Medication Omission Research Articles

Medication Reconciliation at Hospital Discharge: Evaluating Discrepancies

Hospital discharge is an interface of care when patients are at a high risk of medication discrepancies as they transition from hospital to home. These discrepancies are important, as they may contribute to drug-related problems, medication errors, and adverse drug events. To identify, characterize, and assess the clinical impact of unintentional medication discrepancies at hospital discharge. All consecutive general internal medicine patients admitted for at least 72 hours to a tertiary care teaching hospital were prospectively assessed. Patients were excluded if they were discharged with verbal prescriptions; died during hospitalization; or transferred from or to a nursing home, another institution, or another unit within the same hospital. The primary endpoint was to determine the number of patients with at least one unintended medication discrepancy on hospital discharge. Medication discrepancies were assessed through comparison of a best possible medication discharge list with the actual discharge prescriptions. Secondary objectives were to characterize and assess the potential clinical impact of the unintentional discrepancies. From March 14, 2006, to June 2, 2006, 430 patients were screened for eligibility; 150 patients were included in the study. Overall, 106 (70.7%) patients had at least one actual or potential unintentional discrepancy. Sixty-two patients (41.3%) had at least one actual unintentional medication discrepancy at hospital discharge and 83 patients (55.3%) had at least one potential unintentional discrepancy. The most common unintentional discrepancies were an incomplete prescription requiring clarification, which could result in a patient delay in obtaining medications (49.5%), and the omission of medications (22.9%). Of the 105 unintentional discrepancies, 31(29.5%) had the potential to cause possible or probable patient discomfort and/or clinical deterioration. Medication discrepancies occur commonly on hospital discharge. Understanding the type and frequency of discrepancies can help clinicians better understand ways to prevent them. Structured medication reconciliation may help to prevent discharge medication discrepancies.

Risk profiles for non‐adherence to antipsychotic medications

Poor adherence to medications is common in individuals with schizophrenia, and can lead to relapse and re-hospitalization. This paper presents the findings of an Australian study of the factors affecting antipsychotic medication taking in individuals with schizophrenia. The Factors Influencing Neuroleptic Medication Taking Scale was used with a non-probability sample of mental health service users. Ethics approval was obtained from a university and a hospital ethics committee. Data were analysed using spss version 15. Most participants had insight into their illness and were aware of the stigma of mental illness. Around 70% experienced annoying side effects, while nearly half admitted alcohol consumption. About one-fifth admitted they had missed taking medications during the previous week. Significant others played a variable role in medication taking. Over 80% were satisfied with their relationships with health professionals, but were less satisfied with access to these professionals, especially psychiatrists. Logistic regression analysis showed that age, impact of medication side effects, and access to psychiatrists were independent predictors of medication omission. It is argued that medication taking is a complex issue, which needs to be taken into consideration in health professional training and measures to promote adherence.

Impact of a Pharmacist on Medication Reconciliation on Patient Admission to a Veterans Affairs Medical Center

Purpose Medication errors are a leading cause of injury to hospitalized patients, and studies reveal that these errors occur most often at transitions of care. The objective of this study was to evaluate a pharmacist's impact on medication errors at the Veterans Affairs Medical Center (VAMC) through involvement in medication reconciliation on patient admission. Methods A retrospective, observational, single-center study was conducted to evaluate pharmacist-initiated medication reconciliation. Preprogram and postprogram data were compared. In both phases medical records were evaluated for discrepancies by comparing outpatient medications with inpatient medication orders. Inclusion criteria comprised patients with outpatient medications who were admitted to the VAMC for at least 72 hours. The primary outcome measure was the percentage of unreconciled medications. Secondary outcomes included cost savings to the VAMC and avoidance of potential adverse events. Results A total of 206 patients were included in the study. Patients in the postprogram group had a significantly lower percentage of unreconciled medications ( P < 0.001). The most common type of discrepancy was omission of medications at admission, and the most common drug class for discrepancies was psychiatric medications. In the postprogram group, 21 medications were discontinued as a result of a pharmacist intervention, with a median cost savings of $36.58 (range, $1.10 to $2,311). An increase in the number of medications per patient was associated with an increase in unreconciled medications (coefficient of linear regression [ R 2 ] = 0.31; P < 0.001). No adverse drug events (ADEs) were noted. Conclusion Pharmacists' involvement in medication reconciliation significantly reduces the number of unreconciled medications. In addition, this involvement may greatly improve patient safety and reduce the costs of medication errors and the occurrence of ADEs.

The contribution of a pharmacy admissions service to patient care

The aim of this study was to determine the impact of two specialised admissions pharmacists on an acute medical admissions ward. For a one-week period, contributions made to the medical post-take ward round (PTWR), the number of drug histories taken and interventions made as a result, and the availability of medication needed on discharge were documented. An average of 1.1 contributions per patient were made on the PTWR; a large proportion of these concerned therapeutic choice. Pharmacists also intervened to stop medication due to adverse drug reactions in 12% (n=10) of contributions. Fifty-two drug histories were checked by a pharmacist, resulting in 61 interventions (1.1 interventions per patient). The majority of interventions resulted from the unintentional omission of a regular medication (65%, n=39). Only 24% (n=29) of items needed on discharge had to be dispensed in pharmacy and 33% (n=41) were available as patients' own drugs.

Tutorial on Monitoring Time to Next Medication Error

Alemi and colleagues in this issue of the journal have proposed that rare events can be monitored by shifting from frequency of the event to the examination of the time to the event. This article examines their claim with data obtained from an acute care hospital in the United States. We examined the data on medication omissions to see whether changes in underlying process can be detected through control charts. Medication errors are rare; the article examines medication errors due to omission, which makes the phenomena rarer. The empirical question was whether changes in process of care could be detected using control charts from data on medication omissions. Two different types of control chart, the XmR and Tukey charts, were used to analyze the data. The control chart with the tightest control limits was chosen for further interpretation. The XmR chart showed that there was sufficient power to detect unusual days in which the time to omission error was higher than historical norm. This article suggests that even rare events can be monitored through judicious use of time to the event. It shows the viability of safety teams using time to sentinel events to monitor progress in reducing frequency of sentinel events.

Eliciting comprehensive medication histories in the emergency department: the role of the pharmacist.

The Australian Pharmaceutical Advisory Committee guidelines call for a detailed medication history to be taken at the first point of admission to hospital. Accurate medication histories are vital in optimising health outcomes and have been shown to reduce mortality rates. This study aimed to examine the accuracy of medication histories taken in the Emergency Department of the Royal Adelaide Hospital. Medication histories recorded by medical staff were compared to those elicited by a pharmacy researcher. The study, conducted over a six-week period, included 100 patients over the age of 70, who took five or more regular medications, had three or more clinical co-morbidities and/or had been discharged from hospital in three months prior to the study. Following patient interviews, the researcher contacted the patient's pharmacist and GP for confirmation and completion of the medication history. Out of the 1152 medications recorded as being used by the 100 patients, discrepancies were found for 966 medications (83.9%). There were 563 (48.9%) complete omissions of medications. The most common discrepancies were incomplete or omitted dosage and frequency information. Discrepancies were mostly medications that treated dermatological and ear, nose and throat disorders but approximately 29% were used to treat cardiovascular disorders. This study provides support for the presence of an Emergency Department pharmacist who can compile a comprehensive and accurate medication history to enhance medication management along the continuum of care. It is recommended that the patient's community pharmacy and GP be contacted for clarification and confirmation of the medication history.

Resolving Medication Discrepancies

When elderly patients transition from one health care setting to another they are at increased risk of experiencing fragmented care. One of the most common manifestations of this lack of continuity is medication discrepancy. These differences, such as omission of medications, dosing errors, and duplication of therapy, are a significant safety issue for seniors. This case study describes a 76-year-old woman who is a new resident in an assisted living facility and is referred to the consultant pharmacist for medication review and evaluation of possible adverse drug events. In reviewing the drug regimen, the pharmacist uncovered medication discrepancies; other members of the health care team were unaware of them. These discrepancies may have contributed to some of the patient's current health problems. This case study demonstrates the role of the consultant pharmacist during transitions of care setting and reviews strategies that the pharmacist can use to identify and resolve medication discrepancies.

Sedative use in patients receiving neuromuscular blocking agents from a helicopter flight team

Introduction Cognitive awareness under general anesthetic may occur in up to 0.2% of patients, with approximately twice the risk in chemically paralyzed patients. Patients in emergency and critical care areas frequently receive neuromuscular blocking agents (NMBA), but a recent survey indicated that only 90% to 96% of critical care nurses routinely provide concurrent sedative medications to those patients. We sought to determine the potential for awake paralysis in patients transported by helicopter critical care transport teams and to evaluate for associations with clinical factors. Methods A retrospective review was performed of the rotor-wing transport records of 103 consecutive patients receiving NMBAs and without cardiac arrest during their care. Using hospital-approved pharmacological references, independent reviewers determined whether individual patients were likely to be under the effects of sedative medications during their period of neuromuscular blockade. Descriptive statistics are reported, and the chi-square test was used to evaluate relationships. Results The sample population was 70.9% male, 89.3% adult, 53.4% trauma/surgical, 66% interhospital, and 88.3% normotensive (SBP > 90 mm Hg). Clinically, 91.3% of patients were judged as probably to have been under the effects of some sedative during their period of paralysis. There was not a significant association between the use of sedatives and any of the factors studied: sex, age, diagnosis, site of origin, flight nurse experience, or systolic blood pressure. Patients most commonly received benzodiazepine alone (70.2%), followed by benzodiazepine + opioid (23.4%), opioid alone (5.3%), and propofol (1.1%). Medication choice was also unrelated to any of the clinical factors studied. Discussion Awake paralysis is difficult to detect but is a serious practice complication. In anesthesia practice, 96% of such cases were considered substandard care, even with prompt recognition and management. Flight nurses administer sedatives at rates similar to other critical care nurses but not to all chemically paralyzed patients. We were unable to identify clinical correlations with medication use or omission. Additional phenomenological and quantifiable evaluations of consciousness during the transport of chemically paralyzed patients would be valuable studies. Conclusion Patients receiving NMBAs during transport by helicopter flight teams are at risk for awareness during paralysis. Both practice development and research efforts in this area would be useful.

Poster 139: Anticoagulation Errors in a Rehabilitation Hospital

Objective: To investigate causes and severity of anticoagulant prescription and administration errors in a rehabilitation hospital. Setting: Freestanding rehabilitation hospital. Design: Retrospective chart review. Subjects: 2614 patients on anticoagulation medications from 2001 to 2004. Interventions: Not applicable. Main Outcome Measures: Included incidence and severity of anticoagulant prescription and administration errors. Error severity was graded as follows: 1, potential to cause adverse event; 2, errors not causing harm; 3, errors resulting in need for increased patient assessments but no harm; and 4, errors that caused temporary patient harm and required treatment or intervention. Analysis: errors per year was compared using the χ2 test. Frequency of errors was analyzed using correlation analysis. Results: The 2 most common errors were wrong doses and medication omissions, followed by medication given without physician order. The frequency of errors increased with each subsequent year. There were significantly less errors in the first 2 quarters combined as compared with the last 2 quarters (P<.02). 83% of the errors were either grade 1 or 2. 12% were grade 3. None was classified grade 4. Discussion: Possible reasons for increase in errors with subsequent years include actual increase in errors and/or improved reporting. The inverse relationship of the number of errors and length of residency training suggest that the relative inexperience of the house staff may play a role in the errors Medication errors involving warfarin (Coumadin) or enoxaparin in this rehabilitation hospital did not turn out to be that harmful for the patient. Conclusions: The aim is to minimize the errors while improving the reporting of the errors. Avenues being explored to decrease the incidence of anticoagulant errors include computerized physician order entry, bar-coding of medication, and refining of the medication renewal process.

Medical treatment of myocardial ischemia in coronary artery disease: effect of drug regime and irregular dosing in the CAPE II trial

ObjectivesThe Circadian Anti-ischemia Program in Europe (CAPE II) compared the efficacy of amlodipine and diltiazem (Adizem XL) and the combination of amlodipine/atenolol and diltiazem (Adizem XL)/isosorbide 5-mononitrate on exercise and ambulatory myocardial ischemia during regular therapy and after omission of medication. BackgroundThe optimal medical therapy for ischemia suppression and the impact of irregular dosing using agents with different pharmacologic properties has not been established in patients with coronary disease. MethodsPatients with ≥4 ischemic episodes or ≥20 min of ST segment depression on 72-h electrocardiogram were randomized to amlodipine 10 mg once daily or diltiazem (Adizem XL) 300 mg once daily in a 14-week double-blind randomized multicountry study. In the second phase, atenolol 100 mg was added to amlodipine and isosorbide 5-mononitrate 100 mg to diltiazem (Adizem XL). Ambulatory monitoring (72 h) and exercise testing were repeated after both phases, on treatment and after a 24-h drug-free interval. ResultsBoth monotherapy with amlodipine and diltiazem (Adizem XL) were effective on symptoms and ambulatory and exercise ischemia. Combination therapy reduced ischemia further, with amlodipine/atenolol superior to diltiazem (Adizem XL)/isosorbide 5-mononitrate. Amlodipine/atenolol was significantly superior during the drug-free interval with maintenance of ischemia reduction. ConclusionsAmlodipine, with its intrinsically long half-life alone or together with beta-blocker, is likely to produce superior ischemia reduction in clinical practice when patients frequently forget to take medication or dose irregularly.

Medication lists for elderly patients: clinic-derived versus in-home inspection and interview.

To determine how often the lists of regular medications derived in geriatric clinics by examination of "medication bags" and interview matched those found during in-home inspections and interviews. Prospective cross-sectional study. Geriatric clinics at three university-affiliated hospitals. Consecutive community-dwelling outpatients 65 years or older who were newly referred. The in-home medication inspection used a semistructured interview followed by a room-to-room search. The medications identified in the home were compared with the medication list derived in clinic by examination of the "medication bag" and interview. Fifty patients with a mean age of 78.9 years participated. The mean number of regular medications (prescription and nonprescription) was 6.3, and the mean number of regular prescription medications was 3.6. A comparison of clinic versus in-home medication lists revealed that 48% (95% confidence interval [95% CI], 34% to 62%) of patients had at least 1 omission of any regular medication and 19% (95%, CI 10% to 32%) of patients had at least 1 omission of a regular prescription medication. The clinic-derived medication list resulted in a complete listing of all regular medications in only 52% taking regular medications. More specific instructions to patients to bring all prescription and nonprescription medications and all vitamins, herbal, and natural remedies, and more directed questions by physicians may result in more complete clinic medication lists.

Medication adherence in rheumatoid arthritis patients: older is wiser.

To create a profile of individuals nonadherent to their medications in an age-stratified sample (ages 34-84) of community-dwelling rheumatoid arthritis patients. The relative contributions of age, cognitive function, disability, emotional state, lifestyle, and beliefs about illness to nonadherence were assessed. A direct observation approach was used in conjunction with structural equation modeling. All participants were administered a preliminary assessment battery. Medications were then transferred to vials with microelectronic caps that recorded medication events for all medications for the next 4 weeks. A volunteer sample of 121 community-dwelling rheumatoid arthritis (RA) patients were recruited from newspaper ads, posters, and via informal physician contact from private rheumatology practices in Atlanta and Athens, Georgia. Written verification of the RA diagnosis and a disease severity rating were obtained from personal physicians before patients were enrolled in the study. Patients were tested in a private physician's office, and their medication adherence was monitored electronically for a month in their every-day work and home settings. Structural equation modeling techniques were used to develop a model of adherence behavior. Cognitive and psychosocial measures were used to construct latent variables to predict adherence errors. The model of medication adherence explained 39% of the variance in adherence errors. The model demonstrated that older adults made the fewest adherence errors, and middle-aged adults made the most. A busy lifestyle, age, and cognitive deficits predicted nonadherence, whereas coping with arthritis-related moods predicted adherence. Illness severity, medication load, and physical function did not predict adherence errors. Omission of medication accounted for nearly all errors. Despite strong evidence for normal, age-related cognitive decline in this sample, older adults had sufficient cognitive function to manage medications. A busy lifestyle and middle age were more determinant of who was at risk of nonadherence than beliefs about medication or illness. Thus, practicing physicians should not assume that older adults have insufficient cognitive resources to manage medications and that they will be the most likely to make adherence errors. Very busy middle-aged adults seem to be at the greatest risk of managing medications improperly.

Medication Omission Rates After Inclusion of Patients' Names on Medication Drawers

Aim: To determine whether medication omission rates differed if medication drawers in a unit‐of‐use trolley were labelled with patients' names as well as bed numbers.Method: During a two‐month period all doses given or missed were counted in a busy surgical ward. For one month the medication drawers in the unit‐of‐use trolley were labelled only with bed numbers. During the next month drawers were also labelled with the patient's name. Omitted doses were identified by missing signatures on drug administration charts.Results: In the month when drawers had bed numbers only, 1935 doses were ordered and 146 omitted (7.6%). In the month that drawers had patient names and numbers, 3601 doses were ordered and 204 omitted (5.7%). This difference was significant (z = 2.74, p &lt; 0.01).Conclusion: These data suggest that dosage omissions can be reduced by adding a patient's name to their medication drawer in a drug trolley.

The benefits of in-home pharmacy evaluation for older persons.

To assess the potential benefit of a pharmacist performing in-home medication evaluations on frail older people. Prospective analysis with pre-post comparison. A hospital-based home care program at the Sepulveda Veterans Affairs Medical Center. Male veterans in a home care program who live within 15 miles of the medical center and take three or more prescription medications (N = 20, mean age: 75.1 years). Prescribed medications were documented from the medical records and compared with regimens actually being followed in the home. In addition, the home was inspected, patients were educated, and recommendations were made to the prescribing physicians when necessary. At first visit, patients had a mean of 6.0 prescribed daily medications but were only taking 4.7 of these regularly. Also noted were many potentially unnecessary medications (70% of subjects) and multiple problems with the medication regimen (e.g., incorrect drug frequency or dosage, expired medications, medication omission). Follow-up visit revealed a significant decrease in medication discrepancies and problems (P < or = .05). An in-home pharmacy assessment reveals many problems with drug administration not otherwise detected easily. These assessments can lead to potentially useful interventions that can improve medication regimens and compliance. Determination of long-term effects must await controlled trials.

Fertility control with oral medication

As the outstanding findings resulting from this investigation, we may state the following: 1.1. Length of the Menstrual Cycle.— 1.1.A. The ingestion of 10 mg. of norethynodrel, supplemented by varying amounts of estrogen, on a prescribed day 5 through day 24 regime, resulted in a normal distribution of lengths of menstrual cycles.1.2.B. If this regime is altered by omission of medication, there may ensue either shortened menstrual cycles, caused presumably by withdrawal bleeding, or lengthened menstrual cycles, resulting from adequate maintenance of the endometrium despite intermittent lack of medication or from prolonging of the treatment by use after the twenty-fourth day of the tablets missed earlier.2.2. Ovulation.— 2.1.A. Presumption of suppression of ovulation is strengthened by the fact that conception did not occur in any instance in which the medication schedule of day 5 through day 24 was followed faithfully.2.2.B. Among those who omitted medication for 3 or more days, the low incidence of pregnancy was roughly proportional to the number of unused tablets.3.3. Endometrium.— 3.1.A. This compound appeared to exert a prompt progestational effect on the endometrium which, after 5 to 7 days of medication, did not progress in terms of glandular response, but did advance with reference to the stromal reaction.3.2.B. No pathological endometrial changes were observed in specimens taken at different times in the cycle and after varying periods of medication up to 10 months. The sequence of endometrial response to medication, as well as of regression following medication, was generally quite regular, and no distinction could be made between endometrium from short-term and that from long-term treated subjects.4.4. Steroid Excretion.—Studies of urinary excretion of steroids indicated a decrease in 17-hydroxycorticosteroids and, to a questionable extent, of 17-ketosteroids. This decline did not seem to vary with the number of medication cycles, nor did it appear to be accompanied by any discernible signs of adrenocortical hypofunction.5.5. Blood Studies.—No significant differences in hemoglobin level were noted during or after medication as compared with those of untreated women. The average bleeding time, however, both during and after medication, was found to be significantly shorter than in the controls, while the clotting time in the postmedication subjects was significantly less than in either the control or the medicated group.6.6. Side Effects.— 6.1.A. The treated subjects reported certain untoward reactions, the incidence of which did not vary with 0.8 to 1.8 per cent estrogen supplementation of the 10 mg. dose of norethynodrel.6.2.B. It had been calculated that, over an 18 cycle span of medication, troublesome symptoms would cause approximately 27 per cent of the subjects enrolled in the project to discontinue treatment. Actually, in the course of the study to date, only 18 per cent have ceased medication because of side effects.6.3.C. The administration of a magnesium aluminum glycinate antacid has led to the reported disappearance of untoward reactions in 82 per cent of the subjects who took the antacid.7.7. Fertility Control.—In practice, several difficulties have been encountered in maintaining complete fertility control, so that there have occurred 19 pregnancies, 5 of which were in women who had omitted 3 to 17 tablets from the advised regimen, and 14 in individuals who had stopped medication because of “reactions” or carelessness. These 19 produced a pregnancy rate of 13 per 100 marriage years, which may be compared with an expected incidence of 67 pregnancies per 100 marriage years from Puerto Rican women of this age range not known to be practicing contraception; or an actual incidence of 63 per 100 marriage years among these women (some of whom had been using contraceptives) before entering on the study.We believe that our data demonstrate the action of a powerful agent for fertility control among the women utilizing it. Thus far, in the subjects of our study, it has clearly lowered the pregnancy rate. The fact that 14 women who had discontinued medication after 1 to 17 cycles became pregnant within 1 to 3 months thereafter suggests that the drug, as thus used, does not interfere with subsequent fertility.