Pre-admission Medication List Research Articles

The Impact of Real-Time Documentation of In-Hospital Medication Changes on Preventing Undocumented Discrepancies at Discharge and Improving Physician-Pharmacist Communication: A Retrospective Cohort Study and Survey.

Transitional medication safety is crucial, as miscommunication about medication changes can lead to significant risks. Unclear or incomplete documentation during care transitions can result in outdated or incorrect medication lists at discharge, potentially causing medication errors, adverse drug events, and inadequate patient education. These issues are exacerbated by extended hospital stays and multiple care events, making accurate medication recall challenging at discharge. Thus, we aimed to investigate how real-time documentation of in-hospital medication changes prevents undocumented medication changes at discharge and improves physician-pharmacist communication. We conducted a retrospective cohort study in a tertiary hospital. Two pharmacists reviewed medical records of patients admitted to the acute medical unit from April to June 2020. In-hospital medication discrepancies were determined by comparing preadmission and hospitalization medication lists and it was verified whether the physician's intent of medication changes was clarified by documentation. By a documentation rate of medication changes of 100% and <100%, respectively, fully documented (FD) and partially documented (PD) groups were defined. Any undocumented medication changes at discharge were considered a "documentation error at discharge". Pharmacists' survey was conducted to assess the impact of appropriate documentation on the pharmacists. After reviewing 400 medication records, patients were categorized into FD (61.3%) and PD (38.8%) groups. Documentation errors at discharge were significantly higher in the PD than in the FD group. Factors associated with documentation errors at discharge included belonging to the PD group, discharge from a non-hospitalist-managed ward, and having three or more intentional discrepancies. Pharmacists showed favorable attitudes towards physician's documentation. Appropriate documentation of in-hospital medication changes, facilitated by free-text communication, significantly decreased documentation errors at discharge. This analysis underlines the importance of communication between pharmacists and hospitalists in improving patient safety during transitions of care.

Changes in medication regimen complexity index following medication-related hospital admissions: A retrospective single-centre study.

Medication-related hospitalisations present an opportunity for de-prescribing and simplification of medication regimens. The Medication Regimen Complexity Index (MRCI) is a tool for measuring the complexity of medication regimens. To evaluate whether MRCI changes following medication-related hospitalisations, and to evaluate the relationship between MRCI, length of stay (LOS) in hospital, and patient characteristics. A retrospective medical record review of patients admitted to a tertiary referral hospital in Australia for medication-related problems, January 2019 to August 2020. MRCI was calculated using pre-admission medication lists and discharge medication lists. There were 125 patients who met inclusion criteria. The median (IQR) age was 64.0 years (45.0-75.0) and 46.4% were female. Median MRCI decreased by 2.0 following hospitalisation: from median (IQR) 17.0 (7.0-34.5) on admission vs 15.0 (3.0-29.0) on discharge (p<0.001). Admission MRCI predicted LOS ≥2 days (OR 1.03, 95%CI 1.00-1.05, p=0.022). Allergic reaction-related hospitalisations were associated with lower admission MRCI. There was a decrease in MRCI following medication-related hospitalisation. Targeted medication reviews for high-risk patients (e.g., those with medication-related hospitalisations) could further reduce the burden of medication complexity following discharge from hospital and possibly prevent readmissions.

Medication-Related Acute Care Admission and Inappropriate Polypharmacy of Nursing Home Residents.

To evaluate the prevalence of medication-related admissions (MRAs) and their association with potentially inappropriate medications (PIMs) used by nursing home residents admitted to the geriatric center of a tertiary hospital. Cross-sectional study. Older patients admitted from nursing homes to the geriatric center of the Seoul National University Bundang Hospital who had undergone comprehensive geriatric assessment from January 1, 2016, to December 31,2020. MRAs were determined and verified using a previously described MRA adjudication guide. The PIMs in the preadmission medication lists were identified according to each of the following criteria (as well as the combined criteria), the Beers, NORGEP-NH, STOPP/START-NH, and STOPPFrail criteria. Medication use factors associated with MRAs were analyzed using multivariate logistic regression. Among the 304 acute care admissions, 32.2% were MRAs. The main cause of MRAs was acute kidney injury related with use of renin-angiotensin system inhibitors. Approximately 81% of the patients used at least 1 PIM according to the combined criteria. The use of 1 or more PIMs, renin-angiotensin system inhibitors, diuretics, nonsteroidal anti-inflammatory drugs, and benzodiazepines was significantly associated with MRAs. The combined criteria were able to predict MRAs better than the individual criteria. Approximately one-third of acute admissions of nursing home residents may be MRAs. Interventions for the optimal use of medication among nursing home residents are needed.

28 DRUG-DRUG INTERACTIONS IN OLDER HOSPITALISED PATIENTS: A PROSPECTIVE PREVALENCE STUDY

Abstract Background Drug-Drug Interactions (DDIs) are common in older adults and are associated with increased risk of adverse drug events and hospitalisation. Older adults are particularly susceptible to DDIs due to multimorbidity, polypharmacy and age-related changes in pharmacokinetics. A recently published standardised list of 66 potentially significant DDIs specifically relevant to adults aged ≥ 65 years has been validated by an expert consensus group. The aim of the present study was to prospectively assess the prevalence of DDIs in multimorbid older patients with polypharmacy at the point of unscheduled acute hospital admission, using this 66-item DDI list. Methods 77 unselected consecutive patients aged ≥65 years with ≥3 comorbidities and prescribed ≥5 daily regular medications were included. Medication reconciliations were conducted within 48 hours of admission. Medications were confirmed with two or more sources: the patient, their carer, the general practitioner, or the community pharmacist. Drug prescriptions reflecting pre-admission medication lists were manually screened for DDIs according to the 66-item DDI list. Results 47 participants (61.04%) had ≥1 listed DDI. The most commonly identified DDI was concomitant use of ≥3 centrally-acting neuropsychiatric drugs (n=18, 23.28%), which increases the risk of falls and impaired cognition. A highly significant correlation was found between the number of daily medications and the number of DDIs experienced (Spearman’s ρ=0.512, P&amp;lt;0.001). No statistically significant relationship was found between the number of comorbidities and the number of DDIs (Spearman’s ρ=0.194, P=0.107). No significant differences were detected in the number of DDIs, medications or comorbidities between men and women (P=0.818, P=0.428, P=0.281, respectively). Conclusion The majority (61%) of participants had at least one clinically significant DDI. Given the high prevalence of DDIs in this rapidly growing patient population, frequent review and rationalisation of medications using the 66-item DDI list is indicated to minimize DDIs and enhance medication safety.

Impact of a multidisciplinary medication reconciliation program on clinical outcomes: A pre-post intervention study in surgical patients.

Previous studies have evaluated the effects of medication reconciliation (MR) and suggest that it is effective in decreasing medication discrepancies. Nevertheless, a recent overview of systematic reviews concluded that there is no clear evidence in favor of MR in patient-related outcomes and healthcare utilization, and further research about it is needed. To evaluate the impact of a multidisciplinary MR program on clinical outcomes in patients with colorectal cancer presenting other chronic diseases, undergoing elective colorectal surgery. We performed a pre-post study. Adult patients scheduled for elective colorectal cancer surgery were included if they presented at least one "high-risk" criteria. The MR program was developed by internists, pharmacists and surgeons, and ended with the obtention of the patient's pre-admission medication list and follow-up care until discharge. The primary outcome was the length of stay (LOS). Secondly, we evaluated mortality, preventable surgery cancellations and risk factors for complications. Three hundred and eight patients were enrolled. Only one patient in the pre-intervention group suffered a preventable surgery cancellation (p=0.317). The mean LOS was 13±12 vs. 11±5 days in the pre-intervention and the intervention cohort, respectively (p=0.435). A difference in favor of the intervention group in patients with cardiovascular disease (p=0.038) and those >75 years old (p=0.043) was observed. No difference was detected in the mortality rate (p=0.999) neither most of the indicators of risk factors for complications. However, the management of preoperative systolic blood pressure of hypertensive patients (p=0.004) and insulin reconciliation in patients with treated diabetes (p=0.003) were statistically better in the intervention group. No statistically significant change was observed in the mean global LOS. A statistically significant positive effect on LOS was observed in vulnerable populations: patients >75 years old and those with cardiovascular disease, who presented a 5-day reduction in the mean LOS.

The Rural VA Multi-Center Medication Reconciliation Quality Improvement Study (R-VA-MARQUIS).

High-quality medication reconciliation reduces medication discrepancies, but smaller hospitals serving rural patients may have difficulty implementing this because of limited resources. We sought to adapt and implement an evidence-based toolkit of best practices for medication reconciliation in smaller hospitals, evaluate the effect on unintentional medication discrepancies, and assess facilitators and barriers to implementation. We conducted a 2-year mentored-implementation quality improvement feasibility study in 3 Veterans Affairs (VA) hospitals serving rural patients. The primary outcome was unintentional medication discrepancies per medication per patient, determined by comparing the "gold standard" preadmission medication history to the documented preadmission medication list and admission and discharge orders. In total, 797 patients were included; their average age was 68.7 years, 94.4% were male, and they were prescribed an average of 9.6 medications. Sites 2 and 3 implemented toolkit interventions, including clarifying roles among clinical personnel, educating providers on taking a best possible medication history, and hiring pharmacy professionals to obtain a best possible medication history and perform discharge medication reconciliation. Site 1 did not implement an intervention. Discrepancies improved in intervention patients compared with controls at Site 3 (adjusted incidence rate ratio [IRR], 0.55; 95% confidence interval [CI], 0.45-0.67) but increased in intervention patients compared with controls at Site 2 (adjusted IRR, 1.22; 95% CI, 1.08-1.36). An evidence-based toolkit for medication reconciliation adapted to the VA setting was adopted in 2 of 3 small, rural, resource-limited hospitals, resulting in both reduced and increased unintentional medication discrepancies. We highlight facilitators and barriers to implementing evidence-based medication reconciliation in smaller hospitals.

Frequency of undocumented medication discrepancies in discharge letters after hospitalization of older patients: a clinical record review study.

Transitions of care may result in medication errors, when information about a patient’s medications is not communicated sufficiently. In this clinical record review study, we aimed to evaluate the frequency of undocumented medication discrepancies at discharge from hospital and evaluate which patient characteristics could be associated with undocumented medication discrepancies. Preadmission medication lists were compared against the medication list in the discharge letters, taking into account medication changes documented in the patient record throughout the inpatient stay and in the discharge summary. Out of 200 patients, 174 (87%) were affected by at least one undocumented medication discrepancy, mostly for regular medication. Of the 1972 medications used, 744 (38%) medications were changed without documentation in the patient record, the majority being over-the-counter supplements and herbal medications. Polypharmacy at admission and discharge was associated with increased undocumented medication discrepancies. This study indicates a lack of medication reconciliation during inpatient stay. Correct and complete medication lists at admission and discharge may resolve many of these discrepancies, supporting patient safety at transitions of care.

Implications of involving pharmacy technicians in obtaining a best possible medication history from the perspectives of pharmaceutical, medical and nursing staff: a qualitative study

ObjectivesIn recent years, the involvement of pharmacy technicians in medication reconciliation has increasingly been investigated. The aim of this study was to assess the implications on professional roles and collaboration...

Prescribing error at hospital discharge: a retrospective review of medication information in an Irish hospital.

Prescribing error may result in adverse clinical outcomes leading to increased patient morbidity, mortality and increased economic burden. Many errors occur during transitional care as patients move between different stages and settings of care. To conduct a review of medication information and identify prescribing error among an adult population in an urban hospital. Retrospective review of medication information was conducted. Part 1: an audit of discharge prescriptions which assessed: legibility, compliance with legal requirements, therapeutic errors (strength, dose and frequency) and drug interactions. Part 2: A review of all sources of medication information (namely pre-admission medication list, drug Kardex, discharge prescription, discharge letter) for 15 inpatients to identify unintentional prescription discrepancies, defined as: "undocumented and/or unjustified medication alteration" throughout the hospital stay. Part 1: of the 5910 prescribed items; 53 (0.9%) were deemed illegible. Of the controlled drug prescriptions 11.1% (n=167) met all the legal requirements. Therapeutic errors occurred in 41% of prescriptions (n=479) More than 1 in 5 patients (21.9%) received a prescription containing a drug interaction. Part 2: 175 discrepancies were identified across all sources of medication information; of which 78 were deemed unintentional. Of these: 10.2% (n=8) occurred at the point of admission, whereby 76.9% (n=60) occurred at the point of discharge. The study identified the time of discharge as a point at which prescribing errors are likely to occur. This has implications for patient safety and provider work load in both primary and secondary care.

Exploring discharge prescribing errors and their propagation post-discharge: an observational study.

Background Discharge prescribing error is common. Little is known about whether it persists post-discharge. Objective To explore the relationship between discharge prescribing error and post-discharge medication error. Setting This was a prospective observational study (March-May 2013) at an adult academic hospital in Ireland. Method Patients using three or more chronic medications pre-admission, with a clinical pharmacist documented gold-standard pre-admission medication list, having a chronic medication stopped or started in hospital and discharged to home were included. Within 10-14days after discharge a gold standard discharge medication was prepared and compared to the discharge prescription to identify differences. Patients were telephoned to identify actual medication use. Community pharmacists, general practitioners and hospital prescribers were contacted to corroborate actual and intended medication use. Post-discharge medication errors were identified and the relationship to discharge prescribing error was explored. Main outcome measured Incidence, type, and potential severity of post-discharge medication error, and the relationship to discharge prescribing. Results Some 36 (43%) of 83 patients experienced post-discharge medication error(s), for whom the majority (n=31, 86%) were at risk of moderate harm. Most (58 of 66) errors were discharge prescribing errors that persisted post-discharge. Unintentional prescription of an intentionally stopped medication; error in the dose, frequency or formulation and unintentional omission of active medication are the error types most likely to persist after discharge. Conclusion There is a need to implement discharge medication reconciliation to support medication optimisation post-hospitalisation.

Medication discrepancies and associated risk factors identified among elderly patients discharged from a tertiary hospital in Singapore.

Medication discrepancies and poor documentation of medication changes (e.g. lack of justification for medication change) in physician discharge summaries can lead to preventable medication errors and adverse outcomes. This study aimed to identify and characterise discrepancies between preadmission and discharge medication lists, to identify associated risk factors, and in cases of intentional medication discrepancies, to determine the adequacy of the physician discharge summaries in documenting reasons for the changes. A retrospective clinical record review of 150 consecutive elderly patients was done to estimate the number of medication discrepancies between preadmission and discharge medication lists. The two lists were compared for discrepancies (addition, omission or duplication of medications, and/or a change in dosage, frequency or formulation of medication). The patients' clinical records and physician discharge summaries were reviewed to determine whether the discrepancies found were intentional or unintentional. Physician discharge summaries were reviewed to determine if the physicians endorsed and documented reasons for all intentional medication changes. A total of 279 medication discrepancies were identified, of which 42 were unintentional medication discrepancies (35 were related to omission/addition of a medication and seven were related to a change in medication dosage/frequency) and 237 were documented intentional discrepancies. Omission of the baseline medication was the most common unintentional discrepancy. No reasons were provided in the physician discharge summaries for 54 (22.8%) of the intentional discrepancies. Unintentional medication discrepancies are a common occurrence at hospital discharge. Physician discharge summaries often do not have adequate information on the reasons for medication changes.

Electronic medication reconciliation and medication errors.

To measure the impact of electronic medication reconciliation implementation on reports of admission medication reconciliation errors (MREs). Quality improvement project with time-series design. A large, urban, tertiary care children's hospital. All admitted patients from 2011 and 2012. Implementation of an electronic medication reconciliation tool for hospital admissions and regular compliance reporting to inpatient units. The tool encourages active reconciliation by displaying the pre-admission medication list and admission medication orders side-by-side. Rate of non-intercepted admission MREs identified via a voluntary reporting system. During the study period, there were 33 070 hospital admissions. The pre-admission medication list was consistently recorded electronically throughout the study period. In the post-intervention period, the use of the electronic medication reconciliation tool increased to 84%. Reports identified 146 admission MREs during the study period, including 95 non-intercepted errors. Pre- to post-intervention, the rate of non-intercepted errors decreased by 53% (P = 0.02). Reported errors were categorized as intercepted potential adverse drug events (ADEs) (35%), non-intercepted potential ADEs (42%), minor ADEs (22%) or moderate ADEs (1%). There were no reported MREs that resulted in major or catastrophic ADEs. We successfully implemented an electronic process for admission medication reconciliation, which was associated with a reduction in reports of non-intercepted admission MREs.

Impact of incorporating pharmacy claims data into electronic medication reconciliation

The potential value of adding pharmacy claims data to the medication history in the electronic health record (EHR) to improve the accuracy of medication reconciliation was studied. Three medication history sources were used for this evaluation: a gold-standard preadmission medication list (PAML) created by reviewing all available medication history information, an EHR-generated PAML, and pharmacy claims data. The study population consisted of patients from the Partners Medication Reconciliation Study with medication history information available from all three medication history sources. The aggregated medication list from each medication history source was compared with the gold-standard PAML to identify and categorize missing medications, additional medications, and discrepancies in the various attributes of a medication order, including dose, route, and frequency. McNemar's test was used to compare paired proportions of medication entries across each source to the gold-standard PAMLs. Fifteen patients had medication histories in all three medication history sources. Medication entries across all three sources included 169 from the gold- standard PAMLs, 158 from the EHR-PAMLs, and 351 from pharmacy claims data. The EHR-PAMLs and pharmacy claims data correctly reflected 52.1% and 43.2% of the gold-standard PAMLs, respectively. Combining the EHR-PAMLs and pharmacy claims resulted in 69.2% of the gold-standard PAMLs correctly reflected (p < 0.0001). Combining these two data sources increased the accuracy of medication history by 17.1%. Combining the EHR-PAML and pharmacy claims data resulted in a significant increase in the number of medications correctly reflected in the gold-standard PAML compared with the EHR-PAML or claims data separately.

Implementation of a pharmacy technician–centered medication reconciliation program at an urban teaching medical center

An inpatient medication reconciliation (MR) program emphasizing pharmacy technicians' role in the MR process is described. As part of quality-improvement (QI) efforts focused on MR-related adverse drug events, an urban academic medical center in New Jersey implemented a pharmacy technician-centered MR (PTMR) program targeting patients on its internal medicine, oncology, and clinical decision units. The program is staffed by five full- or part-time technicians who are trained in MR methods and work under direct pharmacist supervision, interviewing newly admitted patients and using other information sources (e.g., community pharmacies, physician offices, nursing facilities) to compile an accurate and complete medication list. About 30% of all patients admitted to the hospital are served by the PTMR program, which averages more than 500 cases each month. During one three-month period, 1748 discrepancies on preadmission medication lists were identified, most of which involved the omission of drugs (65.7% of cases) and incorrect information on dose and frequency of use (14.4%). Efforts to overcome resource constraints and other program challenges (e.g., privacy concerns, delays in community pharmacy transmittal of prescription refill lists) are ongoing. To date, most research on PTMR has been conducted in emergency departments or perioperative settings; experience with the PTMR program suggests that this approach can be applied in other hospital areas to improve MR processes and, ultimately, enhance pharmacotherapy safety and effectiveness across transitions of care. Based on experience, providers' perspectives, and QI data, the PTMR program is an effective method to obtain, document, and communicate accurate MR data for patients at this institution.

Medicine reconciliation on admission in a paediatric hospital setting

BackgroundMedication reconciliation is an organisational practice designed to ensure patients' pre-admission medicines are prescribed correctly upon admission to hospital. Multiple sources of information are needed to do this. This is...

Relative accuracy and availability of an Irish National Database of dispensed medication as a source of medication history information: observational study and retrospective record analysis

The medication reconciliation process begins by identifying which medicines a patient used before presentation to hospital. This is time-consuming, labour intensive and may involve interruption of clinicians. We sought to identify the availability and accuracy of data held in a national dispensing database, relative to other sources of medication history information. For patients admitted to two acute hospitals in Ireland, a Gold Standard Pre-Admission Medication List (GSPAML) was identified and corroborated with the patient or carer. The GSPAML was compared for accuracy and availability to PAMLs from other sources, including the Health Service Executive Primary Care Reimbursement Scheme (HSE-PCRS) dispensing database. Some 1111 medication were assessed for 97 patients, who were median age 74years (range 18-92years), median four co-morbidities (range 1-9), used median 10 medications (range 3-25) and half (52%) were male. The HSE-PCRS PAML was the most accurate source compared to lists provided by the general practitioner, community pharmacist or cited in previous hospital documentation: the list agreed for 74% of the medications the patients actually used, representing complete agreement for all medications in 17% of patients. It was equally contemporaneous to other sources, but was less reliable for male than female patients, those using increasing numbers of medications and those using one or more item that was not reimbursable by the HSE. The HSE-PCRS database is a relatively accurate, available and contemporaneous source of medication history information and could support acute hospital medication reconciliation.

Improving Medication Safety with Accurate Preadmission Medication Lists and Postdischarge Education

Gathering a complete preadmission medication list (PAML) at admission remains an essential component of medication reconciliation, as is providing the patient with a written medication list at the time of hospital discharge. A medication reconciliation project was begun in 2007 at an integrated health care system to (1) improve the accuracy of PAMLs within 24 hours of admission for patients admitted through the emergency department (ED) and (2) enhance patient education through telephone calls by pharmacists to the patients most at risk for adverse drug events (ADEs) or readmission. ACCURACY OF PAMLs: In the October 2007-May 2008 period, RN-generated PAMLs were accurate 16% of the time versus 89% for the June 2008-December 2010 period, when they were generated by pharmacy technicians. Medication errors classified as having the potential to cause moderate or serious harm decreased from 13.17% to 1.50%. By summer 2009, the Safe Med pharmacist program was fully staffed, thereby enabling the program to contact nearly 100% of the 10,174 patients meeting the Safe Med criteria from January 2009 through December 2010. When compared with historical controls, the Safe Med intervention was associated with a statistically significant reduction in 30- and 60-day readmissions, ADE-associated 30- and 60-day readmissions, and 30- and 60-day ED visits. ED-deployed pharmacy personnel can enhance the accuracy of PAMLs and may thereby reduce in-hospital ADEs. The postdischarge intervention by pharmacists with the most complex patients may reduce ADEs following hospital discharge. The interventions may compensate for discontinuities in care and lessen the attendant threats to patient safety.

Clinical pharmacist’s contribution to medication reconciliation on admission to hospital in Ireland

Medication reconciliation has been mandated by the Irish government at transfer of care. Research is needed to determine the contribution of clinical pharmacists to the process. To describe the contribution of emergency department based clinical pharmacists to admission medication reconciliation in Ireland. Frequency of clinical pharmacist's activities. Two public university teaching hospitals. Adults admitted via the accident and emergency department, from a non-acute setting, reporting the use of at least three regular prescription medications, were eligible for inclusion. Medication reconciliation was provided by clinical pharmacists to randomly-selected patients within 24-hours of admission. This process includes collecting a gold-standard pre-admission medication list, checking this against the admission prescription and communicating any changes. A discrepancy was defined as any difference between the gold-standard pre-admission medication list and the admission prescription. Discrepancies were communicated to the clinician in the patient's healthcare record. Potentially harmful discrepancies were also communicated verbally. Pharmacist activities and unintentional discrepancies, both resolved and unresolved at 48-hours were measured. Unresolved discrepancies were confirmed verbally by the team as intentional or unintentional. A reliable and validated tool was used to assess clinical significance by medical consultants, clinical pharmacists, community pharmacists and general practitioners. In total, 134 patients, involving 1,556 medications, were included in the survey. Over 97 % of patients (involving 59 % of medications) experienced a medication change on admission. Over 90 % of patients (involving 29 % of medications) warranted clinical pharmacy input to determine whether such changes were intentional or unintentional. There were 447 interventions by the clinical pharmacist regarding apparently unintentional discrepancies, a mean of 3.3 per patient. In total, 227 (50 %) interventions were accepted and discrepancies resolved. At 48-hours under half (46 %) of patients remained affected by an unintentional unresolved discrepancy (60 % related to omissions). Verbally communicated discrepancies were more likely to be resolved than those not communicated verbally (Chi-square (1) = 30.029 p < 0.05). Under half of unintentional unresolved discrepancies (46 %) had the potential to cause minor harm compared to 70 % of the resolved unintentional discrepancies. None had the potential to result in severe harm. Clinical pharmacists contribute positively to admission medication reconciliation and should be engaged to deliver this service in Ireland.

Errors in medication history at hospital admission: prevalence and predicting factors

BackgroundAn accurate medication list at hospital admission is essential for the evaluation and further treatment of patients. The objective of this study was to describe the frequency, type and predictors of errors in medication history, and to evaluate the extent to which standard care corrects these errors.MethodsA descriptive study was carried out in two medical wards in a Swedish hospital using Lund Integrated Medicines Management (LIMM)-based medication reconciliation. A clinical pharmacist identified each patient's most accurate pre-admission medication list by conducting a medication reconciliation process shortly after admission. This list was then compared with the patient's medication list in the hospital medical records. Addition or withdrawal of a drug or changes to the dose or dosage form in the hospital medication list were considered medication discrepancies. Medication discrepancies for which no clinical reason could be identified (unintentional changes) were considered medication history errors.ResultsThe final study population comprised 670 of 818 eligible patients. At least one medication history error was identified by pharmacists conducting medication reconciliations for 313 of these patients (47%; 95% CI 43-51%). The most common medication error was an omitted drug, followed by a wrong dose. Multivariate logistic regression analysis showed that a higher number of drugs at admission (odds ratio [OR] per 1 drug increase = 1.10; 95% CI 1.06-1.14; p < 0.0001) and the patient living in their own home without any care services (OR = 1.58; 95% CI 1.02-2.45; p = 0.042) were predictors for medication history errors at admission. The results further indicated that standard care by non-pharmacist ward staff had partly corrected the errors in affected patients by four days after admission, but a considerable proportion of the errors made in the initial medication history at admission remained undetected by standard care (OR for medication errors detected by pharmacists' medication reconciliation carried out on days 4-11 compared to days 0-1 = 0.52; 95% CI 0.30-0.91; p=0.021).ConclusionsClinical pharmacists conducting LIMM-based medication reconciliations have a high potential for correcting errors in medication history for all patients. In an older Swedish population, those prescribed many drugs seem to benefit most from admission medication reconciliation.

Effect of patient- and medication-related factors on inpatient medication reconciliation errors.

Little research has examined the incidence, clinical relevance, and predictors of medication reconciliation errors at hospital admission and discharge. To identify patient- and medication-related factors that contribute to pre-admission medication list (PAML) errors and admission order errors, and to test whether such errors persist in the discharge medication list. We conducted a cross-sectional analysis of 423 adults with acute coronary syndromes or acute decompensated heart failure admitted to two academic hospitals who received pharmacist-assisted medication reconciliation during the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) Study. Pharmacists assessed the number of total and clinically relevant errors in the PAML and admission and discharge medication orders. We used negative binomial regression and report incidence rate ratios (IRR) of predictors of reconciliation errors. On admission, 174 of 413 patients (42%) had ≥1 PAML error, and 73 (18%) had ≥1 clinically relevant PAML error. At discharge, 158 of 405 patients (39%) had ≥1 discharge medication error, and 126 (31%) had ≥1 clinically relevant discharge medication error. Clinically relevant PAML errors were associated with older age (IRR = 1.46; 95% CI, 1.00- 2.12) and number of pre-admission medications (IRR = 1.17; 95% CI, 1.10-1.25), and were less likely when a recent medication list was present in the electronic medical record (EMR) (IRR = 0.54; 95% CI, 0.30-0.96). Clinically relevant admission order errors were also associated with older age and number of pre-admission medications. Clinically relevant discharge medication errors were more likely for every PAML error (IRR = 1.31; 95% CI, 1.19-1.45) and number of medications changed prior to discharge (IRR = 1.06; 95% CI, 1.01-1.11). Medication reconciliation errors are common at hospital admission and discharge. Errors in preadmission medication histories are associated with older age and number of medications and lead to more discharge reconciliation errors. A recent medication list in the EMR is protective against medication reconciliation errors.