Transition Points Of Care Research Articles

Written communication about the use of medications in medical records in a Brazilian hospital.

Effective communication regarding the use of medications in hospital environments is a process that contributes to patient safety. Despite its importance, written communication about the medication use process in medical records remains insufficiently investigated. To describe the documentation in medical records regarding the medication use process by pharmacists, physicians and nurses on admission, during the hospital stay, and at hospital discharge. A retrospective cross-sectional chart review study was carried out in medical records of patients admitted to a teaching hospital in Northeast Brazil. The study considered all patients admitted between December 2016 and February 2017, aged 18 or older and hospitalised for at least 48hours. Clinical notes made by pharmacists, physicians and nurses were examined at three transition points of care. Data were collected using a questionnaire relating to the use of medications prior to hospital admission, changes in the prescribed medications during the hospital stay and discharge, as well as prescription non-conformities. Communication failures between the three healthcare professional groups were analysed and classified. The study was authorised by the Hospital's Board of Directors and approved by the Research Ethics Committee of the Federal University of Sergipe. This study included 202 medical records of patients with a mean age of 51.48 (SD 6.42, range: 19-97) years. There was no record of a patient or relative interview on allergies and adverse drug reactions in 54 (26.8%) physician notes, 44 (21.9%) nursing notes, and 9 (25.0%) pharmacist notes. Moreover, 1,588 changes in prescriptions were identified during data collection, and 1,198 (75.4%) of these were unjustified. Medication-related information in medical records was incomplete and inconsistent in the clinical notes of the three studied professions, especially in pharmacists' documentation. Future studies should focus on investigating the consequences of interprofessional communication in patient care.

Medication discrepancies in transition of care of hospitalised children in Brazil: a multicentric study

ObjectiveTo determine the incidence of medication discrepancies in transition points of care of hospitalised children.DesignA prospective observational multicentre study was carried out between February and August 2019. Data collection consisted...

Medication reconciliation in the geriatric unit: impact on the maintenance of post-hospitalization prescriptions

Background Medication reconciliation prevents medication errors at care transition points. This process improves communication with general practitioners regarding the reasons for therapeutic changes, allowing those changes to be maintained after hospital discharge. Objective To investigate the impact of medication reconciliation in geriatrics on the sustainability of therapeutic optimization after hospital discharge. Setting This study was conducted in a geriatric unit in a University Hospital Centre in France. Method This was a retrospective study. For 6months, all patients over 65years who underwent the process of medication reconciliation performed by a clinical hospital pharmacist and a physician at admission and discharge, were included. A comparison between drug prescriptions at hospital discharge and the first prescription made outside the hospital was made to identify any differences. Main outcome measure The main outcome measures were the provision of the results of the medication reconciliation performed in the hospital to the relevant general practitioner, the subsequent acceptance of that information, the type of medication discrepancies one month after discharge and the therapeutic classes affected by the modifications. Results Among the 112 patients, medication reconciliation allowed us to identify and correct 87 unintentional discrepancies at admission (88% corrected) and 54 at discharge (92% corrected). Patients were discharged to homes or nursing homes (61%), geriatric rehabilitation units (38%) or psychiatric clinics (1%). A general practitioner wrote the first prescription renewal a mean of 36 ± 23days after discharge, having been made aware of the medication reconciliation in only 24% of the cases (received and taken into account). The impact was a decrease in the number of patients with at least one discrepancy. Twenty-five percent of general practitioners who were aware about the medication reconciliation process accepted all therapeutic changes, while only 7% of those who were not informed did so (p = 0.02). The number of medication discrepancies observed was correlated with the number of medications for which prescriptions were renewed (p < 0.01). Conclusion Medication reconciliation involving therapeutic optimization and the justification of changes is essential to ensure the safety of the prescriptions written for patients. However, its impact after discharge is hampered by the fact that the results are often not received or taken into account by general practitioners. Taking medication reconciliation into account was associated with a significant increase in prescriptions that maintained therapeutic changes made in the hospital, confirming the positive impact of communication between care providers on therapeutic optimization.

Prevalence of medication discrepancies in pediatric patients transferred between hospital wards.

Background Children are more susceptible to harm from medication errors and adverse drug reactions when compared to adults. Such events may occur from medication discrepancies while transitioning patients throughout the healthcare system. Contributing factors include medication discontinuity and lack of information by the healthcare team. Objective To analyze the prevalence of medication discrepancies in transition points of care in a pediatric department. SettingPediatric department of a public hospital in Northeast Brazil. MethodA cross-sectional study was carried out from August 2017 to March 2018. Data collection consisted of the following steps: collection of sociodemographic data, clinical interview with the patient's caregiver, registration of patient prescriptions, and evaluation of medical records. Medication discrepancies were classified as intentional and unintentional. The unintentional medication discrepancies were classified as omission of medication, therapeutic duplicity, and differences in dose, frequency, or route of administration. Main outcomes measureDiscrepancy profile identified at admission, internal transfer and hospital discharge. Results Among the 114 patients included in the study, 85 (74.5%) patients had at least one unintentional medication discrepancy, of which 16 (14.0%) patients presented medication discrepancies at hospital admission, 42 (36.8%) patients at internal transfer, and 52 (45.6%) patients during discharge. Omission of medication represented 20 (74.1%) errors at admission, 26 (37.7%) errors at internal transfer, and 80 (100.0%) errors at hospital discharge. Conclusions The main transition points of care where unintentional discrepancies occurred in the studied pediatric department were at internal transfer and hospital discharge, with omission being the most common type of unintentional discrepancy.

Clinical and economic impact of medication reconciliation in cancer patients: a systematic review.

Medication reconciliation can reduce drug-related iatrogenesis by facilitating exhaustive information transmission at care transition points. Given the vulnerability of cancer patients to adverse drug events, medication reconciliation could provide a significant clinical benefit in cancer care. This review aims to synthesize existing evidence on medication reconciliation in cancer patients. A comprehensive search was performed in the PubMed/Medline, Scopus, and Web of Science databases, associating the keywords "medication reconciliation" and "cancer" or "oncology." Fourteen studies met the selection criteria. Various medication reconciliation practices were reported: performed at admission or discharge, for hospitalized or ambulatory patients treated with oral or parenteral anticancer drugs. In one randomized controlled trial, medication reconciliation decreased clinically significant medication errors by 26%. Although most studies were non-comparative, they highlighted that medication reconciliation led to identification of discrepancies and other drug-related problems in up to 88% and 94.7% of patients, respectively. The impact on post-discharge healthcare utilization remains under-evaluated and mostly inconclusive, despite a trend toward reduction. No comparative economic evaluations were available but one study estimated the benefit:cost ratio of medication reconciliation to be 2.31:1, suggesting its benefits largely outweigh its costs. Several studies also underlined the extended pharmacist time required for the intervention, highlighting the need for further cost analysis. Medication reconciliation can reduce adverse drug events in cancer patients. More robust and economic evaluations are still required to support its development in everyday practice.

Implementation of a Discharge Education Program to Improve Transitions of Care for Patients at High Risk of Medication Errors.

Background: Transitions of care (TOC) points are those where patient outcomes can be affected, especially patients at high risk for medication errors. Pharmacist-led postdischarge telephone counseling positively affects patient outcomes, though challenges exist relating to successful patient contact. Objective: The objective of this study was to develop and evaluate a discharge education service bridging the inpatient and outpatient setting to increase successful patient contact points during the TOC process from hospital to home. Methods: This prospective, single-centered observational study examined the impact of a discharge medication education program on successful telephone follow-up contact. The primary outcome was the percentage of high-risk patients educated at hospital discharge who were successfully reached via follow-up telephone contact within 2 business days of discharge. Secondary end points included hospital readmission rates and patient survey responses. Results: A total of 50 patients were included in the initial evaluation of this service; 78% of patients were successfully contacted within 2 business days after discharge, an increase from a 20% success rate prior to service implementation. At follow-up telephone calls, patients reported taking an average of 16 medications. The 30-day readmission rate was 10% for patients receiving this service, compared with 19% prior to implementation. When asked if they understood the medication component of their care and if they found the TOC service to be satisfactory, 100% and 96% of patients strongly agreed or agreed with these statements, respectively, and none disagreed. Conclusion and Relevance: This service demonstrates how pharmacists can interact with a high-risk population and increase contact points to optimize care at crucial health care transition points.

Development of an oncology-specific instrument to measure care coordination.

148 Background: Care coordination (CC) has been identified by the IOM as critically important for the delivery of quality medical care. Coordination of care is especially important in oncology due to multiple encounters, many physicians, significant toxicities and several care transition points. Standard patient satisfaction surveys do not accurately measure CC and there are few instruments to measure a patient’s perspective of CC directly. In this project, multiple PDSA cycles were utilized with oncology patients to develop a Care Coordination Instrument (CCI) that was then used to compare the level of CC in two distinct practices. Methods: Survey questions were initially prepared by the research team after review of existing literature, submitted to oncology RNs, NPs and MDs and then modified based on their feedback. A new survey was then administered to 30 patients. This was again modified to eliminate or improve questions that were confusing to patients. A third survey instrument was developed and administered to an additional 30 patients. Statistical analysis identified that several questions were too structured leading to many “not applicable” responses. These were changed to a more conceptual framework. The survey was then administered to 30 patients in the myeloma practice and 30 in the GI oncology practice. Results: The CCI included questions from 4 areas of coordination (patient-physician; between health providers; during inpatient-to-ambulatory care transitions; during transitions across different phases of care) and 3 domains (Communication, Operational, Navigation). The GI oncology practice scored significantly better than the myeloma practice on the communication and navigation domains (p &lt; 0.01). There was no significant difference in the operational domain. Conclusions: Testing to date suggests that the CCI is a useful instrument in measuring an oncology patient’s perception of CC. For two distinct practices, significant differences in the delivery of CC were identified. Further refinement is necessary to modify or eliminate questions with high levels of missing data due to non-responsiveness. Separate sub-scores across domains help identify specific targets for quality improvement interventions.

Identifying Effective Nurse-Led Care Transition Interventions for Older Adults With Complex Needs Using a Structured Expert Panel.

Nursing plays a central role in facilitating care transitions for complex older adults, yet there is no consensus of the components of nurse-led care transitions interventions to facilitate high quality care transitions among complex older adults. A structured expert panel was established with the purpose of identifying effective nurse-led care transition interventions. A modified Delphi consensus technique based on the RAND method was employed. Panelists (n = 23) were asked to individually rate a series of statements derived from a realist synthesis of the literature for relevance, feasibility and likely impact. Statements receiving an aggregate score of ≥75% (7/9) were reviewed and revised at a face-to-face consensus meeting. A second round of rating following the same process as round one was used, followed by a final ranking of the statements. The five highest ranked intervention components and contextual factors were: (a) educating and coaching patients, their family members and caregivers about self-management skills; (b) ensuring patients, their family members and caregivers are aware of follow-up medical appointments and postdischarge care plan; (c) using standardized documentation tools and comprehensive communication strategies during care transitions; (d) optimizing nurses' roles and scopes of practice across the care transitions spectrum; and (e) having strong leadership, strategic alignment and accountability structures in organizations to enable quality care transitions for the complex older person population. Key insights on optimizing the nurses' roles and scope of practice during care transitions included having nurses provide "warm hand-offs" and serve as the "go-to person." The panel also identified current challenges to optimizing the nurses' roles and scope of practice across care transition points. Future research is required to determine effective nurse-led intervention components and in which context do they work or do not.

Patient-, medication- and environment-related factors affecting medication discrepancies in older patients

BackgroundAs patients move across different clinical settings, medication changes are likely to occur. AimTo identify patient-, medication- and environment-related factors associated with unintentional medication discrepancies in older patients, who were admitted to hospital via an emergency department and who had a subacute care admission at some point following hospital admission. MethodsA retrospective clinical audit was undertaken using a stratified random sampling approach over a 14-month period. Medical records of patients aged 65 years or over were collected from five hospitals. FindingsData were collected from 426 older patients. Of these patients, 169 (39.7%) had at least one unexplained medication discrepancy. Patients without social supports had 2.956 greater odds of experiencing an unexplained medication discrepancy (95% CI 1.870–4.671), p<0.0001. As the number of prescribed medications increased upon admission to the emergency department, patients had 1.125 greater odds of experiencing an unexplained medication discrepancy (95% CI 1.035–1.223), p=0.006. Patients discharged to destinations other than their home had 2.714 increased odds (95% CI 1.317–5.594), p=0.007 while those experiencing more than four transition points of care had 2.476 increased odds (95% CI 1.208–5.074), p=0.013, of experiencing an unexplained medication discrepancy. A significant association existed between the prevalence of unexplained medication discrepancies and hospital readmission within six months, χ2=36.496, df=1, p<0.001. ConclusionGreat care is needed in managing complex medication regimens of older people with multiple chronic conditions, especially those who move across several transition points of care.

Impact clinique des divergences de traitement constatées chez 200 patients conciliés dans un service de gériatrie aiguë

IntroductionMedication reconciliation is a process used to identify and prevent medication errors at care transition points in hospitals. The present study's main objectives were to quantify the frequency of inadvertent discrepancies (IDs) per patient and estimate the seriousness of the IDs’ clinical impact. Patients and methodsThis was a prospective, single-center study performed in a 38-bed acute geriatric unit. All patients hospitalized over a 70-day period were included in the study. ResultsOver a 70-day period, 200 patients were included (mean±SD age: 85.5±5.9). A total of 316 IDs were recorded in 117 patients (58.5%, i.e. 1.58 per patient). One third of the IDs were considered to be serious or even life-threatening. Omission was the most common type of ID (58%). Cardiovascular drugs were most frequently involved in IDs (33%). ConclusionWe observed an average of more than one ID per patient, when comparing drug treatment at home and drug treatment upon admission to hospital. A third of these IDs may be clinically significant. Geriatric populations with polypharmacy and multiple comorbidities are particularly sensitive to this type of error. Medication reconciliation can detect and correct IDs. Collaboration between physicians and pharmacists will improve the quality of patient care and reduce the iatrogenic risk.

Examining the relationship between multiple primary cancers and psychological distress: A systematic literature review.

214 Background: The incidence of multiple primary cancers (MPC) in cancer survivors is increasing. However, little is known about the psychological effects of MPCs on cancer survivors. The purpose of this systematic review was to synthesize the evidence regarding the impact of MPC on psychological distress in cancer survivors. Methods: Relevant studies were identified in PubMed database (up to June 2015). Non-English articles were excluded. Two independent evaluators reviewed articles for relevancy and data extraction. Data was organized and recorded using a coding log with exclusionary rationale, a PRISMA flow diagram, and a standardized table of evidence. Effect sizes (ES) were calculated using Cohen’s d to measure relationship magnitude and direction. Results: Of the 543 potentially relevant articles identified, four articles met criteria and were retained for analysis. Different quality of life (QOL) measures were used to assess psychological distress across studies, so ES were calculated for individual studies. There were consistently small but significant ES found for the impact of MPC on distress. When compared to survivors of a single cancer: one study found lower global QOL and higher total stress (ES, 0.1430 and 0.3653); one study reported that those with MPC were more likely to experience frequent mental distress and sleep problems (ES, 0.1404 and 0.2235); and one study found that those with MPC had lower global QOL and emotional function and greater anxiety and depressive symptoms (ES range, 0.1026 - 0.3215). Finally, the one study that evaluated suicidal ideation in survivors of childhood cancers did not find a higher incidence among those with MPC. Conclusions: The ES noted in the four studies suggest a small but significant increase in psychological distress in survivors of MPC compared to survivors of a single cancer. Clinicians should be aware of this at-risk population when screening for distress in cancer survivors. Additional studies that control for care transition points known to increase distress are warranted to explore the impact of MPC on psychological distress over time. Additionally, as the science in this area grows, it will be necessary to reevaluate the literature.

Communicating about the management of medications as patients move across transition points of care: an observation and interview study

As patients move across transition points, effective medication management is critical for patient safety. The aims of this study were to examine how health professionals, patients and family members communicate about managing medications as patients moved across transition points of care and to identify possible sources of communication failure. A descriptive approach was used involving observations and interviews. The emergency departments and medical wards of two hospitals were involved. Observations focused on how health professionals managed medications during interactions with other health professionals, patients and family members, as patients moved across clinical settings. Follow-up interviews with participants were also undertaken. Thematic analysis was completed of transcribed data, and descriptive statistics were used to analyse characteristics of communication failure. Three key themes were identified: environmental challenges, interprofessional relationships, and patient and family beliefs and responsibilities. As patients moved between environments, insufficient tracking occurred about medication changes. Before hospital admission, patients participated in self-care medication activities, which did not always involve exemplary behaviours or match the medications that doctors prescribed. During observations, 432 instances of communication failure (42.8%) were detected, which related to purpose, content, audience and occasion of the communication. Extensive challenges exist involving the management of medications at transition points of care. Bedside handovers and ward rounds can be utilized as patient counselling opportunities about changes in the medication regimen. Greater attention is needed on how patients in the community make medication-related decisions.

Impact of pharmacy-led medication reconciliation on medication errors during transition in the hospital setting.

Objective:To assess if the pharmacy department should be more involved in the medication reconciliation process to assist in the reduction of medication errors that occur during transition of care points in the hospital setting.Methods:This was an observational prospective cohort study at a 531-bed hospital in Pensacola, FL from June 1, 2014 to August 31, 2014. Patients were included in the study if they had health insurance and were taking five or more medications. Patients with congestive heart failure were excluded from the study. Student pharmacists collected and evaluated medication histories obtained from patients’ community pharmacies, and directed patient interviews. Primary care providers were only contacted on an as needed basis. The information collected was presented to the clinical pharmacist, where interventions were made utilizing clinical judgment.Results:During the three month study, 1045 home medications were reviewed by student pharmacist. Of these, 290 discrepancies were discovered (27.8%; p=0.02). The most common medication discrepancy found was dose optimization (45.5%). The remaining discrepancies included: added therapy (27.6%), other (15.2%), and discontinued therapy (11.7%). Pharmacists made 143 interventions based on clinical judgment (49.3%; p=0.04).Conclusion:Involvement of pharmacy personnel during the medication reconciliation process can be an essential component in reducing medical errors. With the addition of the pharmacy department during the admission process, accuracy, cost savings, and patient safety across all phases and transition points of care were achieved.

Medication reconciliation at admission and discharge: ananalysis of prevalence and associated risk factors.

Medication errors are frequent at care transition points and can have serious repercussions. Study objectives were to examine the frequency/type of reconciliation errors at hospital admission and discharge and to report on the drugs involved, associated risk factors and potential to cause harm in a healthcare setting with comprehensive digital health records. A prospective observational 2-year study was conducted in the Internal Medicine Department of a regional hospital. The best possible medication history was obtained from different sources by clinical pharmacists and compared with prescriptions at admission and discharge. The frequency and type of reconciliation errors were studied at admission and discharge, evaluating risk factors for their occurrence and their potential to cause harm. The study included 814 patients (mean age: 80.2 years). At least one reconciliation error was detected in 525 (64.5%) patients at admission, with a mean of 2.2 ± 1.3 errors per patient and in 235 (32.4%) patients at discharge. Drug omission was the most frequent reconciliation error (73.6% at admission and 71.4% at discharge); 39% of errors at admission and 51% at discharge had potential to cause moderate or severe harm. The risk of error at admission was higher with more pre-admission drugs (p < 0.001) and, among patients with reconciliation errors, the number of errors was significantly higher in those receiving more drugs pre-admission or with more comorbidities. The risk at discharge was higher in patients with more drugs prescribed at discharge (p = 0.04) and in those with a longer hospital stay (p = 0.03). Medication reconciliation procedures are required to minimise medication discrepancies and enhance patient safety. Integration of patient health records across care levels is necessary but not sufficient to prevent errors.

Challenges of managing medications for older people at transition points of care.

In clinical practice, pharmacists play a very important role in identifying and correcting medication discrepancies as older patients move across transition points of care. With increasing complexity of health care needs of older people, these discrepancies are likely to increase. The major concern with identifying and correcting medication discrepancies is that medication reconciliation is considered a retrospective problem--that is, dealing with medication discrepancies after they have occurred. It is argued here that a more proactive stance should be taken where doctors, nurses and pharmacists collectively work together to prevent medication discrepancies from happening in the first place. Improved involvement of patients and family members will help to facilitate better management of medications across transition points of care. Efficient use of information technology aids, such as electronic medication reconciliation tools, should also assist with organizational systems problems associated with the working culture, heavy workloads, and staff and skill mix of health professionals.

Complexities of medicines safety: communicating about managing medicines at transition points of care across emergency departments and medical wards.

To explore how health professionals, patients and family members communicate about managing medicines across transition points of care in two Australian public hospitals. Medicines errors are common at transition points of care. Little qualitative work has targeted communicating about medicines management across patients' journeys from admission through to discharge. A qualitative descriptive study was undertaken. In-depth, semi-structured interviews were conducted with patients and family members, and focus groups and interviews were undertaken with doctors, nurses and pharmacists (n = 103). These individuals were situated in emergency departments and general medical wards. Data were analysed using thematic analysis. Four themes were identified: contextual environment of care, competing responsibilities of care, awareness of responsibility for safety, and interprofessional communication. Contextual environment of care was affected by time pressure and efficiency, and an overriding priority to move patients out of emergency departments. In competing responsibilities of care, a reactive focus was displayed in emergency departments while a proactive stance was demonstrated in medical wards. There was an awareness of responsibility for safety, whereby key stakeholders appreciated the chain of events involved, interpersonal communication affected patients and carers, and consequences existed for patient education related to lack of information. Interdisciplinary communication was associated with communication modalities used in encounters, compartmentalised thinking, and medicines changes relayed to external providers. Medicines management at transition points involved a complex interplay of dynamic features. This interplay infiltrated across diverse environments, affecting patient care within and outside hospitals. Health professionals require greater appreciation of each other's roles at transition points of care. Prioritisation of high-risk patients is needed, such as those with cognitive impairment and multiple co-morbidities. Establishing workable protocols of communication etiquette and a structured approach to medicines activities may assist in pre-empting problems before they occur.

Computerized Rounding Reports: Individualized Solutions Might Work Better

The paper by Drs. Wohlauer, Rove, and colleagues [1] covers a very important problem that healthcare systems and providers are increasingly faced with today. Well-conducted patient sign-outs and handovers are critical for patient safety, but if done poorly, these care transition points can lead to significant breaks in communication. There is strong evidence that flaws in provider-to-provider hand-offs can directly lead to patient harm [2]. Opportunities for such communication breaks unfortunately will increase even further as we embark on ever-tighter restrictions of work hours.

Medication Use Across Transition Points from the Emergency Department: Identifying Factors Associated with Medication Discrepancies

As patients move across transition points of care, medication discrepancies are likely to occur. In the emergency department (ED), patients are vulnerable to medication discrepancies because they are in an environment in which rapid decisions need to be made under high levels of stress. To identify the patient-, environment-, and medication-related factors involving unexplained medication discrepancies across transition points after ED presentation. Using a retrospective chart review design, a stratified, random sampling of data was undertaken over a 12-month period. Information was obtained from an electronic administrative database and medical records as patients moved from the ED to another transition point of care. Medication discrepancies were classified into 2 outcome groups: (1) no discrepancies and situations in which discrepancies were adequately explained and (2) discrepancies that had no adequate explanation. For the 12-month period, 210 randomly selected patients were included; 73 (34.8%) had at least one unexplained medication discrepancy. Binary logistic regression modeling showed 4 factors that were statistically significant in determining the incidence of at least one unexplained medication discrepancy. Benefit card holders (individuals who receive benefits from government insurance programs comparable to the US-based Medicare and Medicaid initiatives, which include the elderly, the disabled, low income earners, and unemployed persons) had 3.73 greater odds of experiencing an unexplained medication discrepancy (95% CI 1.72 to 8.07; p = 0.001). Patients prescribed 5 or more drugs at discharge from the ED had 12.22 greater odds of having at least one unexplained medication discrepancy (95% CI 5.52 to 27.08; p < 0.001). Patients who were first seen by a physician within 1 hour of a change in working shift had 3.70 greater odds of having an unexplained medication discrepancy (95% CI 1.67 to 8.18; p = 0.001). For each additional minute of wait time for a physician, the odds of having an unexplained medication discrepancy increased by a factor of 1.01 (95% CI 1.00 to 1.01; p = 0.042). Patient-, environment-, and drug-related factors contribute to the risk of medication discrepancies across transition points from the ED.