Medication details documented on hospital discharge: cross-sectional observational study of factors associated with medication non-reconciliation

AIMS

Movement into or out of hospital is a vulnerable period for medication safety. Reconciling the medication a patient is using before admission with the medication prescribed on discharge, and documenting any changes (medication reconciliation) is recommended to improve safety. The aims of the study were to investigate the factors contributing to medication reconciliation on discharge, and identify the prevalence of non-reconciliation.

METHODS

The study was a cross-sectional, observational survey using consecutive discharges from purposively selected services in two acute public hospitals in Ireland. Medication reconciliation, potential for harm and unplanned re-admission were investigated.

RESULTS

Medication non-reconciliation was identified in 50% of 1245 inpatient episodes, involving 16% of 9569 medications. The majority of non-reconciled episodes had potential to result in moderate (63%) or severe (2%) harm. Handwritten rather than computerized discharges (adjusted odds ratio (adjusted OR) 1.60, 95% CI 1.11, 2.99), increasing number of medications (adjusted OR 1.26, 95% CI 1.21, 1.31) or chronic illness (adjusted OR 2.08, 95% CI 1.33, 3.24) were associated with non-reconciliation. Omission of endocrine, central nervous system and nutrition and blood drugs was more likely on discharge, whilst omission on admission and throughout inpatient care, without documentation, was more likely for obstetric, gynaecology and urinary tract (OGU) or respiratory drugs. Documentation in the discharge communication that medication was intentionally stopped during inpatient care was less likely for cardiovascular, musculoskeletal and OGU drugs. Errors involving the dose were most likely for respiratory drugs.

CONCLUSIONS

The findings inform strategies to facilitate medication reconciliation on discharge from acute hospital care.     

临床药师在肾内科实施入院药物重整的实践

目的：临床药师通过在肾内科实施入院药物重整服务,总结入院重整常见的用药错误并给予干预,探讨肾内科药物重整的工作模式及作用。方法：以2016年3月-2016年12月收入某院肾内科的住院患者为研究对象,在入院24 h内,获得患者入院前的用药史,并与患者入院后医师开取的医嘱进行对比。分析评估患者入院前用药和入院后医师医嘱有无用药错误。结果：共对128例患者进行了药物重整,存在用药错误的有62例,用药错误发生率为48.4%。涉及药物医嘱838条,发生用药错误的医嘱为81条。入院前患者服药时间错误,入院后用药频次错误,需停用药物未停用为最常见的用药错误。发生用药错误的药物中,前3位分别为消化道及代谢药物、心血管系统药物、抗肿瘤药和免疫机能调节药。81条用药错误中患者服药时间错误及患者随意改变推荐剂量共34条,临床药师及时给予患者进行教育和指导,均被患者接受。其余的47条用药错误,临床药师全部反馈给医师,40条被医师接受并修改,接受率为85.1%。结论：实施药物重整,可以发现并纠正患者服药时间错误、随意改变推荐剂量等用药问题;可以有效地减少医师在入院及转科等医疗转接点用药错误的发生,促进患者安全合理地使用药物。     

Pharmacy-Based Medication Reconciliation Program Utilizing Pharmacists and Technicians: A Process Improvement Initiative

Background:

Pharmacists and pharmacy technicians have an opportunity to impact the quality of the medication histories and improve patient safety by ensuring accurate medication lists are obtained and complete reconciliation has occurred with the admission medication orders by owning the admission medication reconciliation process.

Objective:

To compare the quality of a pharmacy-based medication reconciliation program on admission utilizing pharmacists and technicians to the usual multidisciplinary process.

Methods:

This was a retrospective chart review process improvement study at a 186-bed tertiary care inpatient facility. Primary outcomes included both the accuracy of pre-admission medications listed and the reconciliation of those medications with admission inpatient orders. Technicians obtained patient medication histories. Pharmacists checked the technician-obtained medication histories and ensured reconciliation of those medications with admission orders.

Results:

Medication accuracy increased from 45.8% to 95% per patient (P < .001) and medication reconciliation increased from 44.2% to 92.8% (P < .001) and remained above benchmark.

Conclusion:

A pharmacy-based medication reconciliation program utilizing both pharmacists and technicians significantly increased the accuracy and reconciliation of medications on admission. These gains were maintained for the duration of the 6-month period studied and beyond per continued process improvement data collection.     

The epidemiology of medication errors: how many,how serious?

1. Errors will always occur in any system, but it is essential to identify causes and attempt to minimize risks.
2. Although it is difficult to quantify precisely the extent of medication errors, they are clearly frequent and often avoidable, representing a major threat to patient safety.
3. Many of the consequences of these errors can be prevented by the intervention of pharmacists.
4. Some errors are due to the conditions under which prescribers work; where possible these should be improved (for example, low staffing levels).
5. Computerized prescribing can help but can also generate its own inherent errors.
6. Improved training of prescribers at the undergraduate and postgraduate levels is vital, a fact that is now being belatedly recognized.     

Prevention of medication errors: teaching and training

1. Poor prescribing is probably the most common cause of preventable medication errors in hospitals, and many of these events involve junior doctors who have recently graduated. Prescribing is a complex skill that depends on a sound knowledge of medicines, an understanding of the principles of clinical pharmacology, the ability to make judgements concerning risks and benefits, and ideally experience. It is not surprising that errors occur.
2. The challenge of being a prescriber is probably greater now than ever before. Medical education has changed radically in the last 20 years, reflecting concerns about an overburdened curriculum and lack of focus on social sciences. In the UK, these changes have resulted in less teaching in clinical pharmacology and practical prescribing as guaranteed features of undergraduate training and assessment. There has been growing concern, not least from students, that medical school training is not sufficient to prepare them for the pressures of becoming prescribers. Similar concerns are being expressed in other countries. While irrefutable evidence that these changes are related to medication errors identified in practice, there is circumstantial evidence that this is so.
3. Systems analysis of errors suggests that knowledge and training are relevant factors in causation and that focused education improves prescribing performance. We believe that there is already sufficient evidence to support a careful review of how students are trained to become prescribers and how these skills are fostered in the postgraduate years. We provide a list of guiding principles on which training might be based.     

临床药师开展药物重整的药学服务实践

目的:为临床药师开展药物重整的药学实践提供参考。方法:探讨临床药师在实践工作中如何通过掌握用药史,及引入诺氏评估量表进行不良反应分析为切入点实现药物重整的药学服务实践。结果和结论:临床药师在药物重整工作中扮演着重要的角色。在临床实践中,临床药师获取精确的用药清单,加强专业知识地学习,借助一些适当的工具,才能实现药物重整。     

Effectiveness of two statin prescribing strategies with respect to adherence and cardiovascular outcomes: observational study

BACKGROUND: There is considerable evidence that statins can reduce cardiovascular events. Currently high-risk patients are treated to a target cholesterol concentration. An alternative prescribing strategy (the 'fire-and-forget' approach) would instead deploy low-dose statins more widely. It has been suggested that for the same cost this approach might prevent more cardiovascular events. We have compared the treat-to-target and fire-and-forget statin prescribing strategies with respect to adherence and cardiovascular outcomes. METHODS: We used a population-based record-linkage database containing several data sets linked by a unique patient identifier. We identified two cohorts of patients. Patients in the treat-to-target cohort were prescribed a statin, and subsequent measurement of their cholesterol was followed by upward titration of their statin dose if necessary. Patients in the fire-and-forget cohort were prescribed a statin, but no further cholesterol measurement was observed during the follow-up period. FINDINGS: Adherence to statin treatment in patients treated to target was significantly better than in patients treated on a fire-and-forget basis (adjusted odds ratio 2.51, 95%CI 2.26-2.78). We found a lower cardiovascular disease (CVD) event rate in patients treated to target than in fire-and-forget patients (hazard ratio of CVD or cardiovascular death 0.41 (0.35-0.48) even after adjustment was made for adherence and baseline CVD risk). INTERPRETATION: Our findings suggest that adherence to statins is worse in patients treated on a fire-and-forget basis than in patients treated to a target cholesterol concentration, and that this prescribing strategy is associated with worse cardiovascular outcomes.     

Perception of potentially inappropriate medication in elderly patients by Slovak physicians

PURPOSE: The aim of the present study was to determine the risk perception of potentially inappropriate drug treatment of elderly patients by Slovak physicians. In Slovakia, a list of such drugs is not available. METHODS: The study sample consisted of 600 patients aged > or =65 years hospitalized at the Department of Internal Medicine in a Slovak general hospital between 1 December 2003 and 31 March 2005. The use of potentially inappropriate drugs at the time of hospital admission and discharge was compared. Potentially inappropriate drug use was defined by Beers 2003 criteria. In addition, 206 physicians were asked to mark the drugs that they considered potentially inappropriate for elderly patients out of a list provided in a questionnaire analysis. RESULTS: Out of 600 patients 20.2% and 20% were treated with at least one potentially inappropriate drug at the time of hospital admission and discharge, respectively. Hospitalization had no significant influence on the number of potentially inappropriate medicines used. The most frequently prescribed potentially inappropriate drugs were digoxin >0.125 mg/day and ticlopidine. Out of 206 responding physicians only 4.9% considered ticlopidine as potentially inappropriate for elderly patient. On the other hand, more than 20% of respondents were aware of the potential inappropriateness of amitriptyline, diazepam and chlordiazepoxide. Mentioned drugs were observed in less than 2% of study population (n = 600). CONCLUSIONS: The results of the questionnaire analysis in physicians as well as the prevalence of potentially inappropriate medication demonstrate that Slovak clinicians are aware of the risk of certain treatments in elderly patients.     

The impact of pharmaceutical care interventions for medication underuse in older people: a systematic review and meta-analysis

Aims

The aim of the present study was to conduct a meta-analysis of controlled trials assessing the impact of pharmaceutical care interventions (e.g. medication reviews) on medication underuse in older patients (≥65 years).

Methods

The databases MEDLINE and EMBASE were searched for controlled studies, and data on interventions, patient characteristics and exposure, and outcome assessment were extracted. Risk of bias was assessed using the Cochrane Collaboration’s ‘risk of bias’ table. Results from reported outcomes were synthesized in multivariate random effects meta-analysis, subgroup meta-analysis and meta-regression.

Results

From 954 identified articles, nine controlled studies, mainly comprising a medication review, were included (2542 patients). These interventions were associated with significant reductions in the mean number of omitted drugs per patient (estimate from six studies with 1469 patients: – 0.44; 95% confidence interval –0.61, –0.26) and the proportion of patients with ≥1 omitted drugs (odds ratio from eight studies with 1833 patients: 0.29; 95% confidence interval 0.13, 0.63). The only significant influential factor for improving success was the utilization of explicit screening instruments when conducting a medication review (P = 0.033).

Conclusion

Pharmaceutical care interventions, including medication reviews, can significantly reduce medication underuse in older people. The use of explicit screening instruments alone or in combination with implicit reasoning is strongly recommendable for clinical practice.     

What probable factors underlie inadequacy of medication history information recorded in patients' case notes by physicians in a Nigerian teaching hospital?

Objective To identify probable factors underlying inadequacy of medication history information recorded in patients' case notes by physicians in an ambulatory tertiary care setting in Nigeria. Method A cross‐sectional survey was conducted, with a pre‐tested 25‐item questionnaire, of 93 physicians at the nine medical units in the Department of Medicine at University College Hospital, Ibadan, Nigeria. Key findings The overall response rate was 79.6% (74/93), and the usable rate was 75% (70/93). A majority of physicians opined that a detailed medication history is an essential component of optimal and patient‐specific care; and they were able to identify correctly the key components of a detailed medication history. However, about 60% of physicians opined that the adequacy of medication history documented by them is affected by heavy workload due to the large number of patients to which they attend. The majority (75%) of physicians also considered detailed documentation of patient medical history to be more important than medication history. Conclusions Physicians' heavy workload, due to the large number of patients, and their belief that medical history is more important than medication history, appear to be the probable factors underlining the inadequacy of physician‐acquired medication history in a developing sub‐Saharan tertiary care setting.     

供方视角药物重整发生率与诱发因素分析

目的： 调查药物重整供方相关医务人员药物重整发生率,分析可能诱发药物重整供方相关医务人员行为的因素。方法： 于2019年4月至2019年9月,在湖北省武汉市内选取18家不同类别医疗机构,采用横断面调查,通过线上分发调查问卷,向有关医务人员了解药物重整发生的基本情况,并使用二元Logistic回归模型分析药物重整行为发生的影响因素。结果： 研究最终纳入214例医务人员,药物重整发生率为73.83%;单因素分析结果显示,医务人员所在医疗机构类别（P=0.001）、执业资格（P=0.001）、是否了解药物重整（P=0.002）、是否通过同行交流了解药物重整（P=0.002）、是否主动关注患者全面用药情况（P=0.001）与其药物重整行为的发生具有相关性,且差异具有统计学意义（P<0.05）。Logistic回归结果显示,执业资格、是否了解药物重整、是否通过同行交流了解药物重整和是否主动关注患者全面用药情况是诱发药物重整供方行为的独立影响因素。结论： 虽然样本医务人员药物重整发生率较高,但他们对药物重整的认知程度不足。药物重整行为的发生是医务人员不同执业资格、是否了解药物重整、会否通过同行交流获取药物重整知识和会否主动关注患者全面用药情况多个因素影响的结果。     

精神卫生中心病区实施药物整合的作用

目的：探讨药物整合服务在防范精神科病人用药差错中的作用。方法：通过病区药房药师参与医嘱审核及药物整合的案例,分析药物整合在防范精神科病人用药失误或药物不良反应中的重要性。结果：药物整合能避免重复或遗漏药物,剂量或给药时间不当,配伍禁忌、药物联用不当、药物不良相互作用等后果。结论：实施药物整合,可提高病人药物治疗的安全性和有效性,但整合制度的推广还需要包括药师在内,政府、医疗机构、临床医师、护士、病患家属等多方面的努力。     

Prescribers prefer people: The sources of information used by doctors for prescribing suggest that the medium is more important than the message

AIMS: The sources of prescribing information are legion but there is little knowledge about which are actually used in practice by doctors when prescribing. The aims of this study were to determine the sources of prescribing information considered important by doctors, establish which were used in practice, and investigate if hospital and primary care physicians differed in their use of the sources. METHODS: Two hundred general practitioners (GPs) and 230 hospital doctors were asked to rate information sources in terms of their importance for prescribing 'old' and 'new' drugs, and then to name the source from which information about the last new drug prescribed was actually derived. RESULTS: Among 108 GPs, the Drugs and Therapeutics Bulletin and medical journal articles were most frequently rated as important for information on both old and new drugs while pharmaceutical representatives and hospital/consultant recommendations were more important for information on new drugs, as opposed to old. In practice, information on the last new drug prescribed was derived from pharmaceutical representatives in 42% of cases and hospital/consultant recommendations in 36%, with other sources used infrequently. Among 118 hospital doctors, the British National Formulary (BNF) and senior colleagues were of greatest theoretical importance. In practice, information on the last new drug prescribed was derived from a broad range of sources: colleagues, 29%; pharmaceutical representatives, 18%; hospital clinical meetings, 15%; journal articles, 13%; lectures, 10%. GPs and hospital doctors differed significantly in their use of pharmaceutical representatives (42% vs 18%) and colleagues (7% vs 29%) as sources of prescribing information (P < 0.0001 for both). CONCLUSIONS: The sources most frequently rated important in theory were not those most used in practice, especially among GPs. Both groups under-estimated the importance of pharmaceutical representatives. Most importantly, the sources of greatest practical importance were those involving the transfer of information through the medium of personal contact.