Pharmacist-led Medication Reconciliation Research Articles

The rate and nature of medication errors among elderly upon admission to hospital after implementation of clinical pharmacist-led medication reconciliation

ObjectivesTo determine the frequency and nature of erroneous transfer of medication information (medication errors) upon admission to hospital and to study the effect of medication reconciliation.MethodsIncluded patients were 65 years...

Medication discrepancies despite pharmacist led medication reconciliation: the challenges of maintaining an accurate medication list in primary care

Describe the types of medication discrepancies that persist despite pharmacist-led medication reconciliation using the primary care electronic medical record (EMR). Observational case series study of established patients from an urban, indigent care clinic. Medication reconciliation was conducted immediately prior to the physician visit at baseline and return visit. Main outcome measures included: frequency, types, and reasons for discrepancies, patient knowledge, and adherence. There was a 14.5% reduction in the number of patients with a discrepancy and the frequency of discrepancies was reduced by 7.3%. The rate of medication discrepancies in the chart was reduced by 31.3%. The most common type of discrepancy that persisted at follow up were medications listed on the chart that the patient stopped taking. Discrepancies were more likely to persist in Caucasian subjects when compared to African Americans. While pharmacist led medication reconciliation appears effective at reducing the likelihood of a medication discrepancy in the EMR, challenges persist in maintaining this accuracy specifically as it relates to patient driven changes to the medication regimen.

Multifaceted Intervention to Improve Medication Adherence and Secondary Prevention Measures After Acute Coronary Syndrome Hospital Discharge

Adherence to cardioprotective medication regimens in the year after hospitalization for acute coronary syndrome (ACS) is poor. To test a multifaceted intervention to improve adherence to cardiac medications. In this randomized clinical trial, 253 patients from 4 Department of Veterans Affairs medical centers located in Denver (Colorado), Seattle (Washington); Durham (North Carolina), and Little Rock (Arkansas) admitted with ACS were randomized to the multifaceted intervention (INT) or usual care (UC) prior to discharge. The INT lasted for 1 year following discharge and comprised (1) pharmacist-led medication reconciliation and tailoring; (2) patient education; (3) collaborative care between pharmacist and a patient's primary care clinician and/or cardiologist; and (4) 2 types of voice messaging (educational and medication refill reminder calls). The primary outcome of interest was proportion of patients adherent to medication regimens based on a mean proportion of days covered (PDC) greater than 0.80 in the year after hospital discharge using pharmacy refill data for 4 cardioprotective medications (clopidogrel, β-blockers, 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors [statins], and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers [ACEI/ARB]). Secondary outcomes included achievement of blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) level targets. RESULTS Of 253 patients, 241 (95.3%) completed the study (122 in INT and 119 in UC). In the INT group, 89.3% of patients were adherent compared with 73.9% in the UC group (P = .003). Mean PDC was higher in the INT group (0.94 vs 0.87; P< .001). A greater proportion of intervention patients were adherent to clopidogrel (86.8% vs 70.7%; P = .03), statins (93.2% vs 71.3%; P < .001), and ACEI/ARB (93.1% vs 81.7%; P = .03) but not β-blockers (88.1% vs 84.8%; P = .59). There were no statistically significant differences in the proportion of patients who achieved BP and LDL-C level goals. A multifaceted intervention comprising pharmacist-led medication reconciliation and tailoring, patient education, collaborative care between pharmacist and patients' primary care clinician and/or cardiologist, and voice messaging increased adherence to medication regimens in the year after ACS hospital discharge without improving BP and LDL-C levels. Understanding the impact of such improvement in adherence on clinical outcomes is needed prior to broader dissemination of the program. clinicaltrials.gov Identifier: NCT00903032.

2013 Late-Breaking Clinical Trial Abstracts

### Nitrites in Acute Myocardial Infarction Nishat Siddiqi1, Margaret Bruce1, Christopher J. Neil1, Graeme MacLennan2, Seonaidh Cotton2, Sofia A. Papadopoulou3, Baljit Jagpal1, Sue Brown3, Fatima Perez Gonzalez3, Satnam Singh1, Konstantin Schwarz1, Martin Feelisch4, Nicholas Bunce5, Pitt O Lim5, David Hildick-Smith6, John Horowitz7, Melanie Madhani8, Nicholas Boon9, Dana Dawson10, Juan-Carlos Kaski3, Michael P Frenneaux10. 1Dept of Cardiovascular Rsch, Univ of Aberdeen, Aberdeen, United Kingdom, 2Health Sciences Building (third floor), Centre for Healthcare Randomised Trials (CHaRT), Aberdeen, United Kingdom, 3Cardiovascular Sciences Rsch Centre, St George’s Univ of London, London, United Kingdom, 4Faculty of Medicine, Univ of Southampton, Southampton, 5Cardiology Dept, St George’s Healthcare NHS Trust, 6Cardiology Research Unit, Brighton and Sussex Univ Hospitals, Brighton, United Kingdom, 7Basil Hetzel Unit for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, 8Centre for Cardiovascular Sciences, Univ of Birmingham, Birmingham, United Kingdom, 9Centre for Cardiovascular Sciences, Univ of Edinburgh, Edinburgh, United Kingdom, 10School of Medicine and Dentistry, Univ of Aberdeen, Aberdeen Introduction :Despite reperfusion therapy for acute myocardial infarction (AMI), heart failure remains a major sequel. Reperfusion leads to further damage, described as ischemia-reperfusion-injury (IRI). This contributes up to 50% of the final infarct size. In pre-clinical models nitrite potently protects against IRI in the heart and other organs. Hypothesis :Intravenous (iv) sodium nitrite, administered immediately before opening of the infarct-related artery, results in significant reduction of IRI in patients with acute ST elevation MI (STEMI). Methods :In this phase II, randomised, placebo-controlled, double-blind, multicentre trial, 220 patients with first acute STEMI and TIMI 0 or 1 flow were randomised …

Pharmacist-led medication reconciliation to reduce discrepancies in transitions of care in Spain

Medication errors are one of the main causes of morbidity amongst hospital inpatients. More than half of medication errors occur at 'interfaces of care', when patients are discharged or transferred to the care of another physician. Medication reconciliation is the process of reviewing patients' complete previous medication regimen, comparing it with current prescriptions, and analysing and resolving any discrepancies that the pharmacist does not believe to be intentional (unjustified discrepancies). To quantify and analyse reconciliation unjustified discrepancies detected by a pharmacist in patients admitted to an internal medicine unit (IMU) over a 3-year period. The hospital employs a pharmacist who acts as a link between the primary care services and the internal medicine specialist care unit. A retrospective descriptive study on the reconciliation discrepancies found was carried out. Medication reconciliation was performed upon admission in all patients transferred from the Accident and Emergency department (A&E) and admitted to the IMU, and also at the time of discharge. The interventions were categorised based on the consensus document on terminology and medication classification published by the Spanish Society of Hospital Pharmacy. Number of patients with unjustified discrepancies, also known as reconciliation errors. 2,473 patients had their treatment reviewed at the time of admission and 1,150 at discharge. 866 reconciliation discrepancies were detected in 446 patients (1.94 per patient). 807 (93 %) were accepted by the prescribing physician and classified as reconciliation errors. 16.8 % of patients had at least one reconciliation error: 63.8 % of these errors were incomplete prescriptions, 16.6 % were medication omissions and 10.5 % were errors in dosage, administration method and/or frequency. The rate of medication errors found in this study is low compared with other similar studies. The most common error was "incomplete prescriptions", most of them generated by the Accident and Emergency department. A computerised clinical history would help to decrease the number of reconciliation errors. Pharmacist interventions focused on medication reconciliation are well accepted by physicians, improving the quality of clinical histories and decreasing the number of medication errors that occur across transitions in patient care.

The effectiveness of medication reconciliation strategies to reduce medication errors in community dwelling older adults: a systematic review

Background Medication errors have been identified as a problem in health care that results in adverse drug events. It has been identified as a failure of an intended plan of action or the initiation of a wrong plan of action. Medication errors are pervasive in community dwelling older adults. Strategies that facilitate the prevention of medication errors warrant consideration. Medication reconciliation has been identified as one such a strategy. Objectives The objective of this systematic review was to identify, appraise and synthesize the best available evidence to determine the effectiveness of medication reconciliation strategies on medication errors among community dwelling older adults. Inclusion criteria Types of participants This review included older adults of all races and ethnicities (65 years of age and older) living in the community. Older adults with dementia or who were dependent on family or other individuals for care were not included. Types of intervention(s) This review considered studies that evaluated the effects of medication reconciliation strategies on medication errors in community dwelling older adults. Types of studies This review considered randomized controlled trials, non-randomized controlled trials and quasi-experimental studies. In the absence of the above, other study designs including case control, cross-sectional cohort, and before and after studies were considered. Types of outcomes This review considered the primary outcome measure of the number of medication errors. Medication errors may include but are not limited to: prescribing, labeling, dispensing, medication administration and medication reconstitution. Search strategy This search examined published and unpublished studies from the inception of databases to the present that were in English. Databases included: MEDLINE, CINAHL, The Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, Academic Search Premier, PsycINFO, Healthsource Nursing/Academic edition, and PubMed. Gray literature included Science.gov, scricus.com, Robert Wood Johnson Institute, and Dissertations Abstract International. Searches were completed in November 2012. Methodological quality Two independent reviewers evaluated the included studies for methodological quality using the standardized critical appraisal instruments from the Joanna Briggs Institute. Disagreements between the reviewers were resolved with a third reviewer. Data collection Data were extracted using the standardized data extraction tool from the Joanna Briggs Institute. Data synthesis Statistical pooling was not possible due to heterogeneity of the studies; therefore findings were presented as a narrative. Results This review yielded two level one randomized controlled trials and one level three prospective randomized comparative study. Studies presented evidence as to the potential positive outcomes of a pharmacist-led medication reconciliation on medication errors for community dwelling older adults. The way in which the pharmacist conducted the medication reconciliation varied across studies. Conclusions Medication reconciliation is complex and may be implemented in a variety of ways. For older adults residing in community settings, pharmacist-led medication reconciliation may possibly play a role in the reduction of medication errors.

Patient-Centered Adherence Intervention After Acute Coronary Syndrome Hospitalization

Adherence to cardioprotective medications in the year after acute coronary syndrome hospitalization is generally poor and is associated with increased risk of rehospitalization and mortality. Few interventions have specifically targeted this high-risk patient population to improve medication adherence. We hypothesize that a multifaceted patient-centered intervention could improve adherence to cardioprotective medications. To evaluate this intervention, we propose enrolling 280 patients with a recent acute coronary syndrome event into a multicenter randomized, controlled trial. The intervention comprises 4 main components: (1) pharmacist-led medication reconciliation and tailoring; (2) patient education; (3) collaborative care between pharmacist and primary care provider/cardiologist; and (4) 2 types of voice messaging (educational and medication refill reminder calls). Patients in the intervention arm will visit with the study pharmacist ≈1 week post-hospital discharge. The pharmacist will work with the patient and collaborate with providers to reconcile medication issues. Voice messages will augment the educational process and remind patients to refill their cardioprotective medications. The study will compare the intervention versus usual care for 12 months. The primary outcome of interest is adherence using the ReComp method. Secondary and tertiary outcomes include achievement of targets for blood pressure and low-density lipoprotein, and reduction in the combined cardiovascular end points of myocardial infarction hospitalization, coronary revascularization, and all-cause mortality. Finally, we will also evaluate the cost-effectiveness of the intervention compared with usual care. If the intervention is effective in improving medication adherence and demonstrating a lower cost, the intervention has the potential to improve cardiovascular outcomes in this high-risk patient population.

Effectiveness and Feasibility of Pharmacist-Led Admission Medication Reconciliation for Geriatric Patients

Purpose: Pharmacists have been shown to improve medication reconciliation at hospital admission. Limited resources may obligate pharmacy departments to target resources for medication reconciliation rather than extend services to the entire hospital. We conducted a prospective, randomized, nonblinded assessment of the effectiveness and feasibility of pharmacist-led admission medication reconciliation for geriatric patients. Methods: Eighty-one geriatric patients were randomized 1:1 to receive medication reconciliation per current hospital practice or to pharmacist-led medication reconciliation at admission. The primary end point was medication profile appropriateness by pharmacist review at 48 hours postadmission. Secondary end points involved in determining the impact and feasibility of this program. Results: Pharmacist-led medication was superior to standard hospital practice, with 48% of controls and 71% of intervention patients having appropriate medication profiles at 48 hours postadmission (P = .033). Pharmacists identified 116 discrepancies among 81 patients including predominantly omissions (41%) and a composite of wrong dose, route, or frequency (35%). Pharmacists spent a median 15 minutes per patient. Conclusion: Pharmacists improved admission medication reconciliation for geriatric patients. Pharmacists identified a significant number of discrepancies, including predominantly omissions and wrong dose, dosage form, or frequency. Pharmacists’ contributions to medication reconciliation could yield substantial benefit to patient care.

Stress Ulcer Prophylaxis: Reducing Non-Indicated Prescribing After Hospital Discharge

Gastric acid suppressant medications used as stress ulcer prophylaxis (SUP) in the intensive care unit (ICU) are often prescribed inappropriately after discharge. We present tools to reduce the use and cost of non-indicated SUP. To reduce the non-indicated use of SUP after hospital discharge originally started in the ICU, using an education intervention and pharmacist-led medication reconciliation on patient care rounds and at hospital discharge. In a retrospective medical record review using a historic control, 356 consecutively admitted patients to the medical/surgical ICU at the University of Wisconsin Hospital were assessed for the appropriate use of SUP at admission to the ICU, at transfer to a general care unit, and at hospital discharge. The education intervention involved teaching both the medical and pharmacist staff about indications for SUP using a memorandum and a pocket guide. Pharmacists also conducted medication reconciliation during daily patient care rounds and at discharge to justify medication use. The outcome of this study is the percentage of patients prescribed non-indicated gastric acid suppressants at hospital discharge. This outcome is compared to a previous study conducted at our hospital. Of 356 eligible patients, 308 (86.5%) received SUP while in the ICU. Thirty-nine (11%) were given continuing SUP after discharge from the hospital, of which 31 (8.7%) had no clear indication. This was a 64.3% reduction from the 24.4% found in the prior study (p < 0.0001). Educational materials that guide prescribing, pharmacist interaction on patient care rounds, and pharmacist-conducted medication reconciliation significantly reduced the prescribing of non-indicated gastric acid suppressant medications after hospital discharge.

Promoting safe use of multiple medications by elderly persons

Polypharmacy is highly prevalent in residential aged care facilities (RACFs). Although polypharmacy is sometimes unavoidable, polypharmacy has been associated with increased morbidity and mortality.To identify and prioritize a range of potential interventions to manage polypharmacy in RACFs from the perspectives of health care professionals, health policy and consumer representatives.Two nominal group technique (NGT) sessions were convened in August 2015. A purposive sample (n = 19) of clinicians, researchers, managers and representatives of consumer, professional and health policy organizations were asked to nominate interventions to address the prevalence and appropriateness of medication use. Participants were then asked to prioritize five interventions suitable for possible implementation at the system level.Six of 16 potential interventions were prioritized highest for possible implementation in clinical practice, with two interventions prioritized as second highest. The top interventions in rank order were ‘implementation of a pharmacist-led medication reconciliation service for new residents,’ ‘conduct facility-level audits and feedback to staff and health care professionals,’ ‘develop deprescribing scripts to assist clinician-resident discussion,’ ‘develop or revise prescribing guidelines specific to older people with multimorbidity in RACFs,’ ‘implement electronic medication charts and records’ and ‘better support Medication Advisory Committees (MACs) to address medication appropriateness.’This study prioritized a range of potential interventions that may be used to assist clinicians and policy makers develop a comprehensive strategy to manage polypharmacy in RACFs.