Prevalence of medication transfer errors in nephrology patients and potential risk factors

BackgroundMedication reconciliation in transitions of care can prevent medication transfer errors (MTE). MTE can cause patient harm. Since performing medication reconciliation for every patient is not always feasible, identification of potential risk factors of MTE could aid in targeting this intervention to the right patients.ObjectiveTo establish the proportion of patients with one or more MTE in the outpatient nephrology setting. Secondary patient characteristics associated with MTE, type and potential harm, and medication groups were investigated.MethodsThis retrospective observational cohort study was conducted in the Leiden University Medical Center, the Netherlands, between November 2017 and April 2018. The cohort involved patients in whom medication reconciliation was performed by a medical attendant using the electronic tool ‘Medical Dashboard’ prior to visiting the nephrologist. MTE were defined as unintended discrepancies between the medication in the hospital system and the result of the medication reconciliation. The proportion of patients with one or more MTE was calculated and the association of patient characteristics (age, sex, number of medications and kidney function (CKD-EPI)) with MTE was analyzed using multivariate logistic regression.ResultsOf 380 patients, 235 patients (61.8%) had at least one MTE. On average patients used 10.3 medications. The number of medications per patient was significantly associated with MTE; OR 1.11 (95%CI 1.05–1.16). No association was found for age, sex, and kidney function.ConclusionIn ambulatory nephrology patients 61.8% had at least one MTE. Nephrology patients using a higher number of drugs are more prone to MTE.     

Medication Discrepancies upon Hospital to Skilled Nursing Facility Transitions

BACKGROUND  Failure to reconcile medications across transitions in care is an important source of harm to patients. Little is known about medication discrepancies upon admission to skilled nursing facilities (SNFs). OBJECTIVE  To describe the prevalence of, type of medications involved in, and sources of medication discrepancies upon admission to the SNF setting. DESIGN  Cross-sectional study. PARTICIPANTS  Patients admitted to SNF for subacute care. MEASUREMENTS  Number of medication discrepancies, defined as unexplained differences among documented medication regimens, including the hospital discharge summary, patient care referral form and SNF admission orders. RESULTS  Of 2,319 medications reviewed on admission, 495 (21.3%) had a medication discrepancy. At least one medication discrepancy was identified in 142 of 199 (71.4%) SNF admissions. The discharge summary and the patient care referral form did not match in 104 of 199 (52.3%) SNF admissions. Disagreement between the discharge summary and the patient care referral form accounted for 62.0% (n = 307) of all medication discrepancies. Cardiovascular agents, opioid analgesics, neuropsychiatric agents, hypoglycemics, antibiotics, and anticoagulants accounted for over 50% of all discrepant medications. CONCLUSIONS  Medication discrepancies occurred in almost three out of four SNF admissions and accounted for one in five medications prescribed on admission. The discharge summary and the patient care referral forms from the discharging institution are often in disagreement. Our study findings underscore the importance of current efforts to improve the quality of inter-institutional communication.     

Challenges at Care Transitions: Failure to Follow Medication Changes Made at Hospital Discharge

BackgroundIn-hospital medication reconciliation has not demonstrated reductions in adverse health outcomes, possibly because patients do not follow the changes made to their preadmission medications. Our objective was to determine the incidence of and variables associated with failure to follow newly prescribed therapies, discontinued medications, and dose changes.MethodsA prospective cohort study of patients admitted to hospitals in Montreal, Quebec between 2014 and 2016 was conducted. Failure to follow medication changes 30 days post discharge was measured by comparing prescribed and dispensed medications. Multivariable logistic regression was used to determine characteristics associated with failure to follow changes.ResultsAmong 2655 patients, mean age was 69.5 years (SD 14.7), and 1581 (60%) were males. There were 10,068 medication changes made at hospital discharge and 24% were not followed in the 30 days post discharge. Thirty percent of dose modifications were filled at the incorrect dose, 27% of new medications were not filled, and 12% of discontinued medications were filled. A number of factors increased the risk of failure to follow medication changes, including increasing out-of-pocket medication costs (adjusted odds ratio [aOR] 1.12; 95% confidence interval [CI], 1.07-1.18), discharge to long-term care facility (aOR 2.29; 95% CI, 1.63-3.08), and not having medications dispensed prior to admission (aOR 4.67; 95% CI, 3.75-5.90).ConclusionOne in 4 hospital medication changes was not followed post discharge. Health policy aimed at eliminating out-of-pocket medication costs and investigation of factors influencing failure to follow changes for those not dispensed medications prior to admission and for long-term care residents are important next steps to address this issue.     

Impact of admission medication reconciliation performed by clinical pharmacists on medication safety

BackgroundMany activities contribute to reduce drug-related problems. Among them, the medication reconciliation (MR) is used to compare the best possible medication history (BPMH) and the current admission medication order (AMO) to identify and solve unintended medication discrepancies (UMD). This study aims to assess the impact of the implementation of admission MR by clinical pharmacists on UMD.MethodThis prospective study was carried out in two units of general medicine and infectious and tropical diseases in a 1844-bed French hospital. A retroactive MR performed in an observational period was compared to a proactive MR realized in an interventional period. We used a logistic regression to identify risk factors of UMD.ResultsDuring both periods, 394 patients were enrolled and 2,725 medications were analyzed in the BPMH. Proactive MR reduced the percentage of patients with at least one UMD compared with retroactive process (respectively 2.1% vs. 45.8%, p < 0.001). Patients with at least one UMD during both periods were older compared to patients without UMD (79 vs. 72, p < 0.005) and had more medications at admission (7 vs. 6, p < 0.0001). UMD occur 38 times more often when there is no clinical pharmacist intervention. Among the 226 UMD detected in both periods, 42% would have required monitoring or intervention to preclude harm, and 10% had potential harm to the patient and 2% were life threatening.ConclusionProactive MR performed by clinical pharmacists is an acute process of detection and correction of UMD, but it requires a lot of human resources.     

High prevalence of malnutrition in Internal Medicine wards – a multicentre ANUMEDI study

BackgroundDisease-related malnutrition is a significant problem in hospitalized patients, with high prevalence rates depending on the studied population. Internal Medicine wards are the backbone of the hospital setting. However, prevalence and determinants of malnutrition in these patients remain unclear. We aimed to determine the prevalence of malnutrition in Internal Medicine wards and to identify and characterize malnourished patients.MethodsA cross-sectional observational multicentre study was performed in Internal Medicine wards of 24 Portuguese hospitals during 2017. Demographics, hospital admissions during the previous year, type of admission, primary diagnosis, Charlson comorbidity index, and education level were registered. Malnutrition at admission was assessed using Patient-Generated Subjective Global Assessment (PG-SGA). Demographic characteristics were compared between well-nourished and malnourished patients. Logistic regression analysis was used to identify determinants of malnutrition.Results729 participants were included (mean age 74 years, 51% male). Main reason for admission was respiratory disease (32%). Mean Charlson comorbidity index was 5.8 ± 2.8. Prevalence of malnutrition was 73% (56% moderate/suspected malnutrition and 17% severe malnutrition), and 54% had a critical need for multidisciplinary intervention (PG-SGA score ≥9). No education (odds ratio [OR] 1.88, 95% confidence interval [CI]: 1.16–3.04), hospital admissions during previous year (OR 1.53, 95%CI: 1.05–2.26), and multiple comorbidities (OR 1.22, 95%CI: 1.14–1.32) significantly increased the odds of being malnourished.ConclusionsPrevalence of malnutrition in the Internal Medicine population is very high, with the majority of patients having critical need for multidisciplinary intervention. Low education level, admissions during previous year, and multiple comorbidities increase the odds of being malnourished.     

Does my patient really need this at admission? Seven opportunities for improving value in patient care during their hospitalization

IntroductionBesides the main treatment for their disease, hospital patients receive multiple care measures which include venous lines (VL), urinary catheters (UC), dietary restrictions (DR), mandatory bed rest (BR), deep venous thrombosis prophylaxis (VTP), stress ulcer prophylaxis (SUP) and anticoagulation bridge therapy for atrial fibrillation (BAF). In many cases these practices are of low value.MethodsWe analysed patients admitted to Internal Medicine wards throughout 2018 (2714 inpatients). We used different methodologies to identify low-value clinical practices.ResultsBR or DR at admission were recommended in 37% (32–44) and 24% (19–30) of the patients respectively. In 81% (71–87) and 33% (21–45) of the cases this restriction was deemed unnecessary. Ninety-six percent (92–98) had VL and 25% (19–32) UC. VL were not used in 10% (6–12), UC had no indications for insertion in 21% (11–35) and for maintenance in 31% (12–46) patients. Fifty-seven percent (49–64) of the patients were administered VTP and 69% (62–76) were prescribed SUP. Twenty-two percent (15–31) of patients with VTP and 52% (43–60) with SUP had no indication. Chronic anticoagulation for AF was interrupted in 65% (53–75) with BAF was prescribed in 38% (25–52) of them.An intervention to reduce low-value care supporting clinical practices addressed only to the Internal Medicine Wards showed very poor results.ConclusionThese results demonstrate that there is ample room for reduction of low-value care. Interventions to implement clinical guidelines at admissions should be addressed to cover the entire admission process, from the emergency room to the ward. Partial approaches are discouraged.     

Effect of Patient- and Medication-Related Factors on Inpatient Medication Reconciliation Errors

Background

Little research has examined the incidence, clinical relevance, and predictors of medication reconciliation errors at hospital admission and discharge.

Objective

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.

Design, Participants

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?CCVD) Study.

Main Measures

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.

Key Results

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?C 2.12) and number of pre-admission medications (IRR?=?1.17; 95% CI, 1.10?C1.25), and were less likely when a recent medication list was present in the electronic medical record (EMR) (IRR?=?0.54; 95% CI, 0.30?C0.96). 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?C1.45) and number of medications changed prior to discharge (IRR?=?1.06; 95% CI, 1.01?C1.11).

Conclusions

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.     

Effectiveness of clinical pharmacist-led smartphone application on medication adherence,insulin injection technique and glycemic control for women with gestational diabetes receiving multiple daily insulin injection: A randomized clinical trial

AimTo investigate the efficacy of a clinical pharmacist-led smartphone application (app) on medication adherence, insulin injection technique (IIT) and diabetes-related outcomes among women with gestational diabetes mellitus (GDM) receiving insulin therapy.MethodIn all, 124 women were randomly (1:1 ratio) assigned to receive app intervention plus usual care (intervention) or usual care (control), and were followed up till 12 weeks postpartum. Interventions centralized on medication adherence and IIT. Primary outcome was medication adherence assessed by the 5-item Medication Adherence Report Scale. Secondary outcomes included IIT, insulin requirement, prepartal and puerperal glycemic control, hypoglycemia, and pregnancy and neonatal outcomes.ResultsA total of 119 patients completed the follow-up evaluation (58 intervention, 61 control). Significant more women with high medication adherence in the intervention group was observed (69.0% vs. 34.4%, p = 0.000). The other notable benefits (all p < 0.05) included patient percentage with appropriate IIT, lesser preprandial insulin dose, patient proportion with both qualified prepartal FPG and 2 hPG, and puerperal FPG or HbA1c, fewer hypoglycemia, and lower neonatal intensive care unit (NICU) admission rate. Cesarean delivery rate was higher among intervention cases (p < 0.05). Qualified prepartal glycemic control was related to high medication adherence and proper IIT. NICU admission was associated with complicated with gestational hypertension, deficient medication adherence and premature rupture of fetal membrane.ConclusionCombined with usual care, clinical pharmacist-led smartphone app might be a valid tool for GDM management.     

Medication Discrepancies in Resident Sign-Outs and Their Potential to Harm

BACKGROUND: The accuracy of information transferred during hand-offs is uncertain. OBJECTIVE: To describe the frequency, types, and harm potential of medication discrepancies in resident-written sign-outs. DESIGN: Retrospective cohort study. PARTICIPANTS: Internal Medicine interns and their patients at a single hospital in January 2006. MEASUREMENTS: Daily written sign-outs were compared to daily medication lists in patient charts (gold standard). Medication discrepancies were labeled omissions (medication in chart, but not on sign-out) or commissions (medication on sign-out, but not in chart). Discrepancies were also classified as index errors (the first time an error was made) and the proportion of index errors that persisted on subsequent days. Using a modified classification scheme, discrepancies were rated as having minimal, moderate, or severe potential to harm. RESULTS: One hundred eighty-six of 247 (75%) patients and 10 of 10(100%) interns consented. In the 165 (89%) patients' charts abstracted and compared with the sign-out, there were 1,876 of 6,942 (27%) medication chart entries that were discrepant with the sign-out with 80% (1,490/1,876) labeled omissions. These discrepancies originated from 758 index errors, of which 63% (481) persisted past the first day. Omissions were more likely to persist than commissions (68% [382 of 580] vs 53% [99 of 188], p < .001). Greater than half (54%) of index discrepancies were moderate or severely harmful. Although omissions were more frequent, commissions were more likely to be severely harmful (38% [72 of 188] vs 11% [65 of 580], p < .0001). CONCLUSIONS: Written sign-outs contain potentially harmful medication discrepancies. Whereas linking sign-outs to electronic medical records can address this problem, current efforts should also emphasize the importance of vigilant updating in the many hospitals without this technology.     

Risk,prevalence, and impact of hospital malnutrition in a Tertiary Care Referral University Hospital: a cross-sectional study

Hospital malnutrition is still underestimated among physicians, even in internal medicine settings. This is a cross-sectional study, aiming to estimate the risk, the prevalence and the impact of malnutrition in an Internal Medicine and Gastroenterology Department of a large Italian hospital (Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome). Patients were evaluated within 72 h from admission according to Nutritional Risk Screening-2002 (NRS-2002) and European Society for Clinical Nutrition and Metabolism (ESPEN) Criteria. Anthropometric, laboratory tests and Bioelectrical Impedance Analysis (BIA) derived phase angle were also performed. Length of hospital stay (LOS) and in-hospital mortality were collected. Univariate and multivariate analyses were conducted to correlate nutritional status with LOS and hospital mortality. In 10 months, 300 patients were enrolled: male patients were 172 (57.3%); mean age was 63.7 (±?17.6). At admission, 157 (52.3%) patients were at risk of malnutrition; 116 (38.7%) were malnourished. Malnourished patients had a mean LOS of 11.5 (±?8.0) days, not-malnourished 9.4 (±?6.2) days (p?<?0.05). In-hospital mortality did not significantly differ between the two groups. Multivariate analysis shows that both malnutrition (p?=?0.04; 95% CI 0.03–3.41) and phase angle (p?=?0.004; 95% CI ??1.92 to ??0.37) independently correlate with LOS. In an Internal Medicine and Gastroenterology Department, over half (52.3%) of the patients were found at risk of malnutrition, and over a third (38.7%) were malnourished at hospital admission. Malnutrition and BIA-derived phase angle are independently associated with LOS. ESPEN Criteria and phase angle could be performed at admission to identify patients deserving specific nutritional support.     

Conciliation médicamenteuse d’entrée en service de médecine interne : retour d’expérience après un an de pratique

Since April 2015, medication reconciliation is performed in our Department. The objective of this study is to assess the impact of this activity on patients’ care after one year of practice.

Pharmacist medication assessments in a surgical preadmission clinic

BACKGROUND: In the hospital setting, postoperative admission is a key vulnerable moment when patients are at increased risk of medication discrepancies. This study measures the reduction of medication discrepancies associated with a combined intervention of structured pharmacist medication history interviews with assessments in a surgical preadmission clinic and a postoperative medication order form. METHODS: In the Surgical Pharmacist in Preadmission Clinic Evaluation (SPPACE) study, patients who had a preadmission clinic appointment before undergoing surgical procedures were eligible for inclusion. Patients were excluded if they were scheduled for discharge the same day as their surgery. Eligible patients were randomly assigned to the intervention arm (structured pharmacist medication history interview with assessment and generation of a postoperative medication order form) or to the standard care arm (nurse-conducted medication histories and surgeon-generated medication orders). The primary end point was the number of patients with at least 1 postoperative medication discrepancy related to home medications. RESULTS: Between April 19, 2005, and June 3, 2005, a total of 464 patients were enrolled in the study, of which 227 and 237 patients were randomized to the intervention and standard care arms, respectively. In the intervention arm, 41 (20.3%) of 202 patients had at least 1 postoperative medication discrepancy related to home medications, compared with 86 (40.2%) of 214 patients in the standard care arm (P<.001). In the intervention arm, 26 (12.9%) of 202 patients had at least 1 postoperative medication discrepancy with the potential to cause possible or probable harm, compared with 64 (29.9%) of 214 patients in the standard care arm (P<.001). These were mostly omissions of reordering home medications. CONCLUSION: A combined intervention of pharmacist medication assessments and a postoperative medication order form can reduce postoperative medication discrepancies related to home medications.     

Medication Reconciliation Accuracy and Patient Understanding of Intended Medication Changes on Hospital Discharge

BACKGROUND

Adverse drug events after hospital discharge are common and often serious. These events may result from provider errors or patient misunderstanding.

OBJECTIVE

To determine the prevalence of medication reconciliation errors and patient misunderstanding of discharge medications.

DESIGN

Prospective cohort study

SUBJECTS

Patients over 64 years of age admitted with heart failure, acute coronary syndrome or pneumonia and discharged to home.

MAIN MEASURES

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.

KEY RESULTS

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).

CONCLUSIONS

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.