To evaluate the cost effectiveness of a multidisciplinary team including a pharmacist for systematic medication review and reconciliation from admission to discharge at hospital among elderly patients (the Lund Integrated Medicines Management (LIMM)) in order to reduce drug-related readmissions and outpatient visits.
Published data from the LIMM project group were used to design a probabilistic decision tree model for evaluating tools for (1) a systematic medication reconciliation and review process at initial hospital admission and during stay (admission part) and (2) a medication report for patients discharged from hospital to primary care (discharge part). The comparator was standard care. Inpatient, outpatient and staff time costs (Euros, 2009) were calculated during a 3-month period. Dis-utilities for hospital readmissions and outpatient visits due to medication errors were taken from the literature.
The total cost for the LIMM model was €290 compared to €630 for standard care, in spite of a €39 intervention cost. The main cost offset arose from avoided drug-related readmissions in the Admission part (€262) whereas only €66 was offset in the Discharge part as a result of fewer outpatient visits and correction time. The reduced disutility was estimated to 0.005 quality-adjusted life-years (QALY), indicating that LIMM was a dominant alternative. The probability that the intervention would be cost-effective at a zero willingness to pay for a gained QALY compared to standard care was estimated to 98%.
The LIMM medication reconciliation (at admission and discharge) and medication review was both cost-saving and generated greater utility compared to standard care, foremost owing to avoided drug-related hospital readmissions. When implementing such a review process with a multidisciplinary team, it may be important to consider a learning curve in order to capture the full advantage.
Little research has examined the incidence, clinical relevance, and predictors of medication reconciliation errors at hospital admission and discharge.
To identify patient- and medication-related factors that contribute to pre-admission medication list (PAML) errors and admission order errors, and to test whether such errors persist in the discharge medication list.
We conducted a cross-sectional analysis of 423 adults with acute coronary syndromes or acute decompensated heart failure admitted to two academic hospitals who received pharmacist-assisted medication reconciliation during the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL–CVD) Study.
Pharmacists assessed the number of total and clinically relevant errors in the PAML and admission and discharge medication orders. We used negative binomial regression and report incidence rate ratios (IRR) of predictors of reconciliation errors.
On admission, 174 of 413 patients (42%) had ≥1 PAML error, and 73 (18%) had ≥1 clinically relevant PAML error. At discharge, 158 of 405 patients (39%) had ≥1 discharge medication error, and 126 (31%) had ≥1 clinically relevant discharge medication error. Clinically relevant PAML errors were associated with older age (IRR = 1.46; 95% CI, 1.00– 2.12) and number of pre-admission medications (IRR = 1.17; 95% CI, 1.10–1.25), and were less likely when a recent medication list was present in the electronic medical record (EMR) (IRR = 0.54; 95% CI, 0.30–0.96). Clinically relevant admission order errors were also associated with older age and number of pre-admission medications. Clinically relevant discharge medication errors were more likely for every PAML error (IRR = 1.31; 95% CI, 1.19–1.45) and number of medications changed prior to discharge (IRR = 1.06; 95% CI, 1.01–1.11).
Medication reconciliation errors are common at hospital admission and discharge. Errors in preadmission medication histories are associated with older age and number of medications and lead to more discharge reconciliation errors. A recent medication list in the EMR is protective against medication reconciliation errors.
medication reconciliation; hospital; medication errors; admission; discharge
The inaccurate recording of medicines on admission to hospital is an important cause of medication error. Medication reconciliation has been used to identify and correct these errors.
To determine if a multimodal intervention involving medication reconciliation with real-time feedback and education would reduce the number of errors made by medical staff when recording medicines at the time of admission to hospital.
Patients admitted to the general medical wards of a teaching hospital were studied prospectively. Patients ≥75 years of age and on ≥5 medications were identified as the ‘target group.’
After admission, a second medication history was taken, and discrepancies were identified and communicated to the medical teams. An educational intervention to encourage prescribers to obtain accurate medication histories was conducted at the same time.
The discrepancy rate was measured before and after the intervention.
There were 470 admissions in the ‘target group.’ Three hundred and thirty-eight of the admissions (71.9%) had one or more unintentional discrepancies. Although many discrepancies had little potential to cause harm, 33% were rated as clinically significant. During the study the discrepancy rate (prior to reconciliation) fell from 2.6 (SD 2.6) to 1.0 (SD 1.1) per admission (p < 0.0001). This decline in discrepancy rate remained significant (p = 0.001) even when only clinically important discrepancies were included. The proportion of admissions with one or more clinically important discrepancies also decreased during the study from 46% to 24% (p = 0.023).
Errors in the recording of medicines at the time of hospital admission are common. Combining the feedback provided by medication reconciliation with prescriber education reduced the error rate. This approach may be useful when the resources are not available to perform medication reconciliation for all patients admitted to hospital.
medical education; medical errors; medical record system
This study was designed to determine risk factors and potential harm associated with medication errors at hospital admission.
Study pharmacist and hospital-physician medication histories were compared with medication orders to identify unexplained history and order discrepancies in 651 adult medicine service inpatients with 5,701 prescription medications. Discrepancies resulting in order changes were considered errors. Logistic regression was used to analyze the association of patient demographic and clinical characteristics including patients’ number of pre-admission prescription medications, pharmacies, prescribing physicians and medication changes; and presentation of medication bottles or lists. These factors were tested after controlling for patient demographics, admitting service and severity of illness.
Over one-third of study patients (35.9%) experienced 309 order errors; 85% of patients had errors originate in medication histories, and almost half were omissions. Cardiovascular agents were commonly in error (29.1%). If undetected, 52.4% of order errors were rated as potentially requiring increased monitoring or intervention to preclude harm; 11.7% were rated as potentially harmful. In logistic regression analysis, patient’s age ≥65 [odds ratio (OR), 2.17; 95% confidence interval (CI), 1.09–4.30] and number of prescription medications (OR, 1.21; 95% CI, 1.14–1.29) were significantly associated with errors potentially requiring monitoring or causing harm. Presenting a medication list (OR, 0.35; 95% CI, 0.19–0.63) or bottles (OR, 0.55; 95% CI, 0.27–1.10) at admission was beneficial.
Over one-third of the patients in our study had a medication error at admission, and of these patients, 85% had errors originate in their medication histories. Attempts to improve the accuracy of medication histories should focus on older patients with a large number of medications. Primary care physicians and other clinicians should help patients utilize and maintain complete, accurate and understandable medication lists.
medication reconciliation; medication errors; medication history taking
Context: The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) instituted a new regulation in 2006 to improve patient safety by decreasing medication errors. This requires a process for obtaining and documenting a complete list of each patient's current medications at hospital admission and communicating this list to the next clinician (“Medication Reconciliation”).
Objective: We sought to determine whether medication discrepancies between outpatient and inpatient care can be decreased through the use of computerized pharmacy data.
Method: We evaluated outpatient medication prescriptions in 2000 and 2004 using computer-generated data for patients admitted from an Emergency Department to a medical ward. The hospital records and pharmacy data were reviewed to determine which ambulatory medications were ordered at admission, continued as an out-patient, and refilled three months after discharge. In 2004 additional computerized pharmacy data were provided to attending physicians. Ambulatory care “essential prescription medication groups” (cardiac, chronic obstructive pulmonary disease, asthma, diabetes, and neurologic) were also evaluated. Medication discrepancies for the years 2000 and 2004 were compared in several categories.
Results: Medication discrepancies were found in all evaluated categories in 2000. The follow-up study showed a decrease in discrepancies for nearly all categories.
Conclusion: Results show that use of outpatient pharmacy data can decrease medication discrepancies in compliance with current JCAHO requirements.
Adverse drug events after hospital discharge are common and often serious. These events may result from provider errors or patient misunderstanding.
To determine the prevalence of medication reconciliation errors and patient misunderstanding of discharge medications.
Prospective cohort study
Patients over 64 years of age admitted with heart failure, acute coronary syndrome or pneumonia and discharged to home.
We assessed medication reconciliation accuracy by comparing admission to discharge medication lists and reviewing charts to resolve discrepancies. Medication reconciliation changes that did not appear intentional were classified as suspected provider errors. We assessed patient understanding of intended medication changes through post-discharge interviews. Understanding was scored as full, partial or absent. We tested the association of relevance of the medication to the primary diagnosis with medication accuracy and with patient understanding, accounting for patient demographics, medical team and primary diagnosis.
A total of 377 patients were enrolled in the study. A total of 565/2534 (22.3 %) of admission medications were redosed or stopped at discharge. Of these, 137 (24.2 %) were classified as suspected provider errors. Excluding suspected errors, patients had no understanding of 142/205 (69.3 %) of redosed medications, 182/223 (81.6 %) of stopped medications, and 493 (62.0 %) of new medications. Altogether, 307 patients (81.4 %) either experienced a provider error, or had no understanding of at least one intended medication change. Providers were significantly more likely to make an error on a medication unrelated to the primary diagnosis than on a medication related to the primary diagnosis (odds ratio (OR) 4.56, 95 % confidence interval (CI) 2.65, 7.85, p < 0.001). Patients were also significantly more likely to misunderstand medication changes unrelated to the primary diagnosis (OR 2.45, 95 % CI 1.68, 3.55), p < 0.001).
Medication reconciliation and patient understanding are inadequate in older patients post-discharge. Errors and misunderstandings are particularly common in medications unrelated to the primary diagnosis. Efforts to improve medication reconciliation and patient understanding should not be disease-specific, but should be focused on the whole patient.
quality of care; acute coronary syndrome; heart failure; pneumonia; discharge instructions; medication reconciliation; adverse drug events; adverse events; patient education
Obtaining an accurate and complete medication list (i.e., the best possible medication history [BPMH]) is the first step in completing medication reconciliation. The ability of pharmacy technicians to obtain medication histories, relative to that of pharmacists, has not been formally assessed.
To determine whether pharmacy technicians at the authors’ institution could obtain a BPMH as accurately and completely as pharmacists and if both groups met national norms for unintentional discrepancies and the success index for medication reconciliation.
Pharmacy technicians were trained in obtaining a BPMH at the beginning of the study, before any patients were enrolled. Patients presenting to the emergency department were prospectively enrolled to be interviewed separately by both a pharmacist and a technician, with information recorded on standard medication reconciliation forms. The completed forms for each patient were compared following each set of interviews, and discrepancies were clarified with the patient.
Fifty-nine patients were included in the study, and 3 pharmacists and 2 technicians obtained the histories. There was no significant difference between pharmacists and technicians in terms of discrepancies involving prescription drugs (χ2 = 0.52, df = 1, n = 118, p = 0.47, Cramer’s V for effect size = 0.07) or over-the-counter medications (χ2 = 0.09, df = 1, n = 118, p = 0.77, Cramer’s V = 0.03). The mean number of discrepancies per patient did not differ significantly between the pharmacists and technicians (t = 0.15, df = 58, p = 0.88 for prescription drugs; t = −0.22, df = 58, p = 0.83 for over-the-counter products). For both groups, the number of unintentional discrepancies per patient was significantly lower and the success index for medication reconciliation significantly higher than the national average.
Trained pharmacy technicians at the authors’ institution were able to obtain a BPMH with as much accuracy and completeness as pharmacists. Both groups were significantly superior to the national average in terms of unintentional discrepancies and success index for medication reconciliation.
medication reconciliation; pharmacy technician; best possible medication history; BPMH; emergency department; bilan comparatif des médicaments; technicien en pharmacie; meilleur schéma thérapeutique possible; MSTP; service des urgences
In a recent study, 50% of the patients who were admitted to a hospital’s general medicine ward had at least one error in medication orders at the time of admission related to inaccuracies in the medication history. The use of computerized prescription databases has been suggested as a way to improve medication reconciliation at the time of admission.
To quantify and describe unintended discrepancies between a best possible medication history and medications ordered on admission to the general medicine ward in a hospital with routine access to a provincial outpatient prescription database (British Columbia’s PharmaNet).
This prospective study involved 20 patients who were regularly using at least 4 prescription medications before admission to hospital. The best possible medication history for each patient (based on a review of the medical chart and the PharmaNet record and an interview with the patient) was compared with the physician’s admission orders to identify any discrepancies. The frequency and perceived severity of discrepancies, graded independently by 3 physicians, were compared with observations from a similar study conducted at a hospital where a prescription database was not available.
The 20 patients were recruited between September 2005 and January 2006. For 8 patients (40%), information in the PharmaNet database was consistent with the prescription medication list obtained during the best possible medication history at the time of admission. For the other 12 patients, a total of 30 unintended discrepancies were identified, 13 (43%) of which were classified as having potential for moderate or severe harm. The proportion of patients with unintended discrepancies was similar to that for the comparison cohort (60% versus 54%). Although the percentage of discrepancies involving omissions was lower than in the comparison population (37% versus 46%), these results were offset by a higher proportion of commission discrepancies (27% versus 0%).
Unintended discrepancies were frequent, despite use of the PharmaNet database at the time of admission. Inconsistencies between the PharmaNet record and patients’ actual medication use, coupled with failure to verify PharmaNet data with patients, were likely contributing factors.
medication history; medication reconciliation; prescription database; medication errors; histoire médicamenteuse; bilan comparatif des médicaments; base de données sur les médicaments d’ordonnance; erreurs de médication
Medication reconciliation was developed to reduce medical mistakes and injuries through a process of creating and comparing a current medication list from independent patient information sources, and resolving discrepancies. The structure and clinician assignments of medication reconciliation varies between institutions, but usually includes physicians, nurses and pharmacists. The Joint Commission has recognized the value of medication reconciliation and mandated implementation in 2006; however, a variety of issues have prevented simple, easy, and universal implementation. This review references issues related to the development and the implementation of medication reconciliation including: – the need of a system or standard for accurate drug identification to create a definitive ‘gold standard’ patient medication list, – identifying stakeholders of medication reconciliation within the institution and contrasting staff interest and participation with institutional resources, – observations and opportunities of integrating medication reconciliation with the electronic patient health record, and – summarizing a series of institutions experiences developing and implementing medication reconciliation. Last, as medication reconciliation becomes a regular process within medical centers, key concepts for effective implementation are discussed.
Medication reconciliation; medical errors; patient safety; medical informatics; drug errors; pharmaceuticals
Confusion about patients’ medication regimens during the hospital admission and discharge process accounts for many preventable and serious medication errors. Many organizations have begun to redesign their clinical processes to address this patient safety concern. Partners HealthCare, an integrated delivery network in Boston, Massachusetts, has answered this interdisciplinary challenge by leveraging its multiple outpatient electronic medical records (EMR) and inpatient computerized provider order entry (CPOE) systems to facilitate the process of medication reconciliation. This manuscript describes the design of a novel application and the associated services that aggregate medication data from EMR and CPOE systems so that clinicians can efficiently generate an accurate pre-admission medication list. Information collected with the use of this application subsequently supports the writing of admission and discharge orders by physicians, performance of admission assessment by nurses, and reconciliation of inpatient orders by pharmacists. Results from early pilot testing suggest that this new medication reconciliation process is well accepted by clinicians and has significant potential to prevent medication errors during transitions of care.
Unresolved medication discrepancies during hospitalization can contribute to adverse drug events, resulting in patient harm. Discrepancies can be reduced by performing medication reconciliation; however, effective implementation of medication reconciliation has proven to be challenging. The goals of the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) are to operationalize best practices for inpatient medication reconciliation, test their effect on potentially harmful unintentional medication discrepancies, and understand barriers and facilitators of successful implementation.
Six U.S. hospitals are participating in this quality improvement mentored implementation study. Each hospital has collected baseline data on the primary outcome: the number of potentially harmful unintentional medication discrepancies per patient, as determined by a trained on-site pharmacist taking a “gold standard” medication history. With the guidance of their mentors, each site has also begun to implement one or more of 11 best practices to improve medication reconciliation. To understand the effect of the implemented interventions on hospital staff and culture, we are performing mixed methods program evaluation including surveys, interviews, and focus groups of front line staff and hospital leaders.
At baseline the number of unintentional medication discrepancies in admission and discharge orders per patient varies by site from 2.35 to 4.67 (mean=3.35). Most discrepancies are due to history errors (mean 2.12 per patient) as opposed to reconciliation errors (mean 1.23 per patient). Potentially harmful medication discrepancies averages 0.45 per patient and varies by site from 0.13 to 0.82 per patient. We discuss several barriers to implementation encountered thus far. In the end, we anticipate that MARQUIS tools and lessons learned have the potential to decrease medication discrepancies and improve patient outcomes.
Clinicaltrials.gov identifier NCT01337063
Medication reconciliation; Hospitalization; Quality improvement; Care transitions
Medication errors at the time of hospital admission and discharge are common and can lead to preventable adverse drug events. The objective of this study was to describe the potential impact of a medication reconciliation process to identify and rectify medication errors at the time of hospital admission and discharge.
Sixty randomly selected patients were prospectively enrolled at the time of admission to a Canadian community hospital. At admission, patients' medication orders were compared with pre‐admission medication use based on medication vials and interviews with patients, caregivers, and/or outpatient healthcare providers. At discharge, pre‐admission and in‐patient medications were compared with discharge orders and written instructions. All variances were discussed with the prescribing physician and classified as intended or unintended; unintended variances were considered to be medication errors. An internist classified the clinical importance of each unintended variance.
Overall, 60% (95% CI 48 to 72) of patients had at least one unintended variance and 18% (95% CI 9 to 28) had at least one clinically important unintended variance. None of the variances had been detected by usual clinical practice before reconciliation was conducted. Of the 20 clinically important variances, 75% (95% CI 56 to 94) were intercepted by medication reconciliation before patients were harmed.
Unintended medication variances at the time of hospital admission and discharge are common and clinically important. The medication reconciliation process identified and addressed most of these unintended variances before harm occurred. In this small study, medication reconciliation was a useful method for identifying and rectifying medication errors at times of transition. Reconciliation warrants broader evaluation.
medication reconciliation; continuity of patient care; safety management; medication errors
Medication errors are a common cause of avoidable morbidity, and transfer between clinical settings is a known risk factor for such errors. Medicines reconciliation means there is no unintended discrepancy between the medication prescribed for a patient prior to admission and on admission. Our aim was to improve the quality of practice supporting medicines reconciliation at the point of admission to a psychiatric ward.
An audit-based quality improvement programme (QIP), using the proxy measure for medicines reconciliation of two or more sources of information being consulted about current medicines, and compared.
At baseline audit, 42 Trusts submitted data for 1790 patients. At re-audit 16 months later, 43 Trusts submitted data for 2296 patients. While doctors were most commonly identified in Trust policies as having overall responsibility for medicines reconciliation, the task was most often undertaken by pharmacy staff, with most activity occurring within 24 h of admission. The proportion of patients in whom medicines reconciliation was possible was 71% at baseline and 79% at re-audit. In such patients, discrepancies were identified in 25% at baseline and 31% at re-audit; a small proportion of these discrepancies were clearly clinically significant.
This QIP achieved modest improvement in medicines reconciliation practice.
Inaccurate records of pre-admission medication exposure have been identified as a major source of medication error. Authors collected records of patients’ pre-admission medications: 1) the most recent outpatient medication list (“EMR”), 2) the medication list recorded by admitting providers (“H&P”), and 3) a list generated by a medication reconciliation process conducted by nursing staff (“PAML”). Forty-eight sets of pre-admission records composed of 1087 medication entries were compared to a reference standard generated by trained study staff conducting an independent interview. Sensitivity was greatest for PAML (85%), compared to EMR (76%) and H&P (76%) sources. However, positive predictive value was greatest for the H&P source at 96% vs 88% and 91% for PAML and EMR sources respectively. Potentially harmful medication discrepancies were found within all lists. The authors concluded no single list was sufficiently accurate to avoid serious medication errors.
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.
medication errors; medication systems, hospital; continuity of patient care; inpatients
Serious medication errors occur commonly in the period after hospital discharge. Medication reconciliation in the postdischarge ambulatory setting may be one way to reduce the frequency of these errors. The authors describe the design and implementation of a novel tool built into an ambulatory electronic medical record (EMR) to facilitate postdischarge medication reconciliation. The tool compares the preadmission medication list within the ambulatory EMR to the hospital discharge medication list, highlights all changes, and allows the EMR medication list to be easily updated. As might be expected for a novel tool intended for use in a minority of visits, use of the tool was low at first: 20% of applicable patient visits within 30 days of discharge. Clinician outreach, education, and a pop-up reminder succeeded in increasing use to 41% of applicable visits. Review of feedback identified several usability issues that will inform subsequent versions of the tool and provide generalizable lessons for how best to design medication reconciliation tools for this setting.
Quality improvement; patient safety; clinical decision support; hospital medicine; rascal; clinical; informatics; measuring/improving patient safety and reducing medical errors; natural-language processing; measuring/improving outcomes in specific conditions and patient subgroups; patient safety; decision support; data exchange machine learning; medication reconciliation; information systems; patient discharge
This study evaluated the effectiveness of a medication reconciliation program conducted by doctor of pharmacy (PharmD) students during an advanced pharmacy practice experience.
Patients admitted to medicine or surgery units at 3 hospitals were included. Students were instructed to interview each patient to obtain a medication history, reconcile this list with the medical chart, and identify and solve drug-related problems.
Eleven students reconciled medications for 330 patients over 10 months and identified 922 discrepancies. The median number of discrepancies found per patient was 2, and no discrepancies were found in 25% of the cases. In cases in which discrepancies were identified, a greater number of medications had been prescribed for the patient (7.9 ± 4.0 medications compared to 5.4 ± 3.9 medications; p < 0.05). The students completed 59 interventions. Differences were found in the numbers of discrepancies and drug-related problems that different students at different sites identified (p < 0.05).
Pharmacy students provided a valuable service to 3 community hospitals. The students improved the quality of patient care by identifying and solving significant drug-related problems, identifying drug allergy information, and resolving home and admission medication discrepancies.
medication reconciliation; advanced pharmacy practice experience
Medication errors may result in serious safety issues for patients. Medication error issues are more prevalent among elderly patients, who take more medications and have prescriptions that change frequently. The challenge of obtaining accurate medication histories for the elderly at the time of hospital admission creates the potential for medication errors starting at admission.
A study at a central Texas hospital was conducted to assess whether an electronic medication checklist can enhance the accuracy of medication histories for the elderly. The empirical outcome demonstrated that medication errors were significantly reduced by using an electronic medication checklist at the time of admission. The findings of this study suggest that implementing electronic health record systems with decision support for identifying inaccurate doses and frequencies of prescribed medicines will increase the accuracy of patients’ medication histories.
electronic medication checklist; medication history; adverse drug events (ADEs); admission interview; the elderly; medication errors; electronic health record
Errors associated with medication documentation account for a substantial fraction of preventable medical errors. Hence, the Joint Commission has called for the adoption of reconciliation strategies at all United States healthcare institutions. Although studies suggest that reconciliation tools can reduce errors, it remains unclear how best to implement systems and processes that are reliable and sensitive to clinical workflow. The authors designed a primary care process that supported reconciliation without compromising clinic efficiency. This manuscript describes the design and implementation of Automated Patient History Intake Device (APHID): ambulatory check-in kiosks that allow patients to review the names, dosage, frequency, and pictures of their medications before their appointment. Medication lists are retrieved from the electronic health record and patient updates are captured and reviewed by providers during the clinic session. Results from the roll-in phase indicate the device is easy for patients to use and integrates well with clinic workflow.
The Joint Commission continues to emphasize the importance of medication
reconciliation in all practice settings. Pharmacists and student pharmacists
are uniquely trained in this aspect of patient care, and can assist with
keeping accurate and complete medication records through patient interview
in the outpatient setting.
The objective of this study was to quantify and describe medication
reconciliation efforts by student pharmacists in an outpatient family
A retrospective review was conducted of all standard medication
reconciliation forms completed by student pharmacists during patient
interviews from April 2010 to July 2010. The number of reviews conducted was
recorded, along with the frequency of each type of discrepancy. A
discrepancy was defined as any lack of agreement between the medication list
in the electronic health record (EHR) and the patient-reported regimen and
included any differences in dose or frequency of a medication, duplication
of the same medication, medication no longer taken or omission of any
A total of 213 standard medication forms from the 4 month period were
reviewed. A total of 555 discrepancies were found, including medications no
longer taken, prescription medications that needed to be added to the EHR,
over-the-counter(OTC) and herbal medications that needed to be added to the
EHR, medications taken differently than recorded in the EHR, and medication
allergies which needed to be updated. An average of 2.6 discrepancies was
found per patient interviewed.
Student pharmacist-initiated medication reconciliation in an outpatient
family medicine center resulted in the resolution of numerous discrepancies
in the medication lists of individual patients. Pharmacists and student
pharmacists are uniquely trained in medication history taking and play a
vital role in medication reconciliation in the outpatient setting.
Medication Reconciliation; Continuity of Patient Care; Electronic Health Records; Students, Pharmacy; United States
Inaccurate medication history at admission to hospitals leads to preventable adverse drug events, which in turn increase mortality, morbidity, and health care costs. The objective of this study was to investigate the role of pharmacists in identifying discrepancies in medication histories at admission to a tertiary referral hospital in Saudi Arabia.
We performed a prospective observational study in a 1200 bed tertiary hospital in Riyadh, Saudi Arabia. Patients were included if they were aged 16 years or older, were taking 5 or more medications, and were able to communicate or were accompanied by a caregiver who could communicate. Over 2 months in 2009, a pharmacist interviewed patients to ascertain all medications used prior to hospitalization, then all discrepancies were discussed with the admitting physician and unintended discrepancies were reported as errors.
A pharmacist interviewed 60 patients who were taking 564 medications total. Of these patients, 65% were male, and their mean age was 62. Patients were taking an average of 9.4 medications. Twenty-two (37%) patients had at least one discrepancy, with the most common being omissions of medications (35%) and dosage errors (35%). The mean age for patients with discrepancies was 64.6 years, and without discrepancies, 60.8 years (P = 0.37).
Inaccurate medication history at admission to a hospital was common in Saudi Arabia. This has the potential to cause harm to patients if it remains undetected. Pharmacists could potentially play a major role in obtaining this medication history at the time of hospital admission.
Medication errors; Transitions; Discrepancies
Medication reconciliation can reduce medication errors and mortality. With limited availability of clinical pharmacists, it is important to determine the resources that will yield the most complete information about a patient’s medication history.
To identify the most time-efficient sources of information about medication history for use by clinicians in a pediatric care setting.
In July and August 2009, newly admitted pediatric patients (under 18 years of age) were identified, and a best possible medication history (BPMH) was compiled from the admission history in each patient’s chart, a provincial prescription database, a community pharmacy record, and an “informed interview”. Each individual source of information was compared with the BPMH and given a completeness score based on 3 pieces of information about each medication (name, dose, and frequency).
Data were collected for 99 pediatric patients. Of these, 76 (77%) were taking at least one medication, and 49 (50%) were taking at least one prescription medication. Among patients who were taking at least one medication, the informed interview, based on background information from other sources, resulted in the most comprehensive medication history, with a median completeness score of 100% (interquartile range [IQR] 90% to 100%). The admission history had a median completeness score of 33% (IQR 4% to 56%), with documentation of dose and frequency lacking most frequently. Information from community pharmacies had a median completeness score of 67% (IQR 42% to 87%), but this source was available for only 24 of the 99 patients. The prescription database was the least complete source, with a median completeness score of 0% (IQR 0% to 37%).
An informed interview by a trained professional resulted in the most complete medication history. Admission histories represented the next most complete source. The data from this study indicated a need for education on the performance of medication reconciliation that would emphasize the use of all available background information, documentation of dose and frequency for each medication, and inclusion of both over-the-counter and herbal products.
pediatrics; medication reconciliation; adverse drug events; best possible medication history; pédiatrie; bilan comparatif des médicaments; événements indésirables liés aux médicaments; meilleur schéma thérapeutique possible
Many hospitals have experienced challenges with accomplishing the Joint Commission’s National Patient Safety Goal for medication reconciliation. Our institution implemented a fully electronic process for performing and documenting medication reconciliation at hospital admission. The process used a commercial EHR and relied on a longitudinal medication list called the “Outpatient Medication Profile” (OMP). Clinician compliance with documenting medication reconciliation was difficult to achieve, but approached 100% after a “hard-stop” reminder was implemented. We evaluated the impact of the process at a large urban academic medical center. Before the new process was adopted, the average number of medications contained in the OMP for a patient upon admission was <2. One year after adoption, the average number had increased to 4.7, and there were regular updates made to the list. Updating the OMP was predominantly done by physicians, NPs, and PAs (94%), followed by nurses (5%) and pharmacists (1%).
A physician’s prescribing decisions depend on knowledge of the patient’s medication list. This knowledge is often incomplete, and errors or omissions could result in adverse outcomes. To address this problem, the Joint Commission recommends medication reconciliation for creating a more accurate list of a patient’s medications. In this paper, we develop techniques for automatic detection of omissions in medication lists, identifying drugs that the patient may be taking but are not on the patient’s medication list. Our key insight is that this problem is analogous to the collaborative filtering framework increasingly used by online retailers to recommend relevant products to customers. The collaborative filtering approach enables a variety of solution techniques, including nearest neighbor and co-occurrence approaches. We evaluate the effectiveness of these approaches using medication data from a long-term care center in the Eastern US. Preliminary results suggest that this framework may become a valuable tool for medication reconciliation.
Patient Safety; Data Quality; Medication Reconciliation; Collaborative Filtering; Machine Learning
Increasingly, hospitals are implementing multi-faceted programs to improve medication reconciliation and transitions of care, often involving pharmacists.
To help delineate the optimal role of pharmacists in this context, this qualitative study assessed pharmacists’ views on their roles in hospital-based medication reconciliation and discharge counseling. We also provide pharmacists’ recommendations for improving care transitions.
Eleven study pharmacists at two hospitals who participated in the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study completed semi-structured one-on-one interviews, which were coded systematically in NVivo. Pharmacists provided their perspectives on admission and discharge medication reconciliation, in-hospital patient counseling, provision of simple medication adherence aids (e.g., pill box, illustrated daily medication schedule), and telephone follow-up.
Pharmacists considered medication reconciliation, though time-consuming, to be their most important role in improving care transitions, particularly through detection of errors in the admission medication history that required correction. They also identified patients with poor understanding of their medications, who required additional counseling. Providing adherence aids was felt to be highly valuable for patients with low health literacy, though less useful for patients with adequate health literacy. Pharmacists noted that having trained administrative staff conduct the initial post-discharge follow-up call to screen for issues and triage which patients needed pharmacist follow-up was helpful and an efficient use of resources. Pharmacists’ recommendations for improving care transitions included clear communication among team members, protected time for discharge counseling, patient and family engagement in discharge counseling, and provision of patient education materials.
Pharmacists are well-positioned to participate in hospital-based medication reconciliation, identify patients with poor medication understanding or adherence, and provide tailored patient counseling to improve transitions of care. Additional studies are needed to confirm these findings in other settings, and to determine the efficacy and cost-effectiveness of different models of pharmacist involvement.
pharmacist; health literacy; care transitions; medication reconciliation; qualitative research