Unintentional Medication Discrepancies Research Articles

Medication Reconciliation: A Necessary Process for Patient Safety

Medication Reconciliation: A Necessary Process for Patient Safety

Risk factors for medication errors at admission in preoperatively screened patients.

Preoperative screening (POS) may help to reduce medication errors at admission (MEA). However, due to the time window between POS and hospital admission, unintentional medication discrepancies may still occur and thus a second medication reconciliation at hospital admission can be necessary. Insight into potential risk factors associated with these discrepancies would be helpful to focus the second medication reconciliation on high-risk patients. To determine the proportion of POS patients with MEA and to identify risk factors for MEA. This single-centre observational cross-sectional study included elective surgical patients between October 26 and December 18, 2015. Main exclusion criteria were age younger than 18years and daycare admissions. Medication reconciliation took place at the POS and was repeated within 30hours of admission. Unintended discrepancies between the first and second medication reconciliation were defined as MEA. The primary outcome was the proportion of patients with one or more MEA. The association of this outcome with potential risk factors was analysed using multivariate logistic regression analysis. Of the 183 included patients, 60 (32.8%) patients had at least one MEA. In a multivariate model, the number of medications at POS (adjusted odds ratio 1.16 [95% confidence interval, 1.04-1.30]) and respiratory disease (4.25 [1.52-11.83]) were significantly associated with MEA. In one-third of preoperatively screened patients, an MEA was found. The number of medications and respiratory comorbidities are risk factors for MEA in preoperatively screened patients.

Medication errors at hospital admission and discharge in Type 1 and 2 diabetes

To assess the prevalence and characteristics of medication errors at hospital admission and discharge in people with Type 1 and Type 2 diabetes, and identify potential risk factors for these errors. This prospective observational study included all people with Type 1 (n=163) and Type 2 diabetes (n=508) admitted to the Diabetology-Department of the University Hospital of Montpellier, France, between 2013 and 2015. Pharmacists conducted medication reconciliation within 24h of admission and at hospital discharge. Medication history collected from different sources (patient/family interviews, prescriptions/medical records, contact with community pharmacies/general practitioners/nurses) was compared with admission and discharge prescriptions to detect unintentional discrepancies in medication indicating involuntary medication changes. Medication errors were defined as unintentional medication discrepancies corrected by physicians. Risk factors for medication errors and serious errors (i.e. errors that may cause harm) were assessed using logistic regression. A total of 322 medication errors were identified and were mainly omissions. Prevalence of medication errors in Type 1 and Type 2 diabetes was 21.5% and 22.2% respectively at admission, and 9.0% and 12.2% at discharge. After adjusting for age and number of treatments, people with Type 1 diabetes had nearly a twofold higher odds of having medication errors (odds ratio (OR) 1.72, 95% confidence interval (CI) 1.02-2.94) and serious errors (OR 2.17, 95% CI 1.02-4.76) at admission compared with those with Type 2 diabetes. Medication reconciliation identified medication errors in one third of individuals. Clinical pharmacists should focus on poly-medicated individuals, but also on other high-risk people, for example, those with Type 1 diabetes.

Impact of a medication reconciliation program on cardiac surgery patients.

Background Cardiac surgery patients are at high risk of medication errors. Resumption of home medications reduces the significance and number of medication errors. This could be achieved by implementing a medication reconciliation program. Patients and Methods Patients were eligible for inclusion in this prospective study if they were admitted, transferred, and/or discharged under cardiac surgery team care from September 2015 to March 2016. The primary outcome was the number and proportion of unintentional medication discrepancies. Secondary outcomes included the number of interventions to resolve discrepancies and their clinical significance, and the medication regimen complexity index and its correlation with discrepancies. Results There were 374 patients included and 1000 encounters tracked. Four-hundred and seventy (47%) of the included encounters were for adult patients. Of the 260 medication discrepancies detected, 181 (69.61%) were detected during admission. Discrepancies among adults were 0.913, 0.307, and 0.176 on admission, transfer, and discharge, respectively. Two-hundred (76.92%) of the interventions recommended by the pharmacy residents were accepted by the medical team, and the remaining were accepted with modifications, with no rejections. One-hundred and sixty-six (83%) of the accepted interventions were of high clinical significance. There was a significant correlation between the number of medication discrepancies and medication regimen complexity index on admission ( p < 0.0001, r = 0.34), transfer, and discharge. Conclusion Implementation of a medication reconciliation program in cardiac surgery units and its step-down units can be a powerful mean of identifying medication errors in post-cardiac surgery patients at admission and throughout the transition of care.

Validation of the assessment of risk tool: patient prioritisation technology for clinical pharmacist interventions

BackgroundAdverse drug events (ADEs) pose a heavy burden on health systems worldwide. The assessment of risk tool (ART) was developed to help prioritise hospitalised patients for interventions such as medication...

Medication Reconciliation Failures in Children and Young Adults With Chronic Disease During Intensive and Intermediate Care.

Although medication reconciliation has become standard during hospital admission, rates of unintentional medication discrepancies during intensive care of pediatric patients with chronic disease are unknown. Such discrepancies are an important cause of adverse drug events in adults with chronic illness and are associated with unintentional discontinuation of chronic medications. We sought to determine the rate, type, timing, and predictors of potentially harmful unintentional medication discrepancies in children and young adults with chronic disease. Prospective observational cohort study. Patients discharged from the intensive and intermediate care units at a tertiary care children's hospital from September 2013 to May 2014. Consecutive sample of 308 patients less than 25 years old with chronic disease defined by prescription of at least one predetermined class of chronic medication prior to hospitalization. The number of unintentional medication discrepancies with the potential for harm, as well as patient and medication-related factors predisposing patients to these errors were assessed. Two thousand seven hundred thirty-nine medication discrepancies were identified; 284 (10%) were unintentional and had the potential for harm (0.9/patient). Of these, 128 (45%) were due to errors in taking the preadmission medication history, whereas 156 (55%) were due to errors reconciling the medication history with orders. Most events occurred at admission (66%) and were dosing errors (45%). In multivariable negative binomial regression analyses (adjusted rate ratios [95% CI]), each additional preadmission medication (1.07 [1.04-1.10]), chronic respiratory medications (1.51 [1.01-2.28]), and chronic noninvasive ventilation (1.53 [1.07-2.19]) were associated with increased risk of a discrepancy. Unintentional medication discrepancies with the potential for harm are common among children and young adults with chronic disease during critical care admission due to both failure to obtain an accurate medication history and errors in reconciling the history with patient orders. The use of current medication reconciliation processes is insufficient to prevent errors in this high-risk population.

Clinical pharmacist-led program on medication reconciliation implementation at hospital admission: experience of a single university hospital in Croatia.

AimTo evaluate the clinical pharmacist-led medication reconciliation process in clinical practice by quantifying and analyzing unintentional medication discrepancies at hospital admission.MethodsAn observational prospective study was conducted at the Clinical Department of Internal Medicine, University Hospital Dubrava, during a 1-year period (October 2014 – September 2015) as a part of the implementation of Safe Clinical Practice, Medication Reconciliation of the European Network for Patient Safety and Quality of Care Joint Action (PASQ JA) project. Patients older than 18 years taking at least one regular prescription medication were eligible for inclusion. Discrepancies between pharmacists' Best Possible Medication History (BPMH) and physicians' admission orders were detected and communicated directly to the physicians to clarify whether the observed changes in therapy were intentional or unintentional. All discrepancies were discussed by an expert panel and classified according to their potential to cause harm.ResultsIn 411 patients included in the study, 1200 medication discrepancies were identified, with 202 (16.8%) being unintentional. One or more unintentional medication discrepancy was found in 148 (35%) patients. The most frequent type of unintentional medication discrepancy was drug omission (63.9%) followed by an incorrect dose (24.2%). More than half (59.9%) of the identified unintentional medication discrepancies had the potential to cause moderate to severe discomfort or clinical deterioration in the patient.ConclusionAround 60% of medication errors were assessed as having the potential to threaten the patient safety. Clinical pharmacist-led medication reconciliation was shown to be an important tool in detecting medication discrepancies and preventing adverse patient outcomes. This standardized medication reconciliation process may be widely applicable to other health care organizations and clinical settings.

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 of electronic medication reconciliation interventions on medication discrepancies at hospital transitions: a systematic review and meta-analysis.

BackgroundMedication reconciliation has been identified as an important intervention to minimize the incidence of unintentional medication discrepancies at transitions in care. However, there is a lack of evidence for the impact of information technology on the rate and incidence of medication discrepancies identified during care transitions. This systematic review was thus, aimed to evaluate the impact of electronic medication reconciliation interventions on the occurrence of medication discrepancies at hospital transitions.MethodsSystematic literature searches were performed in MEDLINE, PubMed, CINHAL, and EMBASE from inception to November, 2015. We included published studies in English that evaluated the effect of information technology on the incidence and rate of medication discrepancies compared with usual care. Cochrane’s tools were used for assessment of the quality of included studies. We performed meta-analyses using random-effects models.ResultsTen studies met our inclusion criteria; of which only one was a randomized controlled trial. Interventions were carried out at various hospital transitions (admission, 5; discharge, 2 and multiple transitions, 3 studies). Meta-analysis showed a significant reduction of 45 % in the proportion of medications with unintentional discrepancies after the use of electronic medication reconciliation (RR 0.55; 95 % CI 0.51 to 0.58). However, there was no significant reduction in either the proportion of patients with medication discrepancies or the mean number of discrepancies per patient. Drug omissions were the most common types of unintended discrepancies, and with an electronic tool a significant but heterogeneously distributed reduction of omission errors over the total number of medications reconciled have been observed (RR 0.20; 95 % CI 0.06 to 0.66). The clinical impact of unintended discrepancies was evaluated in five studies, and there was no potentially fatal error identified and most errors were minor in severity.ConclusionMedication reconciliation supported by an electronic tool was able to minimize the incidence of medications with unintended discrepancy, mainly drug omissions. But, this did not consistently reduce other process outcomes, although there was a lack of rigorous design to conform these results.Electronic supplementary materialThe online version of this article (doi:10.1186/s12911-016-0353-9) contains supplementary material, which is available to authorized users.

Medication Discrepancies Associated With a Medication Reconciliation Program and Clinical Outcomes After Hospital Discharge.

To identify the frequency of unintended medication discrepancies 30 days postdischarge from medicine wards with interprofessional medication reconciliation processes and clinical import. Prospective cohort study of adults discharged between October 2013 and November 2014 from two teaching hospitals in Edmonton, Canada. The Best Possible Medication Discharge Plan (BPMDP) was prepared for all patients. Patients were called 30 days postdischarge to determine the medication discrepancy rate from the BPMDP and whether this was intentional or unintentional; three clinicians used standardized criteria to determine if the discrepancy was inconsequential. Electronic health records and patient contact were used to ascertain death, hospital readmissions, and emergency department (ED) visits at 90 days. Of 433 patients (mean age 64 yrs, 52% female, median discharge prescriptions 6 [interquartile range 4-9]), 168 (38.8%) had at least one unintentional medication discrepancy at 30 days (325 total discrepancies; median one [interquartile range 1-2 discrepancies per patient]). Patients with unintentional medication discrepancies were older (65.9 vs 61.9 yrs, p=0.03) with more discharge medications (7 vs 6, p=0.03). Most unintentional discrepancies (91.1%) were judged inconsequential. The presence of an unintentional medication discrepancy was not associated with 90-day readmission or death (42/167 [25.1%] vs 64/263 [24.3%], adjusted odds ratio 0.96 [95% confidence interval 0.60-1.54]) or ED visits (69 [41.3%] vs 101 [38.4%], adjusted odds ratio 1.11 [95% confidence interval 0.74-1.67]. Despite the presence of an interprofessional medication reconciliation process, over one-third of patients had a medication discrepancy within 30 days of discharge, although most were inconsequential and there was no association between unintended medication discrepancies and risk of readmission, ED visit, or death 3 months after discharge.

Impact of Medication Reconciliation upon Discharge on Reducing Medication Errors

Background: Medication errors at the time of hospital admission and discharge are common and can lead to preventable adverse drug events. Medication reconciliation is a technique for identifying discrepancies in drug regimens, forming prescribing decisions and preventing medication errors. Accurate and complete medication reconciliation is an important patient safety issue which can prevent harm. Objective: To determine the incidence and characteristics of unintentional medication discrepancies and to describe the potential impact of medication reconciliation to identify and rectify medication errors at the time of hospital discharge. Design and setting: Retrospective study conducted at King Faisal Specialist Hospital (KFSH) in Jeddah from the period of July 2010 till June 2011. Patients: 100 patients were selected from each month (February, March, April-2010) making a total of 300. Method: Data was retrieved from the outpatient pharmacy, discharge section where medication reconciliation is conducted and records are kept in a monthly filing system. Medication discrepancies at discharge were determined by comparing medications lists at discharge with pre-admission and in-patient medications. All variances were classified as intended or unintended (medication errors). The primary outcome was the number and type of these unintentional discrepancies. Results: Majority of patients where under internal medicine and lowest percentage being in pediatrics. Mean number of discharge medications was 8 (SD ± 3). Total number of discrepancies was 200 (8.6%). 108 (34.67%) patients had discrepancies. Out of these, 93 (86.1%) were adults and 15 (13.9%) were children. Omission error was the most common type of discrepancy (63%), and drug interactions (0.3%) was the least. Improper dose was the most common prescribing error (32.4%), and improper frequency (15.1%) was the least. 19.3% of patients had at least 1 discrepancy. Most of the discrepancies where under internal medicine and cardiology. Most discrepancies were noticed in the month of February. Conclusion: Unintended medication variances at the time of hospital discharge are common. Medication reconciliation was a successful tool in detecting and rectifying discharge medication errors.

An evaluation of the epidemiology of medication discrepancies and clinical significance of medicines reconciliation in children admitted to hospital.

To determine the incidence of unintended medication discrepancies in paediatric patients at the time of hospital admission; evaluate the process of medicines reconciliation; assess the benefit of medicines reconciliation in preventing clinical harm. A 5 month prospective multisite study. Pharmacists at four English hospitals conducted admission medicines reconciliation in children using a standardised data collection form. A discrepancy was defined as a difference between the patient's preadmission medication (PAM), compared with the initial admission medication orders written by the hospital doctor. The discrepancies were classified into intentional and unintentional discrepancies. The unintentional discrepancies were assessed for potential clinical harm by a team of healthcare professionals, which included doctors, pharmacists and nurses. Medicines reconciliation was conducted in 244 children admitted to hospital. 45% (109/244) of the children had at least one unintentional medication discrepancy between the PAM and admission medication order. The overall results indicated that 32% (78/244) of patients had at least one clinically significant unintentional medication discrepancy with potential to cause moderate 20% (50/244) or severe 11% (28/244) harm. No single source of information provided all the relevant details of a patient's medication history. Parents/carers provided the most accurate details of a patient's medication history in 81% of cases. This study demonstrates that in the absence of medicines reconciliation, children admitted to hospitals across England are at risk of harm from unintended medication discrepancies at the transition of care from the community to hospital. No single source of information provided a reliable medication history.

The effect on potential adverse drug events of a pharmacist-acquired medication history in an emergency department: a multicentre, double-blind, randomised, controlled, parallel-group study.

BackgroundPotential adverse drug events (PADEs) are defined as being potentially harmful unintentional medication discrepancies. Discrepancies regarding medication history (MH) often occur when a patient is being admitted to a hospital’s emergency department (ED); they are clinically important and represent a significant source of data regarding adverse drug events occurring during emergency admission to hospital. This study sought to measure the impact of pharmacist-acquired MH during admission to an ED; it focused on whether a patient’s current home medication regimen being available for a doctor when consulting a patient in an ED would have reduced potential adverse drug events.MethodA multicentre, double-blind, randomised, controlled parallel-group study was carried out at 3 large teaching hospitals in Bogota, Colombia. Two hundred and seventy patients who had been admitted to an ED were enrolled; each had a standardised, comprehensive MH interview, focusing on a patient’s current home medication regimen prior to being seen by a doctor. Data recorded on the admission medication order form was available to be used by a doctor during consultation in the ED. The main outcome dealt with comparing the intervention and control groups regarding the percentage of patients having at least 1 potential adverse drug event.ResultsThere were 811 PADE (3.35 per patient), 528 (65 %) on the standard care arm and 283 (35 %) on an intervention arm. Most PADEs were judged to have had the potential to cause moderate discomfort (42.6 %), 33.4 % were deemed unlikely to have caused harm and 23.9 % were judged to have had the potential to cause clinical deterioration.ConclusionMany patients suffer potentially adverse drugs events during the transition of care from home to a hospital. Patient safety-focused medication reconciliation during admission to an ED involving a pharmacist and drawing up a history of complete medication could contribute towards reducing the risk of PADES occurring and improve follow-up of patients’ medication-based therapy.Trial registration28/10/2012, ISRCTN63455839.

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.

Impact of pharmacist‐led medication reconciliation on admission using electronic medical records on accuracy of discharge prescriptions

AbstractBackgroundUnintentional medication errors are common at hospital discharge and have the potential to cause significant patient harm. Current electronic medical records systems offer the facility to change the process of medication reconciliation by pharmacists.AimTo test the impact of pharmacist‐led medication reconciliation at admission recorded on the electronic medication form, on the timeliness and accuracy of discharge prescriptions.MethodA prospective pre‐ and post‐interventional observational study was carried out from June to October 2013 at two district hospitals. Pharmacists recorded admission medication using National Medication Management Plan (phase 1) and the electronic medication form in patients’ electronic medical records (phase 2). Data collected included time taken for the medical officer to complete the medication form in electronic medical records, the number of times the medical officer was contacted by the pharmacist completing the discharge reconciliation and unintentional discharge medication discrepancy types.ResultsIn total 118 patients were included: 66 patients in phase 1 and 52 in phase 2. Data were analysed using chi‐squared test, Fisher's exact test and Mann–Whitney test. There was a significant (33–13%, p &lt; 0.0001) reduction in the proportion of medication orders with a discrepancy. This was because of the significant (25.5–1.9%, p &lt; 0.0001) reduction in discrepancies relating to patients’ usual medication. Time taken for the medical officer to complete the medication form in electronic medical records decreased from 37 s/item (interquartile range, 29–48; n = 51) to 21 s/item (interquartile range, 11–35; n = 35) (p &lt; 0.001). The number of telephone calls to medical officers decreased from 95 to 73%.ConclusionThis integrated approach to medication reconciliation has highlighted patient safety benefits, and reduced medical and pharmacy workload.

Nurse Practitioner–led Medication Reconciliation in Critical Access Hospitals

Medication discrepancies are common in cardiac patients discharged from hospital to home, leading to increased risk for adverse drug events and hospital readmissions. Medication reconciliation identifies discrepancies and reduces medication error–related adverse drug events. The objective of this study is to examine the effect of advanced practice nurse–managed medication reconciliation on the occurrence of medication discrepancies in elderly cardiac patients discharged from a rural hospital. The study findings showed that advanced practice nurse–managed medication reconciliation reduced the total unintentional medication discrepancies in elderly cardiac patients during the transition from the rural hospital to home.

A formal medication reconciliation programme in a haemodialysis unit can identify medication discrepancies and potentially prevent adverse drug events.

Patients on haemodialysis have been identified as high-risk for medication discrepancies and adverse drug events. Medication reconciliation is an important patient safety initiative to prevent adverse drug events. The primary objective of our study was to determine the number and types of medication discrepancies and drug therapy problems (DTPs) identified in patients on haemodialysis. Our second objective was to assess the potential clinical impact and severity of all unintentional medication discrepancies identified. Patients in an academic haemodialysis unit were interviewed to obtain a best possible medication history (BPMH) between May and August 2010. The BPMH was documented and discrepancies were identified, classified and resolved with the interprofessional team. An interprofessional panel conducted a discrepancy clinical impact assessment for potential adverse drug events. Two hundred and twenty-eight patients on haemodialysis were interviewed and 512 discrepancies were identified for 151 patients (3.4 discrepancies per patient). Of these, 174 (34%) were undocumented intentional discrepancies and 338 (66%) were unintentional discrepancies. The unintentional discrepancies were classified as 21% omissions, 36% commissions and 43% incorrect dose/frequency. Most drug therapy problems were related to patient taking a medication that was not indicated (25%), medication required but patient not taking (25%), patient not willing to take the medication as prescribed (28%) or incorrect dosing of a drug (20%). Overall, 6% of discrepancies were classified as clinically significant potential adverse drug events. Medication discrepancies appear to be common in patients on haemodialysis. Formal interprofessional medication reconciliation practice models are essential to identify discrepancies and prevent patients from experiencing adverse drug events.

Impact of medication reconciliation and review on clinical outcomes.

To examine the evidence regarding the effectiveness of medication reconciliation and review and to improve clinical outcomes in hospitals, the community, and aged care facilities. This systematic review was undertaken in concordance with the PRISMA statement. Electronic databases, including MEDLINE, PsycINFO, EMBASE, and CINAHL were searched for relevant articles published between January 2000 and March 2014. Randomized and nonrandomized studies rating the severity of medication discrepancies and medication-related problems identified during medication reconciliation and/or review were considered for inclusion. Data were extracted independently by 2 authors using a data collection form. Of the 5292 articles identified, 83 articles met the inclusion criteria. Medication reconciliation identified unintentional medication discrepancies in 3.4% to 98.2% of patients. There is limited evidence of the potential of these discrepancies to cause harm. Medication reviews identified medication-related problems or possible adverse drug reactions in 17.2% to 94.0% of patients. The studies reported conflicting findings regarding the impact of medication review on length of stays, readmissions, and mortality. The evidence demonstrates that medication reconciliation has the potential to identify many medication discrepancies and reduce potential harm, but the impact on clinical outcomes is less clear. Similarly, medication review can detect medication-related problems in many patients, but evidence of clinical impact is scant. Overall, there is limited evidence that medication reconciliation and medication review processes, as currently performed, significantly improve clinical outcomes, such as reductions in hospital readmissions.

Medication reconciliation by a pharmacy technician in a mental health assessment unit

Medication discrepancies are common when patients cross organisational boundaries. However, little is known about the frequency of discrepancies within mental health and the efficacy of interventions to reduce discrepancies. To evaluate the impact of a pharmacy-led reconciliation service on medication discrepancies on admissions to a secondary care mental health trust. In-patient mental health services. Prospective evaluation of pharmacy technician led medication reconciliation for admissions to a UK Mental Health NHS Trust. From March to June 2012 information on any unintentional discrepancies (dose, frequency and name of medication); patient demographics;and type and cause of the discrepancy was collected. The potential for harm was assessed based on two scenarios; the discrepancy was continued into primary care, and the discrepancy was corrected during admission. Logistic regression identified factors associated with discrepancies. Mean number of discrepancies per admission corrected by the pharmacy technician. Unintentional medication discrepancies occurred in 212 of 377 admissions (56.2 %). Discrepancies involving 569 medicines (mean 1.5 medicines per admission) were corrected.The most common discrepancy was omission(n = 464). Severity was assessed for 114 discrepancies. If the discrepancy was corrected within 16 days the potential harm was minor in 71 (62.3 %) cases and moderate in 43(37.7 %) cases whereas if the discrepancy was not corrected the potential harm was minor in 27 (23.7 %) cases and moderate in 87 (76.3 %) cases. Discrepancies were associated with both age and number of medications; the stronger association was age. Medication discrepancies are common within mental health services with potentially significant consequences for patients.Trained pharmacy technicians are able to reduce the frequency of discrepancies, improving safety.

Project Marches Toward Better Medication Reconciliation

NATIONAL HARBOR, MD. – How confident are you that the medication list your patient is discharged with is completely accurate? Dr. Jason Stein, a hospitalist at Emory University in Atlanta, said that most physicians don't know if they're dealing with “gold” or “garbage.” Dr. Stein, who is a mentor in the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS), said that hospitalists are often faced with either taking a “leap of faith” that the medication list is complete and accurate or throwing out the list at discharge and starting over. MARQUIS, which was launched in 2010 by the Society of Hospital Medicine, is funded by a $1.5-million grant from the Agency for Healthcare Research and Quality. The study seeks to identify and disseminate evidence-based techniques for getting the best possible medication history from hospitalized patients with the ultimate goal of preventing medication errors. Data collection is scheduled to end this year. The first part of the study was a literature review to cull the best available evidence on medication reconciliation practices in the hospital. That information was then used to develop a toolkit synthesizing those best practices for clinicians. “One thing that we've found really valuable is to not lead the witness,” Dr. Jeffrey L. Schnipper, the MARQUIS principal investigator, said at the annual meeting of the Society of Hospital Medicine. Don't just sit there and read the medication list because the patient will likely just say yes to everything, said Dr. Schnipper, who is a hospitalist at Brigham and Women's Hospital and assistant professor of medicine at Harvard Medical School in Boston. Instead, ask patients to explain what they are taking. The toolkit also provides some standard prompts to use to get patients to remember certain medications, such as ones they take only once a week or medications that are over the counter. Another big piece of MARQUIS is a mentored implementation project across six hospitals. The mentored implementation was kicked off about a year and a half ago, and the sites are now actively experimenting with interventions aimed at decreasing the number of unintentional medication discrepancies among their noncritical medical and surgical patients. Each hospital identified a local champion, typically a hospitalist, who formed an interdisciplinary quality improvement team. That team then worked with a MARQUIS mentor, a hospitalist outside the institution with experience in both quality improvement and medication safety. The mentors had monthly phone calls with each of the sites. There are also two site visits built into the study. During the study, teams at each participating site chose from a menu of interventions recommended by the MARQUIS researchers to try to improve their medication reconciliation process. The menu includes: ▸Defining medication reconciliation at their individual site.▸Assigning roles and responsibilities related to medication reconciliation.▸Improving access to preadmission medication information sources.▸Encouraging patients to keep their own up-to-date medication lists.▸Educating providers about how to take the best possible medication history.▸Implementing discharge counseling that includes patient education tools and teach back.▸Stratifying patients as low, intermediate, or high risk according to disease state and number of medications.▸Improving information-technology capability. The sites are making progress, said Dr. Stein, who serves as a mentor to three of the six hospitals. The MARQUIS researchers are collecting data on the number of potentially harmful unintentional medication discrepancies per patient. The researchers collect the raw data from each of the sites and then send it on to physicians who consider the context for the discrepancies and the potential for harm.