Unintentional Medication Discrepancies Research Articles

Pharmacist’s Role in Improving Medication Safety for Patients in an Allogeneic Hematopoietic Cell Transplant Ambulatory Clinic

Patients undergoing allogeneic hematopoietic cell transplantation (allo-HCT), supported by complex drug regimens, are vulnerable to drug therapy problems (DTPs) at interfaces of care after discharge from hospital and may benefit from timely pharmacy interventions and education. To determine the effect on medication safety of, as well as potential barriers to, incorporating a pharmacist in the multidisciplinary team of an allo-HCT clinic. Two pharmacists rotated to attend the allo-HCT clinic of a tertiary care, university-affiliated cancer centre between January and June 2010 (coverage for 1 of 3 clinic days per week). For every patient who was seen by a pharmacist, all discharge medications were reconciled from the inpatient ward to the clinic. The pharmacists' primary task was to perform medication reconciliation and to identify and resolve DTPs. The pharmacists also provided medication education to patients and pharmacy consultations to clinic staff. Working with the outpatient pharmacy, the pharmacists helped to clarify prescriptions and drug coverage issues. Medication discrepancies identified and interventions performed by the pharmacists were recorded and were later graded for clinical significance by a panel of clinicians. Patient and staff satisfaction surveys were conducted at random during the study period. Barriers to the flow of patient care and other operational issues were documented. The 2 pharmacists saw a total of 35 patients over 100 visits. They identified a total of 50 medication discrepancies involving 17 (49%) of the patients and 70 DTPs involving 23 (66%) of the patients. Thirty-one of the 70 DTPs resulted directly from a medication discrepancy. Twenty (95%) of the 21 unintentional medication discrepancies and 7 (70%) of the 10 undocumented intentional medication discrepancies were graded as clinically significant or moderately significant. Satisfaction surveys completed by patients and clinic staff yielded positive responses supporting pharmacists' participation. Pharmacists working as part of the multidisciplinary team identified and resolved medication discrepancies, thereby improving medication safety at the allo-HCT clinic.

Potential clinical impact of medication discrepancies at hospital admission

BackgroundMedication errors at the interfaces of care are highly prevalent. This study aims to identify unintentional medication discrepancies at hospital admission and to explore their potential clinical impact in elderly patients. MethodThe study was conducted in an Internal Medicine Department. Patients≥65years admitted through the emergency department were eligible. Best possible medication histories, obtained from different sources by pharmacists, were compared to admission medication prescriptions to identify and correct unintentional discrepancies. A three-category scale was used to rate errors for their potential to cause harm: Level (L) 1 “no potential harm”, L2 “monitoring or intervention potentially required to preclude harm”, and L3 “potential harm”. This scale was also designed to take into account patient's clinical characteristics and high-risk drugs. Results256 patients were included. Mean age was 82.2±7.2years old. 85 patients (33.2%) had ≥1 unintentional discrepancies. Overall, there were 173 unintentional discrepancies. The 3 most common drug classes involved in errors were nervous system (22.0%), gastrointestinal (20.0%) and cardiovascular (18.0%) medications. The most common types of errors were “omission” (87.9%) and “incorrect dose” (8.1%). Among the unintentional discrepancies, 20.8% had the potential to require increased monitoring or intervention to preclude harm (L2) and 6.4% had the potential to cause clinical deterioration (L3). ConclusionMore than 25% of the identified errors presented a potential clinical impact. These results show that a combined intervention of pharmacists and physicians in a collaborative medication reconciliation process has a high potential to reduce clinical relevant errors at hospital admission.

The effect of a multicomponent transitional pharmaceutical care intervention on the incidence and nature of unintentional medication discrepancies in geriatric patients after hospital discharge

The effect of a multicomponent transitional pharmaceutical care intervention on the incidence and nature of unintentional medication discrepancies in geriatric patients after hospital discharge

Content Validity and Inter-Rater Reliability of an Instrument to Characterize Unintentional Medication Discrepancies

Medication discrepancies are medication-related problems (MRPs) that frequently occur when patients are transferred between settings of care. Older patients are at high risk for several reasons, including high consumption of medicines, and physical and cognitive deficiencies that can impair the communication process. Most previous studies that have evaluated medication discrepancies used instruments designed for clinical practice, but a well-validated and reliable instrument for clinical research is still lacking. The aims of this study were to (i) develop an instrument to characterize medication discrepancies that fulfils quality requirements for classification of MRPs related to continuity of care and (ii) assess its content validity and inter-rater reliability. The instrument was developed based on three main inputs: (i) a literature review to collect information about the quality requirements of instruments to characterize MRPs; (ii) another literature review to identify existing instruments to characterize MRPs and, more specifically, medication discrepancies; and (iii) previous experience from a pilot study on Belgian patients discharged from surgical and medical wards. Content validity was assessed using a modified Delphi technique with 11 healthcare professionals. Content validity indexes were calculated. For inter-rater reliability, three pharmacists (one experienced and two naive) were asked to identify and categorize (type and cause of) unintentional medication discrepancies for 21 patients discharged from hospital into the community. The intra-class correlation coefficient was calculated to compare the number of discrepancies identified, and a paradox-resistant index (AC1) was used to determine the inter-rater reliability for the type and cause of the discrepancy. The instrument had 54 items classified in three sections (type of discrepancy, cause and intervention), with detailed specifications on how to use it. All evaluations relative to content validity met predefined cut-off values, except for two of them. Intra-class correlation coefficients of ≥0.76 and AC1 coefficients of ≥0.89 were found for the number and the type of discrepancies, respectively. Regarding evaluation of the specific causes of medication discrepancies, final AC1 results of ≥0.86 were obtained, except for three items (which had values between 0.62 and 0.79). The validity and reliability of the instrument developed to assess unintentional medication discrepancies at patient transition from the hospital to the community setting was found to be satisfactory.

Content Validity and Inter-Rater Reliability of an Instrument to Characterize Unintentional Medication Discrepancies

Content Validity and Inter-Rater Reliability of an Instrument to Characterize Unintentional Medication Discrepancies

Medication Reconciliation: Identifying Medication Discrepancies in Acutely Ill Hospitalized Older Adults

Background Medication discrepancies may occur during transitions from community to acute care hospitals. The elderly are at risk for such discrepancies due to multiple comorbidities and complex medication regimens. Medication reconciliation involves verifying medication use and identifying and rectifying discrepancies. Objective The aim of this study was to describe the prevalences and types of medication discrepancies in acutely ill older patients. Methods Patients who were ≥70 years and were admitted to any of 3 acute care for elders (ACE) units over a period of 2 nonconsecutive months in 2008 were prospectively enrolled. Medication discrepancies were classified as intentional, undocumented intentional, and unintentional. Unintentional medication discrepancies were classified by a blinded rater for potential to harm. This study was primarily qualitative, and descriptive (univariate) statistics are presented. Results Sixty-seven patients (42 women; mean [SD] age, 84.0 [6.5] years) were enrolled. There were 37 unintentional prescription-medication discrepancies in 27 patients (40.3%) and 43 unintentional over-the-counter (OTC) medication discrepancies in 19 patients (28.4%), which translates to Medication Reconciliation Success Index (MRSI) of 89% for prescription medications and 59% for OTC medications. The overall MRSI was 83%. More than half of the prescription-medication discrepancies (56.8%) were classified as potentially causing moderate/severe discomfort or clinical deterioration. Conclusion Despite a fairly high overall MRSI in these patients admitted to ACE units, a substantial proportion of the prescription-medication discrepancies were associated with potential harm.

Medication Reconciliation During Internal Hospital Transfer and Impact of Computerized Prescriber Order Entry

Internal hospital transfer is a vulnerable time during which patients are at high risk of medication discrepancies that can result in clinically significant harm, medication errors, and adverse drug events. To identify, characterize, and assess the clinical impact of unintentional medication discrepancies during internal hospital transfer and to investigate the influence of computerized prescriber order entry (CPOE) on medication discrepancies. All patients transferred between 10 inpatient units at 2 tertiary care hospitals were prospectively assessed to identify discrepancies. Interfaces included transfers between (1) units that both used paper-based medication ordering systems; (2) units that both used CPOE-based systems; and (3) units that used both paper-based and CPOE-based systems (hybrid transfer). The primary endpoint was the number of patients with at least 1 unintentional medication discrepancy during internal hospital transfer. Discrepancies were identified through assessment and comparison of a best possible medication transfer list with the actual transfer orders. A multidisciplinary team of clinicians assessed the potential clinical impact and severity of unintentional discrepancies. Overall, 190 patients were screened and 129 patients were included. Eighty patients (62.0%) had at least 1 unintentional medication discrepancy at the time of transfer, and the most common discrepancy was medication omission (55.6%). Factors that independently increased the risk of a patient experiencing at least 1 unintentional discrepancy included lack of best possible medication history, increasing number of home medications, and increasing number of transfer medications. Forty-seven patients (36.4%) had at least 1 unintentional discrepancy with the potential to cause discomfort and/or clinical deterioration. The risk of discrepancies was present regardless of the medication-ordering system (paper, CPOE, or hybrid). Clinically significant medication discrepancies occur commonly during internal hospital transfer. A structured, collaborative, and clearly defined medication reconciliation process is needed to prevent internal transfer discrepancies and patient harm.

“Partners in Crime”: Pharmacists and Pharmacy Technicians

1The model indicated that implementing a core set of 5 clinical pharmacy services that have been associated with improvements in patients’ outcomes (i.e., providing drug information, managing adverse drug reactions, attending rounds, managing drug protocols, and obtaining medication histories) for 100% of inpatients by the year 2020 would require 14 508 additional full-time equivalent pharmacist positions! Although similar modelling has not been reported from Canada, the recent federally funded report Moving Forward: Pharmacy Human Resources for the Future seems to echo the US shortage. 2 In the face of such workforce shortages, and given the continually expanding roles of pharmacists as providers of patient care, the use of pharmacy technicians to support pharmacists by performing selected clinical duties has been advocated as a potential, if only partial, solution. In this issue of the Journal, Johnston and others 3 report a randomized controlled trial comparing best possible medication histories obtained in the emergency department by pharmacists and by pharmacy technicians. 3 In their study, Johnston and coauthors found that trained pharmacy techni cians were just as effective as pharmacists in obtaining medication histories in the emergency department of a community hospital and that the numbers of discrepancies identified during the subsequent medication reconciliation process for randomly selected patients were similar. Further more, these discrepancies were similar in severity, as adjudicated by a third-party reviewer. The study was underpowered, with only 59 patients, and for the majority of patients, there were no unintentional medication discrepan cies (47 patients as determined by pharmacists, 50 patients as determined by technicians). Nonetheless, this study adds to a growing body of literature supporting the role of pharmacy technicians in this aspect of the medication reconciliation process. 4,5 To push the prover bial envelope even further, the “Point Counterpoint” column in this issue of the Journal presents a debate on the further extension of the clinical role of pharmacy techni cians in areas where there are no pharmacists at all. 6,7

Perioperative Medication Management (POMM) Pilot: Integrating a Community-Based Medication History (MedsCheck) into Medication Reconciliation for Elective Orthopedic Surgery Inpatients

Background: Medication safety along the continuum of care is dependent on the quality of medication information at each point of transfer. The purpose of our study was to assess the impact of integrating a community-based medication history (MedsCheck) into perioperative medication reconciliation for elective orthopedic surgery patients by assessing postoperative unintentional medication discrepancies. Secondary objectives were to evaluate community pharmacist participation and patient satisfaction. Methods: Patients scheduled for elective hip or knee surgery between April and September 2008 were identified as the study population. Patients and community pharmacies were contacted to coordinate the MedsCheck prior to the pre-admission clinic visit. At the visit, the Meds Check document was used to prepare a best possible medication history, which was documented in the patient chart. Medications were reconciled postoperatively. Participants were surveyed for feedback on the process. Results: Eighty-two patients were included in the study. A MedsCheck was completed for 73.8% (31/42) of eligible patients who were contacted prior to their pre-admission clinic visit. The average number of medications per patient was 8.4. The percentage of patients with at least 1 unintentional medication discrepancy decreased from 68.4% (13/19) to 47.6% (39/82) post-intervention. Total unintentional medication discrepancies decreased from 25.6% to 10.6%. Discussion: Integrating MedsCheck into the perioperative medication reconciliation process resulted in positive outcomes. The main challenge was coordination of the MedsCheck service prior to the patient's pre-admission clinic visit. Conclusion: Integrating MedsCheck into routine perioperative care for orthopedic patients is a feasible way to facilitate pharmacist medication reconciliation and increase patient satisfaction.

Effect of an Electronic Medication Reconciliation Application and Process Redesign on Potential Adverse Drug Events

Medication reconciliation at transitions in care is a national patient safety goal, but its effects on important patient outcomes require further evaluation. We sought to measure the impact of an information technology-based medication reconciliation intervention on medication discrepancies with potential for harm (potential adverse drug events [PADEs]). We performed a controlled trial, randomized by medical team, on general medical inpatient units at 2 academic hospitals from May to June 2006. We enrolled 322 patients admitted to 14 medical teams, for whom a medication history could be obtained before discharge. The intervention was a computerized medication reconciliation tool and process redesign involving physicians, nurses, and pharmacists. The main outcome was unintentional discrepancies between preadmission medications and admission or discharge medications that had potential for harm (PADEs). Among 160 control patients, there were 230 PADEs (1.44 per patient), while among 162 intervention patients there were 170 PADEs (1.05 per patient) (adjusted relative risk [ARR], 0.72; 95% confidence interval [CI], 0.52-0.99). A significant benefit was found at hospital 1 (ARR, 0.60; 95% CI, 0.38-0.97) but not at hospital 2 (ARR, 0.87; 95% CI, 0.57-1.32) (P = .32 for test of effect modification). Hospitals differed in the extent of integration of the medication reconciliation tool into computerized provider order entry applications at discharge. A computerized medication reconciliation tool and process redesign were associated with a decrease in unintentional medication discrepancies with potential for patient harm. Software integration issues are likely important for successful implementation of computerized medication reconciliation tools.

Medication Reconciliation at Hospital Discharge: Evaluating Discrepancies

Hospital discharge is an interface of care when patients are at a high risk of medication discrepancies as they transition from hospital to home. These discrepancies are important, as they may contribute to drug-related problems, medication errors, and adverse drug events. To identify, characterize, and assess the clinical impact of unintentional medication discrepancies at hospital discharge. All consecutive general internal medicine patients admitted for at least 72 hours to a tertiary care teaching hospital were prospectively assessed. Patients were excluded if they were discharged with verbal prescriptions; died during hospitalization; or transferred from or to a nursing home, another institution, or another unit within the same hospital. The primary endpoint was to determine the number of patients with at least one unintended medication discrepancy on hospital discharge. Medication discrepancies were assessed through comparison of a best possible medication discharge list with the actual discharge prescriptions. Secondary objectives were to characterize and assess the potential clinical impact of the unintentional discrepancies. From March 14, 2006, to June 2, 2006, 430 patients were screened for eligibility; 150 patients were included in the study. Overall, 106 (70.7%) patients had at least one actual or potential unintentional discrepancy. Sixty-two patients (41.3%) had at least one actual unintentional medication discrepancy at hospital discharge and 83 patients (55.3%) had at least one potential unintentional discrepancy. The most common unintentional discrepancies were an incomplete prescription requiring clarification, which could result in a patient delay in obtaining medications (49.5%), and the omission of medications (22.9%). Of the 105 unintentional discrepancies, 31(29.5%) had the potential to cause possible or probable patient discomfort and/or clinical deterioration. Medication discrepancies occur commonly on hospital discharge. Understanding the type and frequency of discrepancies can help clinicians better understand ways to prevent them. Structured medication reconciliation may help to prevent discharge medication discrepancies.

Classifying and Predicting Errors of Inpatient Medication Reconciliation

Failure to reconcile medications across transitions in care is an important source of potential harm to patients. Little is known about the predictors of unintentional medication discrepancies and how, when, and where they occur. To determine the reasons, timing, and predictors of potentially harmful medication discrepancies. Prospective observational study. Admitted general medical patients. Study pharmacists took gold-standard medication histories and compared them with medical teams' medication histories, admission and discharge orders. Blinded teams of physicians adjudicated all unexplained discrepancies using a modification of an existing typology. The main outcome was the number of potentially harmful unintentional medication discrepancies per patient (potential adverse drug events or PADEs). Among 180 patients, 2066 medication discrepancies were identified, and 257 (12%) were unintentional and had potential for harm (1.4 per patient). Of these, 186 (72%) were due to errors taking the preadmission medication history, while 68 (26%) were due to errors reconciling the medication history with discharge orders. Most PADEs occurred at discharge (75%). In multivariable analyses, low patient understanding of preadmission medications, number of medication changes from preadmission to discharge, and medication history taken by an intern were associated with PADEs. Unintentional medication discrepancies are common and more often due to errors taking an accurate medication history than errors reconciling this history with patient orders. Focusing on accurate medication histories, on potential medication errors at discharge, and on identifying high-risk patients for more intensive interventions may improve medication safety during and after hospitalization.