Reduce Medication Discrepancies Research Articles

Improving the medication literacy at the time of discharge from hospital (the LiMeTiD study)

Unintended discrepancy in medications at the time of discharge from the hospital is associated with an increased incidence of adverse drug events, including readmission to hospital. Medication literacy is an essential part of health literacy and can reduce medication discrepancies. This prospective observational cohort study aimed to measure the medication literacy of patients at the time of discharge from the hospital when managed with usual care and after the introduction of a medication literacy improvement instrument. This study involved a baseline cohort receiving usual care and a post-intervention cohort aged 50–80 years with high health literacy. The 7 Things I Should Know About My Medications at the Time of Discharge from Hospital instrument, in short, The 7 Domains MedLit Instrument, was designed by the researchers in addition to three medication literacy measurement questionnaires. Medication literacy was measured at 30 h post-discharge. The impact on readmission to hospital was assessed at 30 days post-discharge. The 7 Domains MedLit Instrument was found to significantly increase the number of patients reporting increased counselling by a clinician at the time of discharge from the hospital (clinician, 59.3 % vs. 100.0 %, X2 (1, n = 49) = 11.10, p < 0.01, physician, 28.6 % vs. 76.2, X2 (1, n = 49) = 10.9, p < 0.01, pharmacist 25.0 % vs. 71.4 %, X2 (1, n = 49) = 10.4, p < 0.01)). Significantly, more patients had increased knowledge on drug interactions or adverse drug reactions after using the instrument (26.1 % vs. 61.9 %, P = 0.032 and 30.4 % vs. 66.7 %, P = 0.033, respectively). The 7 Domains MedLit Instrument and the schooling years significantly correlated with the knowledge of drug interactions and adverse drug reactions. Less post-intervention participants visited an emergency department within 30 days post-discharge. The 7 Domains MedLit Instrument significantly improved the patients’ medication literacy at the time of discharge from hospital.

Medication discrepancies across care transitions and the role of pharmacy technicians: A retrospective chart review

BackgroundAfter hospitalization, older adults are increasingly discharged to postacute care facilities such as skilled nursing facilities (SNFs). Medication reconciliation and obtaining the best possible medication history (BPMH) are key components of medication management for care transitions and essential for preventing medication errors and adverse drug events. ObjectiveThis study aimed to assess medication discrepancies across care transitions after a Certified Pharmacy Technician (CPhT) obtains the BPMH on hospital admission. MethodsSingle-center, retrospective chart review and included adults ≥ 18 years admitted to the medicine service and discharged to a SNF between November 2016 and June 2017. Medication lists were evaluated for discrepancies across 3 transitions: hospital admission to hospital discharge (Time I), hospital discharge to SNF admission (Time II), and SNF admission to SNF discharge (Time III). Discrepancies were categorized by medication class, type of discrepancy, and whether it was potentially intentional or unintentional. ResultsIn 127 patients, the average age was 83.3 (SD 9.16), 61% (n = 77) were female, and 67% (n = 85) were white. Median hospital length of stay (LOS) was 6 days (interquartile range [IQR] 4-10) and SNF LOS 21 days (IQR 15-30). Across 381 transitions, 6322 medications were reviewed, and 2602 discrepancies identified. The total number of medication discrepancies was 1034 (Time I), 687 (Time II), and 881 (Time III), respectively. All patients had at least one medication discrepancy. The average number of potentially unintentional discrepancies per patient at each transition was 0.14, 0.2, and 0.16, respectively. The most common discrepancy type was omissions (39%), and the highest number of discrepancies in the potentially intentional and unintentional discrepancy groups was gastrointestinal (21%) and cardiovascular medications (24%), respectively. ConclusionMedication discrepancies are common across all care transitions. Future studies are needed to evaluate the role of CPhT in obtaining the BPMH on hospital admission for reducing medication discrepancies across the continuum of care.

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

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

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

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

Impact of pharmacist-led admission medication reconciliation on patient outcomes in a large health system

Objective Performing accurate medication history and reconciliation is recognized to reduce medication discrepancies and errors resulting in improved patient safety. This quality improvement project retrospectively evaluated the impact of a newly implemented pharmacy-led admission medication reconciliation program for several hospitals. Methods In 2020, a pharmacy-led admission medication reconciliation program was implemented in 16 hospitals across a large health system. The program targeted high-risk, complex inpatients admitted through the emergency department and directly to the hospital. Medication history technicians captured the best possible medication list and medication reconciliation pharmacists reviewed the list, collaborating with providers to complete reconciliation, and intervening to optimize drug therapy. A retrospective, pre-post analysis was performed comparing the preimplementation time period of June to November 2019 to the postimplementation time period of June to November 2020. Outcomes evaluated included pharmacy staff productivity, adverse drug events (ADEs), complications, and healthcare professional satisfaction. Results A total of 311,473 patients were admitted to the 16 hospitals during the pre- and postimplementation time periods. During the six-month postimplementation period, nearly 80,000 medication histories and reconciliations were completed, with 39.9% of those histories requiring medication clarification. Both the ADE rate and complication rate decreased significantly after program implementation, 12% decrease ( p &lt; 0.017) and 14% decrease ( p &lt; 0.001), respectively. Healthcare professional survey results from nurse, physician, and pharmacist respondents indicated a statistically significant improvement in satisfaction. Conclusion After implementation of pharmacy-led admission medication reconciliation, patient ADEs and complications decreased during hospitalization, and physician, nurse, and pharmacist satisfaction significantly improved.

An electronic pillbox intervention designed to improve medication safety during care transitions: challenges and lessons learned regarding implementation and evaluation

BackgroundAdverse drug events are common during transitions of care. As part of the Smart Pillbox study, a cluster-randomized controlled trial of an electronic pillbox designed to reduce medication discrepancies and improve medication adherence after hospital discharge, we explored barriers to successful implementation and evaluation of this intervention.MethodsEligible patients were those admitted to a medicine service of a large teaching hospital with a plan to be discharged home on five or more chronic medications. The intervention consisted of an electronic pillbox with pre-filled weekly blister pack medication trays given to patients prior to discharge. Pillbox features included alarms to take medications, detection of pill removal from each well, alerts to patients or caregivers by phone, email, or text if medications were not taken, and adherence reports accessible by providers. Greater than 20% missed doses for three days in a row triggered outreach from a pharmacist. To identify barriers to implementation and evaluation of the intervention, we reviewed patient exit surveys, including quantitative data on satisfaction and free-text responses regarding their experiences; technical issue logs; and team meeting minutes. Themes were derived by consensus among the study authors and organized using the Consolidated Framework for Implementation Research.ResultsBarriers to implementation included intervention characteristics such as perceived portability issues with the pillbox and time required by pharmacists to enter medication information into the software; external policies such as lack of insurance coverage for early refills and regulatory prohibitions on repackaging medications; implementation climate issues such as the incompatibility between the rushed nature of hospital discharge with the time required to deploy the intervention; and patient issues such as denial of previous problems with medication adherence. We founds several obstacles to conducting the study, including patients declining study enrollment and limited attempts by the hospital to streamline logistics by building the intervention into usual care. Several solutions to address many of these challenges were implemented or planned. Despite these challenges, many patients with the pillbox were pleased with the service and believed the intervention worked well for them.ConclusionsIn this evaluation, several barriers to implementing and conducting a study of the effectiveness of the intervention were identified. Our findings provide lessons learned for others wishing to implement and evaluate HIT-related interventions designed to improve medication safety during care transitions.Trial registrationClinicaltrials.gov NCT03475030

The Perceived Effectiveness of Secure Messaging for Medication Reconciliation During Transitions of Care: Semistructured Interviews With Patients.

BackgroundMedication discrepancies can lead to adverse drug events and patient harm. Medication reconciliation is a process intended to reduce medication discrepancies. We developed a Secure Messaging for Medication Reconciliation Tool (SMMRT), integrated into a web-based patient portal, to identify and reconcile medication discrepancies during transitions from hospital to home.ObjectiveWe aimed to characterize patients’ perceptions of the ease of use and effectiveness of SMMRT.MethodsWe recruited 20 participants for semistructured interviews from a sample of patients who had participated in a randomized controlled trial of SMMRT. Interview transcripts were transcribed and then qualitatively analyzed to identify emergent themes.ResultsAlthough most patients found SMMRT easy to view at home, many patients struggled to return SMMRT through secure messaging to clinicians due to technology-related barriers. Patients who did use SMMRT indicated that it was time-saving and liked that they could review it at their own pace and in the comfort of their own home. Patients reported SMMRT was effective at clarifying issues related to medication directions or dosages and that SMMRT helped remove medications erroneously listed as active in the patient’s electronic health record.ConclusionsPatients viewed SMMRT utilization as a positive experience and endorsed future use of the tool. Veterans reported SMMRT is an effective tool to aid patients with medication reconciliation. Adoption of SMMRT into regular clinical practice could reduce medication discrepancies while increasing accessibility for patients to help manage their medications.Trial RegistrationClinicalTrials.gov NCT02482025; https://clinicaltrials.gov/ct2/show/NCT02482025

A Prospective Observational Study of Medication Reconciliation at Admission, Transfer and Discharge to Reduce Medication Discrepancies in Inpatient

Abstract: Background: Medication reconciliation is the method in which patient’s medication orders were compared to all the medications that the patient has been taking. This Reconciliation process for circumvent the medication discrepancies such as omission, drug interaction, duplications, or any medication related errors. Medication reconciliation ensures standard treatment for patients and also avoid harm from medicines is reduced. It is the baseline from which drug treatment is continued on admission, therapeutic interventions are made, and self-caring will be continued on discharge. Objectives: The primary objective of this study was to assess the prevalence and types of medication discrepancies found during medication reconciliation. The secondary objective was to determine the impact of medication reconciliation and to examine the potential severity of medication discrepancies also to find out drug’s involvement in medication errors. Methodology: A prospective, observational study of medication reconciliation was done for 3 months in the inpatient department of the hospital. Results: A total 120 patients were included in this study, out of which 67(55.83%) were, male and 53(44.17%) were female. We found discrepancies in 45(37.50%) patients. Discrepancies were found at different transition points-At admission 34(57.36%) discrepancies identified, at transfer 4(6.78%) discrepancies identified, and at discharge 21(35.59%) discrepancies identified. Conclusion: Medication reconciliation process has a highly latent to recognize clinically important discrepancies for all patients. Medication reconciliation requires more focus in hospitals along with requirement for clinical pharmacy department for the medication safety. Keywords: Medication reconciliation, Patient safety, Transitions of care, Medication discrepancies, Medication Error.

Impact of Pharmacist-Directed Medication Reconciliation in Reducing Medication Discrepancies: A Randomized Controlled Trial.

In hospital surgical wards, patients are at higher risk for medication errors, in part because physicians may not consider themselves sufficiently trained to prescribe medications. Hence, collaborative teamwork involving the pharmacist is needed. To assess the impact of medication reconciliation directed by pharmacists on decreasing medication discrepancies after discharge from the surgical ward. Patients admitted to the surgical unit at a tertiary teaching hospital in Amman, Jordan, between July 2017 and July 2018 were selected and randomly assigned to either the control or the intervention group. Upon admission, the number and kinds of unintentional medication discrepancies were determined for both groups. Medication reconciliation was then provided to patients in the intervention group. The number of unintentional discrepancies was re-evaluated upon discharge for both groups. To assess differences between the control and intervention groups, the χ2 or Fisher exact test was used for categorical variables and an independent-sample t test for continuous data. A paired t test was conducted to determine whether the number of medication discrepancies was reduced as a result of pharmacists' recommendations. A total of 123 patients met the inclusion criteria, 61 in the intervention group and 62 in the control group. Discrepancies of omission and wrong dose constituted 41 (77%) of the 53 discrepancies in the intervention group and 25 (76%) of the 33 discrepancies in the control group. The number of unintentional discrepancies was significantly reduced from admission to discharge in both the intervention group (p = 0.002) and the control group (p = 0.007). Of 53 recommendations made by pharmacists, 20 (38%) were accepted by the treating physician, and all of these discrepancies were resolved. This study sheds light on the existence of unintentional medication discrepancies upon admission for surgical patients, which may expose the patients to potential harm upon discharge from hospital. Additional studies with a larger sample size are needed to gain further insights on pharmacists' role in implementing medication reconciliation for surgical patients.

Drug Reconciliation Program as a Patient Safety Initiative in a Specialty Hospital in the Southeastern Region of Brazil: A Study Protocol

A common problem observed in patient safety is the lack of accurate and complete information about medications in regular use during transfers of care between different health facilities. In view of this, medication reconciliation is postulated as a barrier to reducing medication discrepancies and consequently medication errors. This project aims to evaluate the implementation of safe clinical practices conducted by clinical pharmacists. To this end, we will conduct a standardized process to obtain the best possible medication history (BPMH); assessment of the patient's level of understanding of pre-admission therapy; quantification, classification and analysis of discrepancies of unintentional drugs at hospital admission; effect of interventions conducted by clinical pharmacists and impact on patient safety. This prospective, pilot, descriptive, interventional and single-center study will be carried out in the Clinical Pharmacy Department of a large hospital in the state of São Paulo. In order to standardize the process of data collection and reconciliation of prescription drugs, the interview with the patient will be carried out using an adapted and modified form. After collecting information in the structured interview, clinical pharmacists will identify, analyze and classify possible discrepancies. All unintentional discrepancies found without any clinical justification will be considered medication errors. Finally, the degree of impact of each drug discrepancy will be defined as: clinically insignificant; clinically significant; serious and life-threatening.

CancelRx: a health IT tool to reduce medication discrepancies in the outpatient setting.

Medication list discrepancies between outpatient clinics and pharmacies can lead to medication errors. Within the last decade, a new health information technology (IT), CancelRx, emerged to send a medication cancellation message from the clinic's electronic health record (EHR) to the outpatient pharmacy's software. The objective of this study was to measure the impact of CancelRx on reducing medication discrepancies between the EHR and pharmacy dispensing software. CancelRx was implemented in October 2017 at an academic health system. For 12 months prior, and 12 months after CancelRx implementation, data were collected on discontinued medications in the health system's EHR and whether those prescriptions were successfully discontinued in the pharmacy's dispensing software. An interrupted time series analysis was conducted to model the occurrence of prescriptions successfully discontinued over time. There was an immediate (lag = 0), significant (P < 0.001), and sustained (post-implementation slope 0.02) increase in the proportion of successful medication discontinuations after CancelRx implementation (from 34% to 93%). CancelRx had variable impact based on whether the clinic was primary care (71.4% change prepost) or specialty care (53.9% change prepost). CancelRx reduced the time between when a medication was discontinued in the clinic EHR and pharmacy dispensing software. CancelRx automated a manual process and illustrated the role for health IT in communicating medication discontinuations between clinics and pharmacies. Overall, CancelRx had a marked benefit on medication list discrepancies and illustrated how health IT can be used across different settings to improve patient care.

A blueprint for success: Using an implementation framework to create a medication history technician pilot program

BackgroundMedication discrepancies at transitions of care may compromise patient safety. Trained pharmacy technicians can reduce harmful medication discrepancies at transitions of care by collecting medication histories. ObjectiveWe describe how to create a program integrating medication history technicians (MHTs) into the hospital discharge process using implementation science. Practice descriptionWe created our MHT program at a Veterans Affairs (VA) hospital. Practice innovationWe used an evidence-based framework and implementation science to tailor our MHT program to meet local stakeholder needs. Evaluation methodsWe completed a literature review and review of current discharge practices. Then, we completed a workflow pilot, a needs assessment, and semistructured interviews with pharmacy technicians and pharmacists. We integrated these findings to identify barriers of MHT program implementation. Finally, we mapped these barriers to implementation strategies to create an MHT program implementation blueprint. ResultsThe literature review and review of current discharge practices revealed opportunities for our program to reduce medication discrepancies. We applied these findings to our proof-of-concept workflow pilot, which reduced medication discrepancy rates at discharge. When we explored barriers in the needs assessment, we learned that 4 of 6 pharmacy technicians had some training conducting medication histories, but 5 of 6 requested additional training for the new MHT role. We explored these and additional barriers in semistructured interviews. Four themes emerged: elements of pharmacy technician training, challenges to implementation, program logistics and workflow, and pharmacy technician self-efficacy. We mapped barriers to implementation strategies to create an MHT program implementation blueprint, including developing pharmacy technician training materials, modifying our workflow, creating program evaluation materials, and strategizing how to overcome anticipated and current implementation barriers. ConclusionsWe used implementation science to create a tailored MHT program. Others may adapt our implementation blueprint to fit local stakeholder needs.

Evidence for the impact of interventions and medicines reconciliation on problematic polypharmacy in the UK: A rapid review of systematic reviews.

This was a rapid review of systematic reviews (SRs) on problematic polypharmacy (PP) in the UK. The commissioner-defined topics were burden of PP, interventions to reduce PP, implementation activities to increase uptake of interventions, and efficient handover between primary and secondary care to reduce PP. Databases including Medline were searched to June 2019, SR quality was assessed using AMSTAR-2 (A MeaSurement Tool to Assess systematic Reviews) and a narrative synthesis was undertaken. Except for burden of PP (SRs had to include UK studies), there were no restrictions on country, location of care or outcomes. Nine SRs were included. On burden, three SRs (including six UK studies) found a high prevalence of polypharmacy in long term care. PP was associated with mortality, although unclear if causal, with no information on costs or health consequences. On interventions, six reviews (27 UK studies) found that interventions can reduce PP, but no effects on health outcomes. On handover between primary and secondary care, one review (two UK studies) found medicine reconciliation activities to reduce medication discrepancies at care transitions reduce PP, although the evidence is low quality. No SRs on implementation activities to increase uptake of interventions were found. SR quality was variable, with some concerns regarding meta-analysis methods. Evidence of the extent of PP in the UK, and what interventions to address it are effective in the UK, is limited. Future UK research is needed on the prevalence and consequences of PP, the effectiveness and cost-effectiveness of interventions to reduce PP, and barriers and activities to ensure uptake.

Effect of an Electronic Medication Reconciliation Intervention on Adverse Drug Events

Adverse drug events (ADEs) account for up to 16% of emergency department (ED) visits and 7% of hospital admissions. Medication reconciliation is required for hospital accreditation because it can reduce medication discrepancies, but there is no evidence that reducing discrepancies reduces ADEs or other adverse outcomes. To evaluate whether electronic medication reconciliation reduces ADEs, medication discrepancies, and other adverse outcomes compared with usual care. This cluster randomized trial involved 3491 patients who were discharged from 2 medical units and 2 surgical units at the McGill University Health Centre, Montreal, Quebec, Canada, between October 2014 and November 2016. Data analysis took place from July 2017 to July 2019. The RightRx intervention electronically retrieved community drugs from the provincial insurer and aligned them with in-hospital drugs to facilitate reconciliation and communication at care transitions. The primary outcome was ADEs in 30 days after discharge. Secondary outcomes included medication discrepancies, ED visits, hospital readmissions, and a composite outcome of ED visits, readmissions, and death up to 90 days after discharge. Of 4656 eligible patients, 3567 (76.6%) consented to participate (2060 [57.8%] men; mean [SD] age, 69.8 [14.9] years). Overall, 76 patients died during the hospital stay, so 3491 patients were included in the analysis. There was no significant difference in the risk of ADEs between intervention and control groups (76 [4.6%] vs 73 [4.0%]; OR, 0.97; 95% CI, 0.33-1.48), ED visits (433 [26.2%] vs 488 [26.6%]; OR, 0.83; 95% CI, 0.36-1.42), hospital readmission (170 [10.3%] vs 261 [14.2%]; OR, 0.22; 95% CI, 0.06-1.14), or the composite outcome (447 [27.0%] vs 506 [27.6%]; OR, 0.75; 95% CI, 0.34-1.27) at 30 days. Medication discrepancies were significantly reduced in the intervention group compared with the control group (437 [26.4%] vs 1029 [56.0%]; OR, 0.24; 95% CI, 0.12-0.57). Changes made to community medications (OR, 1.05; 95% CI, 1.01-1.10) and new medications (OR, 1.09; 95% CI, 1.01-1.18) were significant risk factors for ADEs. Electronic medication reconciliation reduced medication discrepancies but did not reduce ADEs or other adverse outcomes. Hospital accreditation should focus on interventions that reduce the risk of adverse events for patients with multiple changes to community medications. ClinicalTrials.gov identifier: NCT01179867.

Impact of Pharmacists Directed Medication Reconciliation on Reducing Medication Discrepancies in a Surgery Ward

Impact of Pharmacists Directed Medication Reconciliation on Reducing Medication Discrepancies in a Surgery Ward

A Mixed-Method Study of Practitioners' Perspectives on Issues Related to EHR Medication Reconciliation at a Health System

In an effort to reduce medication discrepancies during transitions of care and improve accuracy of the patient's medication list, AU Health conducted a study to identify a comprehensive set of issues related to electronic health record (EHR) medication reconciliation (MedRec) from the perspective of practitioners directly involved in the EHR MedRec process. An exploratory mixed-method design was used. The 2-round study included 15 individual interviews, followed by a survey of 200 practitioners (ie, physicians, nurses, and pharmacists) based in the outpatient and inpatient medicine service at AU Health. Thematic analysis of interview data identified 55 issue items related to EHR MedRec under 9 issue categories. The survey sought practitioners' importance rating of all issue items identified from interviews. A total of 127 (63%) survey responses were received. Factor analysis served to validate the following 6 of the 9 issue categories, all of which were rated "important" or higher (on average), by over 70% of all respondents: (1) care coordination (CCI); (2) patient education (PEI); (3) ownership and accountability (OAI); (4) processes-of-care (PCI); (5) IT-related (ITRI); and (6) workforce training (WTI). Significance testing of importance rating by professional affiliation revealed no statistically significant differences for CCI and PEI, and some statistically significant differences for OAI, PCI, ITRI, and WTI. There were 2 key gleanings from the issues related to EHR MedRec unearthed by this study: (1) there was an absence of shared understanding among practitioners, of the value of EHR MedRec in promoting patient safety, which contributed to workarounds, and suboptimal use of the EHR MedRec system; and (2) there was a sociotechnical dimension to many of the issues, creating an added layer of complexity. These gleanings, in turn, provide insights into best practices for managing both (1) clinical transitions of care in the EHR MedRec process and (2) sociotechnical challenges encountered in EHR MedRec implementation.

Automated E-mail Reminders Linked to Electronic Health Records to Improve Medication Reconciliation on Admission.

Introduction:Medication reconciliation can reduce medication discrepancies, errors, and patient harm. After a large academic hospital introduced a medication reconciliation software program, there was low compliance with electronic health record documentation of home medication reconciliation. This quality improvement project aimed to improve medication reconciliation on admission in 4 pediatric inpatient units by 50% over 3 months.Methods:We used Lean Sigma methodology to observe medication reconciliation processes; interview residents, nurses, pharmacists, and families; and perform swim lane process mapping and Ishikawa Cause and Effect analysis. The improvement plan included education and automated e-mails sent to admitting residents who had not completed medication reconciliation within 24 hours of admission. The daily percentage of patients without medication reconciliation within 24 hours of admission, indicated by the presence of old prescriptions in Sunrise Prescription Writer (RxWriter) (Allscripts Healthcare Solutions, Chicago, Ill.) from prior admissions, was assessed from March 2015-June 2016. We constructed statistical process control charts and identified special causes.Results:Key barriers included lack of knowledge about RxWriter and lack of accountability for completing medication reconciliation. The percentage of patients without medication reconciliation decreased from 32% at baseline to 22% with education (P < 0.001), to 15% with the use of automated e-mail reminders (P < 0.001). We sustained improvement over the following year. Statistical process control testing indicated shifts aligning with each stage of the study.Conclusion:Provider-tailored, automated e-mail reminders linked to electronic health record with educational training significantly improved resident compliance with use of an electronic tool for documentation of home medication reconciliation on hospital admission.

Impact of pharmacist's directed medication reconciliation on reducing medication discrepancies during transition of care in hospital setting

Abstract Objectives To evaluate the effect of pharmacist's directed services (reconciliation plus counselling) on reducing medication discrepancies and improving patient's outcomes at discharge from hospital. Methods During the 3-month study period, 200 patients were randomly selected from internal medicine department from Jordan University Hospital (JUH) and allocated into two groups (intervention and control groups). The number and types of medication discrepancies were identified at admission. Then, pharmacist implemented medication reconciliation and medication counselling services to the intervention group patients. At discharge, the number of unintentional discrepancies was evaluated for both groups. Patients were assessed at 1 month following their discharge for any subsequent hospital readmissions, emergency department visits or side effects of medication therapy. Key findings The total number of identified unintentional discrepancies was 84 for the intervention group compared with 60 discrepancies for the control group. Omission and addition represented the most common types of discrepancies for both groups. Of the 84 recommendations submitted by pharmacists, clinicians accepted 78 cases (92.8%), and implemented only 46 recommendations (54.7%). At discharge, a significant reduction in the number of unintentional discrepancies was achieved for the intervention group, P-value (0.014), while no significant change was found for the control group, P-value = 0.508. One month postdischarge, a significantly higher number of patients in the control group reported experiencing side effects compared with the intervention group, P-value = 0.020. Conclusion The presence of clinical pharmacists in hospital wards had a promising effect on decreasing the number of medication errors and improving health outcomes.

Reducing medication errors at transitions of care is everyone's business.

Medication errors are a common and significant problem, particularly when patients transition between healthcare providers. Discrepancies are especially prevalent on hospital admission and discharge. People with complex medication regimens, older people, those with mental health problems, people who are poor or have low literacy, and Aboriginal and Torres Strait Islander and migrant populations are particularly at risk of medication discrepancies. A patient-centred approach is a necessary shift towards reducing medication discrepancies and errors. The patient is the one ‘constant’ as they progress through GP and ancillary primary care services, hospital services, and specialist outpatient and private clinics. Patients and their carers need to be involved as active participants in this process. Maintaining an accurate, comprehensive and up-to-date medicines list that follows the patient, reduces serious medication error. Pivotal to this record is a medicines reconciliation review at error-prone transition points. Multiple health professionals involved in a patient’s journey through healthcare services need to embrace accountability for medicines-related outcomes. Emerging technologies for communication between primary care and specialist or secondary services will facilitate this, but importantly, there needs to be commitment from each health professional to undertake this approach.

Creating and evaluating an opportunity for medication reconciliation in the adult population of South Africa to improve patient care

ABSTRACTObjective: Adverse drug events (ADEs) are a major cause of morbidity and mortality, with more than 50% of ADEs being preventable. Adverse Drug Reactions (ADRs) are typically the result of an incomplete medication history, prescribing or dispensing error, as well as over- or under-use of prescribed pharmacotherapy. Medication reconciliation is the process of creating the most accurate list of medications a patient is taking and subsequently comparing the list against the different transitions of care. It is used to reduce medication discrepancies, and thereby ultimately decreasing ADEs. However, little is known about medicine reconciliation activities among public hospitals in South Africa.Methods: Prospective quantitative, descriptive design among Internal and Surgical wards in a leading public hospital in South Africa.Results: 145 study participants were enrolled. Over 1300 (1329) medicines were reviewed of which there was a significant difference (p = 0.006) when comparing the medications that the patient was taking before or during hospitalisation. A total of 552 (41.53%) interventions were undertaken and the majority of patients had at least 3.96 medication discrepancies. The most common intervention upon admission was transcribing the home medication onto the hospital prescription (65.2%) followed by medication duplication (13.44%). During patient’s hospital stay, interventions included patient counselling (32.5%) and stopping the previous treatment (37.5%).Conclusion: To ensure continuity of patient care, medication reconciliation should be implemented throughout patients’ hospital stay. This involves all key professionals in hospitals.