications around the time of operation is critical to avoid complications, hence we aimed to conduct an audit to review perioperative diabetic medication prescribing. Method Drug charts for peri-operative cardiac and thoracic patients were reviewed retrospectively on Medchart, a local electronic system used for prescribing medications. The omission or adjustment of oral anti-diabetic medications and insulin prescriptions were recorded. Results Over a one-month period, the prescriptions of 104 patients were recorded with an average age of 65.8 and out of which 21 patients were diabetic. Conclusions Our Audit demonstrated errors in perioperative diabetic medication prescribing. We focused our intervention by circulating a poster depicting the guidelines around the doctors and ANP offices. We did a re-audit in two months’ time to check the adherence. These are the findings we found in the re-audit for 101 patients: -

English

Medication administration omission errors (MAOE) are very common and often affect patient outcomes and length of stay in the hospitals. This study was a cross-sectional study in which the frequency and causes of MAOE over four weeks at Ndola University Teaching Hospital (NUTH) was assessed. It involved reviewing patients&rsquo; drug charts and observation of nurses during the administration of medications to inpatients to detect the MAOE. A total of 259 drug charts were reviewed using a checklist and administered semi-structured questionnaires to 50 nurses who were involved in medication administration to solicit the cause of MAOE. To assess factors associated with MAOE, multivariate logistic regression was used. In this study, 259 drug charts were reviewed of which 220 (84.9%) had one or more MAOE. Of the 1100 doses prescribed to 259 inpatients, 317 doses were omitted resulting in an overall MAOE frequency of 28.8%. In multivariate regression analysis, increased number of medications that the patient used (AOR: 2.18, CI: 1.62-2.94; p=0.0001), being male (AOR: 2.42, Cl: 1.05-5.53: p=0.036) and surgical wards (AOR: 8.56, CI: 3.04 -24.1; p=0.0001) were significant predictors of MAOE. The most common causes of MAOE were the unavailability of medication on the ward followed by work overload. The most omitted class of medication was anti-infective. Medication omission errors are common and affect adult inpatients at Ndola Teaching. There is a need to highlight the magnitude of this problem to promote awareness so that specific interventions are put in place to address the identified causes.&nbsp; Key words: Medication omission, administration errors, frequency, medication administration.

The Importance of Electronic Health Record Access For Accurately Completing Drug Regimen Reviews.

OBJECTIVE: To challenge the standard of practice by evaluating the identification of medication discrepancies found depending on type of access to an electronic health record (EHR). In other words, is there a difference in the number of discrepancies between a pharmacist with only access to the postacute long-term care (PALTC) EHR (ie, single-access pharmacist [SAP]) compared with a pharmacist with access to both the PALTC and hospital EHRs (ie, dual-access pharmacist DAP) In October 2018, the Improving Medicare PostAcute Care Transformation (IMPACT) Act mandated admission drug review (DRR) upon admission to a postacute, long-term care (PALTC) facility.<br/> SUMMARY:This was a prospective study investigating the occurrence of medication therapy problems (MTP) identified by two different DRR processes; SAP versus DAP. Data were collected in a community hospital and a stand-alone PALTC facility. It was found that the DAP identified more safety-related medication needs and medication omissions than an SAP. There was a significant association between the type of access and whether a MTP (ie, yes or no) was discovered, the type of medication-related need, and MTP category.<br/> CONCLUSION: These results strongly suggest that current standard of practice should change to require access to both hospital and PALTC EHR systems for a pharmacist completing the medication reconciliation. Until the gap in EHR interoperability is closed, the potential breakdown in communication associated with SAP places patients transitioning from hospital to PALTC facilities at increased risk for medication problems and accompanying adverse medication events.

The Importance of Electronic Health Record Access For Accurately Completing Drug Regimen Reviews

OBJECTIVE: To challenge the standard of practice by evaluating the identification of medication discrepancies found depending on type of access to an electronic health record (EHR). In other words, is there a difference in the number of discrepancies between a pharmacist with only access to the postacute long-term care (PALTC) EHR (ie, single-access pharmacist [SAP]) compared with a pharmacist with access to both the PALTC and hospital EHRs (ie, dual-access pharmacist DAP) In October 2018, the Improving Medicare PostAcute Care Transformation (IMPACT) Act mandated admission drug review (DRR) upon admission to a postacute, long-term care (PALTC) facility.&lt;br/&gt; SUMMARY:This was a prospective study investigating the occurrence of medication therapy problems (MTP) identified by two different DRR processes; SAP versus DAP. Data were collected in a community hospital and a stand-alone PALTC facility. It was found that the DAP identified more safety-related medication needs and medication omissions than an SAP. There was a significant association between the type of access and whether a MTP (ie, yes or no) was discovered, the type of medication-related need, and MTP category.&lt;br/&gt; CONCLUSION: These results strongly suggest that current standard of practice should change to require access to both hospital and PALTC EHR systems for a pharmacist completing the medication reconciliation. Until the gap in EHR interoperability is closed, the potential breakdown in communication associated with SAP places patients transitioning from hospital to PALTC facilities at increased risk for medication problems and accompanying adverse medication events.

Assessment of an electronic patient record system on discharge prescribing errors in a Tertiary University Hospital

BackgroundPrescribing error represent a significant source of preventable harm to patients. Prescribing errors at discharge, including omission of pre-admission medications (PAM), are particularly harmful as they frequently propagate following discharge. This study assesses the impact of an educational intervention and introduction of an electronic patient record (EPR) in the same centre on omission of PAM at discharge using a pragmatic design. A survey of newly qualified doctors is used to contextualise findings.MethodsDischarge prescriptions and discharge summaries were reviewed at discharge, and compared to admission medicine lists, using a paper-based chart system. Discrepancies were noted, using Health Information and Quality Authority guidelines for discharge prescribing. An educational intervention was conducted. Further review of discharge prescriptions and discharge summaries took place. Following introduction of an EPR, review of discharge summaries and discharge prescriptions was repeated. A survey was administered to recently qualified doctors (interns), and analysed using descriptive statistics and thematic analysis.ResultsOmission of PAM as prescribed or discontinued items at discharge occurs frequently. An educational intervention did not significantly change prescribing error rates (U = 1255.5, p = 0.206). EPR introduction did significantly reduce omission of PAM on discharge prescribing (U = 694, p < 0.001), however there was also a reduction in the rate of deliberate discontinuation of PAM at discharge (U = 1237.5, p = 0.007). Survey results demonstrated that multiple sources are required to develop a discharge prescription. Time pressure, access to documentation and lack of admission medicine reconciliation are frequently cited causes of discharge prescribing error.ConclusionThis study verified passive educational interventions alone do not improve discharge prescribing. Introduction of EPR improved discharge prescribing, but negatively impacted deliberate discontinuation of PAM at discharge. This is attributable to reduced access to key sources of information used in formulating discharge prescriptions, and separation of the discontinuation function from the prescribing function on the EPR discharge application.