How reliable are patient-completed medication reconciliation forms compared with pharmacy lists?

Objectives

Medication reconciliation is a Joint Commission for the Accreditation of Healthcare Organizations requirement to reduce medication errors. This study evaluated the reliability of patient-completed medication reconciliation forms (MRs) compared with pharmacy-generated lists and determined if there was a difference in concordance when patients completed the forms from memory compared with when they brought a separate list or pill bottles.

Methods

We prospectively enrolled patients with completed MRs. Research assistants contacted the patient's pharmacy to determine medications filled in the prior 3 months, which was compared with the MR. Discrepancies and the method by which the patient completed the MR (memory, list, or pill bottles) were recorded.

Results

Three hundred fifteen patients were enrolled. Thirty-three percent made errors of omission (reported by pharmacy, but not on MR), 12.7% made errors of addition (reported on MR, but not by pharmacy), 18.1% made both types of errors, and 36.3% made no errors. Patients with errors were on 5.6 medications compared with 3.6 medications for those without errors (P < .0001). Those completing the MR from a list made 2.3 errors compared with 1.2 for those completing from memory and 1.8 for those completing from their pill bottles (P < .001). Of 390 medications omitted from patient lists, 16% were cardiac medications, 13% were neuropsychiatric agents, and 9.5% were narcotics.

Conclusions

Thirty-six percent of patients were able to provide a medication list that matched their pharmacy-prescribed drugs. More errors were noted from patients taking more medications and from those completing their MR from a separate list.     

Perceptions of sexual responsibility: do young men and women agree?

A nonprobability, convenience sample of 248 subjects of a large midwestern university agreed to participate in this study designed to investigate the perception of responsibility for contraception among late adolescents (over age 17), to determine whether age, gender, or sexual activity influences perceptions of responsibility, and to explore the relationship between perceived contraceptive responsibility and subsequent contraceptive choice among late adolescent males and females. The students were enrolled in an undergraduate public health class during the 1984 spring quarter. After initial data examination, 28 married subjects were eliminated from analysis. Of the final sample size of 220 students, 131 were female and 89 were male. The majority of the students, 57.5%, were between the ages of 20-22; 19% were between the ages of 17-19; and the remaining 23% were older than 22. The students completed a questionnaire anonymously as part of the development of a slide-tape program entitled "Young Men's Sexual Responsibility." Contraceptive responsibility was defined as perceived responsibility for pregnancy control, perceived responsibility to initiate conversation about contraception in a dating relationship, and perceived responsibility for who should pay for contraceptives. 63% of the students indicated that they had engaged in sexual intercourse at least once. Male students were significantly more likely to have had sexual intercourse than female students. Only 7% of the entire sample reported having had intercourse before the age of 15, but this sample consisted primarily of white, middle-class college students who may not represent students in inner-city school districts reported to have had 1st intercourse at earlier ages. 91% of the students perceived contraceptive responsibility as a shared responsibility. Of the small number of students who perceived 1 sex or the other responsible for pregnancy control, most (7%) perceived that it was the woman's responsibility. No relationship was found between age or intercourse experience and perceived contraceptive responsibility. 52.3% of the students reported using effective birth control methods at 1st intercourse, but 37.2% reported not using contraceptives. The remaining students used 2 of the least effective methods for adolescents (withdrawal, 7.2%; rhythm, 3.5%). No relationship was found between the students' perception of responsibility for pregnancy control or responsibility for initiating a conversation about contraception and the type of contraceptive used at most recent intercourse. If the concept of shared responsibility is in fact an emerging value, health professionals and educators must reconsider sex education curricula for adolescents.     

Contraindications for superficial heat and therapeutic ultrasound: do sources agree?

OBJECTIVES: To determine the amount of agreement among general rehabilitation sources for both superficial heating and therapeutic ultrasound contraindications. DATA SOURCES: English-language textbook and peer-reviewed journal sources, from January 1992 to July 2002. Searches of computerized databases (HealthSTAR, CINAHL, MEDLINE, Embase) as well as Library of Congress Online Catalogs, Books in Print, and AcqWeb's Directory of Publishers and Venders. DATA SELECTION: Sources were excluded if they (1) were published before 1992, (2) failed to address general rehabilitation audiences, or (3) were identified as a researcher's related publication with similar information on the topic. DATA EXTRACTION: Type and number of contraindications, type of audience, year of publication, number of references, rationales, and alternative treatment strategies. DATA SYNTHESIS: Eighteen superficial heat and 20 ultrasound sources identified anywhere from 5 to 22 and 9 to 36 contraindications/precautions, respectively. Agreement among sources was generally high but ranged from 11% to 95%, with lower agreement noted for pregnancy, metal implants, edema, skin integrity, and cognitive/communicative concerns. Seventy-two percent of superficial heat sources and 25% of ultrasound sources failed to reference at least 1 contraindication claim. CONCLUSIONS: Agreement among contraindication sources was generally good for both superficial heat and therapeutic ultrasound. Sources varied with regard to the number of contraindications, references, and rationales cited. Greater reliance on objective data and standardized classification systems may serve to develop more uniform guidelines for superficial heat and therapeutic ultrasound.     

What is the concordance between the medical record and patient self-report as data sources for ambulatory care?

BACKGROUND: The validity of quality of care assessments relies upon data quality, yet little is known about the relative completeness and validity of data sources for evaluating the quality of care. OBJECTIVES: We evaluated concordance between ambulatory medical record and patient survey data. Levels of concordance, variations by type of item, sources of disagreement between data sources, and implications for quality of care assessment efforts are discussed. DESIGN AND SUBJECTS: This was an observational study that included 1270 patients sampled from 39 West Coast medical organizations with at least 1 of the following: diabetes, ischemic heart disease, asthma or chronic obstructive pulmonary disease, or low back pain. MEASURES: Items from both data sources were grouped into 4 conceptual domains: diagnosis, clinical services delivered, counseling and referral, and medication use. We present total agreement, kappa, sensitivity, and specificity at the item and domain-levels and for all items combined. RESULTS: We found good concordance between survey and medical records overall, but there was substantial variation within and across domains. The worst concordance was in the counseling and referrals domain, the best in the medication use domain. Patients were able to report with good sensitivity on memorable items. CONCLUSIONS: Quality ratings are likely to vary in differing directions, depending on the data source used. The most appropriate data source for analyses of components of and overall quality of care must be considered in light of study objectives and resources. We recommend data collection from multiple sources to most accurately portray the patient and provider experience of medical care.     

Patient safety: do nursing and medical curricula address this theme?

In this literature review, we examine to what extent patient safety is addressed within medical and nursing curricula. Patient safety is the foundation of healthcare practice and education both in the UK and internationally. Recent research and policy initiatives have highlighted this issue. The paper highlights the significance of this topic as an aspect of study in its own right by examining not only the fiscal but also the human costs such events invite. In the United Kingdom patient safety issues feature prominently in the (Department of Health, 2000a. An organisation with a memory. The report of an expert group on learning from adverse events. The Stationery Office, London, Department of Health, 2000b. Handling complaints: monitoring the NHS complaints procedures (England, Financial year 1998-99). The Stationery Office, London.) policy documentation but this is not reflected within the formal curricula guidelines issued by the NMC and GMC. Yet if healthcare educational curricula were to recognise the value of learning from errors, such events could become part of a wider educational resource enabling both students and facilitators to prevent threats to patient safety. For this reason, the paper attempts to articulate why patient safety should be afforded greater prominence within medical and nursing curricula. We argue that learning how to manage errors effectively would enable trainee practitioners to improve patient care, reduce the burden on an overstretched health care system and engage in dynamic as opposed to defensive practice.     

Children and adolescents with headache: what do they need?

Headache is the most frequent neurological symptom and common manifestation of pain in children. The needs of this group are poorly understood. The aim of this study is to quantify the extent of unmet need in a primary care paediatric population. A patient questionnaire survey of 2,425 children between the ages of 8 and 17 and an uncontrolled intervention study was undertaken in a large general practice in England. Headache impact was measured before and 4 months after a headache clinic intervention using the paediatric migraine disability assessment score. A total number of 74 (3%) children accepted an invitation for a headache assessment. However, only 49 (2%) attended for consultation of whom 84% were judged to have migraine. A total number of 43 (58%) had been seen before for a headache by their general practitioner. The median impact score was 17 days headache impact in a 3-month period. An intervention by a general practitioner with an interest in headache significantly reduced the headache impact score. There is a significant need amongst children with headache that can be addressed by interventions well within the capacity of general practitioners. Further studies are needed to explore why so few children with headache present to primary care and when they do, why their needs are not adequately addressed.     

Can pharmacy data improve prediction of hospital outcomes? Comparisons with a diagnosis-based comorbidity measure

OBJECTIVES: The performance of comorbidity measures derived from the hospital discharge abstract, the outpatient pharmacy record, and from both sources combined, were compared in predicting all-cause and unplanned hospital readmission and length of stay. MATERIALS AND METHODS: Automated hospital and pharmacy data came from Kaiser-Permanente and included 6721 acute hospitalizations in Southern California from April 1993 to February 1995. The Deyo adaptation of Charlson's 17 comorbidities was derived from hospital discharge data and the 29 Chronic Disease Score (CDS) comorbidity markers were derived from outpatient pharmacy claims data. Logistic and OLS regression models were used to compare the performance of each measure in baseline models and to evaluate whether the CDS contributed additional explanatory power in a combined model. RESULTS: The CDS was a significant predictor of unplanned readmission (C = 0.68) and LOS (Adjusted R(2) = 0.26) in multivariable models adjusted for baseline patient demographic and hospitalization characteristics. The Deyo measure was a significant predictor of all-cause readmission (C = 0.63), unplanned readmission (C = 0.68), and LOS (Adjusted R(2) = 0.26). When pharmacy-based disease markers were added to the Deyo baseline model, modest, statistically significant improvements in predictive power were noted in the unplanned readmission and LOS models. CONCLUSIONS: The finding that both measures of comorbid disease demonstrated similar predictive power is noteworthy, because secondary diagnosis data document relevant illness in hospital patients and pharmacy claims data were never intended for that purpose. The results suggest that small improvements in model performance may come from combining both sources of data in models to predict hospital readmission and LOS.     

Patient education and the Internet: do patients want us to provide them with medical web sites to learn more about their medical problems?

This study was performed to assess inner city Emergency Department (ED) patients' use of the Internet to obtain medical information, and patients' interest in being provided medical links by their ED physician to learn more about their medical condition. A convenience sample of inner city ED patients were surveyed regarding computer/Internet access, past searches for medical information, and whether they desired medical links provided with discharge paperwork. Of 328 patients completing the survey, 178 (54%) had computers, whereas 150 (46%) had access to the Internet. Seventy-nine (24%) had previously used the World Wide Web (WWW) to obtain medical information, and 26 (33%) of these reported difficulty in obtaining useful information. One hundred ninety-two (59%) were interested or very interested in being provided links to medical sites. Patients more likely to want medical links were younger, college educated, and in higher salary ranges. There was no difference in desire to be provided links based on number of past medical problems or duration of symptoms. In conclusion, almost half the inner city ED patients in this survey have Internet access and over half were interested in being provided quality medical links as a part of their discharge paperwork.     

What is the solution for clinical nurse educators and the electronic medical record?

Health care facilities are implementing the electronic medical record for a variety of reasons. The purpose of this article will summarize the challenges nurse educators and students face as a result of recent changes in documentation. A review of literature revealed impacting technology, curriculum considerations, ethical considerations, and economic influences evolving from these changes. The summarized data is presented along with possible solutions as increased technology enters the clinical setting.     

Measuring critical thinking in graduate education: what do we know?

Accrediting and specialty organizations agree that a master's education expands critical thinking skills gained during undergraduate study, yet a review of literature revealed a lack of research measuring critical thinking of students enrolled in postbaccalaureate education in nursing and other fields. Of 35 studies retrieved, 17 were conducted on undergraduate nursing students, with the remainder spread across practicing RNs, and master's level students in physical therapy, business, medicine, and nursing. A critique of this research and recommendations for future study are presented.