Medication prescribing errors in the prehospital setting and in the ED

Background

Medication errors are a common cause of iatrogenic adverse drug events. The incidence and nature of medication errors during prehospital treatment have not been fully described.

Objectives

The objectives of this study are to describe the incidence and characteristics of medication errors in adults during prehospital emergency treatment and in the emergency department (ED) and to identify risk factors for medication errors in those settings.

Methods

This is a retrospective study of adult patients transferred by emergency medical services to the ED of a university-affiliated hospital in Israel. The drugs administered in the mobile intensive care unit and in the ED were reviewed by 2 reviewers, who independently decided whether an error had occurred. The primary outcome was the number of drug errors per patient. Secondary outcomes were the type and severity of the errors and variables associated with increased incidence of drug errors.

Results

During the study period, 1837 patients were brought to the ED by mobile intensive care unit vehicles. Five hundred thirty-six patient charts (29%) were randomly selected for review; 65 charts (12.12%) could not be found; thus, 471 charts were reviewed. In the emergency vehicle, 188 patients (45.63%) received medications; of those, 12.76% (24 patients) were subject to a medication error. The number of drugs administered and long evacuation times were associated with higher risk for an error (P < .01 and P = .011, respectively). The presence of a physician in the emergency vehicle did not alter the risk of an error (P = .95). In the ED, 332 patients (72.6%) received medications. Of those, medication errors occurred in 120 patients (36.1%). The more medications administered, the higher the risk of error (P < .01). Less errors occurred in trauma patients (P = .041).

Conclusion

More medication errors occur in the ED than in the emergency vehicles. Patients treated with multiple medications are more prone to medication errors.     

Looking beyond polypharmacy: quantification of medication regimen complexity in the elderly

BackgroundPolypharmacy has been shown to influence outcomes in elderly patients. However, the impact of medication regimen complexity, quantified by the Medication Regimen Complexity Index (MRCI), on health outcomes after discharge of elderly patients has not been studied.ObjectiveOur aim was to test the convergent, discriminant, and predictive validity of the MRCI in older hospitalized patients with varying functional and cognitive levels.MethodsWe retrospectively applied the MRCI to the medication regimen of 212 hospitalized patients and assessed its validity.ResultsThe mean (SD) MRCI scores for medication regimens and number of medications at discharge were 30.27 (13.95) and 5.95 (2.40), respectively. The MRCI scores were strongly correlated with the number of medications (r = 0.94, P < 0.001) and the number of daily doses (r = 0.87, P < 0.001) and increased as the number of medications taken ≥3 times daily increased (27.35, 34.45, and 43.00 for none, 1, and 2 drugs, respectively; P < 0.001). Positive correlations were observed between the Cumulative Illness Rating Scale–Geriatrics score and both the number of medications and the MRCI score (r = 0.40, r = 0.46, P < 0.001, respectively). No relationship was found between MRCI scores and the number of medications and age, sex, and postdischarge medication modifications. Patients nonadherent to at least 1 drug were discharged with a higher MRCI score and higher number of medications compared with medication-compliant patients (33.3 and 7.0 vs 27 and 5.8, respectively; P < 0.01). An inverse correlation was found between overall adherence 1 month after discharge and the MRCI score (r = ?0.188, P = 0.028); however, no such correlation was found regarding the number of medications at discharge.ConclusionsThe MRCI showed satisfactory validity and good evidence of classifying regimen complexity over a simple medication count. The MRCI demonstrated application in clinical research and practice in the elderly. However, more studies are needed to investigate its advantage over the number of medications for identifying patients with complex medication regimens and directing interventions to simplify their medication regimen complexity.     

Adding medications in the emergency department: effect on knowledge of medications in older adults.

INTRODUCTION: Older adults constitute 20% of the ED population. Of older patients discharged from the emergency department, 40% receive at least one new medication to add to their already complex medication regimen. The purpose of this study was to determine the effect of increasing medication complexity on knowledge of newly prescribed medications for older adults discharged from the emergency department. METHODS: The complexity of self-administered medications after ED treatment was measured with the Medication Complexity Index to determine its potential influence on the patient's knowledge of medication. The Knowledge of Medication Subtest, a measure of the effectiveness of medication teaching, was administered by telephone interview 48 to 72 hours after ED discharge. RESULTS: Sixty rural ED patients ranging in age from 60 to 98 years completed the study. Higher medication complexity after the addition of medications in the emergency department was associated with less knowledge of their medications (r = 0.37, P =. 004). DISCUSSION: The increase in medication complexity that results from ED therapeutic intervention may decrease knowledge of medications. A heightened emphasis should be placed on effective medication teaching, counseling, and follow-up for older adult ED patients.     

Inpatient medication reconciliation at admission and discharge: A retrospective cohort study of age and other risk factors for medication discrepancies

Background: Medication discrepancies are unintended differences between medication regimens (ie, between a patient's home regimen and medications prescribed on admission to the hospital).Objective: The goal of this study was to describe the incidence, drug classes, and probable importance of hospital admission medication discrepancies and discharge regimen differences, and to determine whether factors such as age and specific hospital services were associated with greater frequency of medication discrepancies and differences.Methods: This was a retrospective cohort study of a random sample of adult patients admitted to the general medicine, cardiology, or general surgery services of a tertiary care academic teaching hospital between July 1, 2006, and August 31, 2006. A chart review was performed to collect the following information: patient demographic characteristics, comorbid conditions, number of preadmission medications, discrepant medications identified by the hospital's reconciliation process, reasons for the discrepancies, and discharge medications that differed from the home regimen. Potentially high-risk discrepancies and differences were identified by determining if the medications were included on either the Institute for Safe Medication Practices high-alert list or the North Carolina Narrow Therapeutic Index list. Univariate and multivariate logistic regression analyses were used to identify factors associated with medication discrepancies and differences.Results: Of the 205 patients (mean age, 59.9 years; 116 men, 89 women; 60% white) included in the study, 27 did not have any medications recorded on admission. Of the 178 patients who did have medications listed, 41 had ≥1 discrepancy identified by the reconciliation process on admission (23%; 95% CI, 17–29); 19% (95% CI, 11–31) of these medications were considered to be potentially high risk. In the multivariate logistic regression model, age (odds ratio [OR] per 5-year increase = 1.16; 95% CI, 1.01–1.33; P = 0.035), presence of high-risk medications on admission (OR = 76.68; 95% CI, 9.13–643.76; P < 0.001), and general surgery service (OR = 3.31; 95% CI, 1.40–7.87; P < 0.007) were associated with a higher proportion of patients with discrepancies on admission. At discharge, 196 patients (96% [95% CI, 93<98]) had ≥1 medication change from their home regimen, with 1102 total differences for 205 patients. Less than half (44% [95% CI, 37–51]) of these patients were explicitly alerted at discharge to new medications or dose changes; 12% (95% CI, 7–18) were given written instructions to stop taking discontinued home medications. Cardiovascular drugs were the most frequent class involved at both admission (31%) and discharge (27%) in medication discrepancies or differences.Conclusions: Medication discrepancies on admission and medication differences at discharge were prevalent for adult patients admitted to the general medicine, cardiology, and general surgery services in this academic teaching hospital. Medication reconciliation processes have a high potential to identify clinically important discrepancies for all patients.     

Appropriateness of Medication Selection for Older Persons in an Urban Academic Emergency Department

OBJECTIVES: To determine the frequency of potentially inappropriate medication selection for older persons presenting to the ED, the most common problematic drugs, risk factors for suboptimal medication selection, and whether use of these medications is associated with worse outcomes. METHODS: The authors performed a prospective cohort study of 898 patients 65 years or older who presented to an urban academic ED in 1995 and 1996. Seventy-nine percent of the patients were African-American and 43% did not graduate from high school. Potentially inappropriate medications and adverse drug-disease interactions were identified using the 1997 Beers explicit criteria for elders. During the three months after the initial visit, revisits to the ED or hospital, death, and changes in health-related quality of life were analyzed as measured by validated questions adapted from the Medical Outcomes Study. RESULTS: Upon presentation, 10.6% of the patients were taking a potentially inappropriate medication, 3.6% were given one in the ED, and 5.6% were prescribed one upon discharge from the ED. The most frequently prescribed potentially inappropriate medications in the ED were diphenhydramine, indomethacin, meperidine, and cyclobenzaprine. Emergency physicians added potentially inappropriate medications most often to patients with discharge diagnoses of musculoskeletal disorder, back pain, gout, and allergy or urticaria. Potentially adverse drug-disease interactions were relatively uncommon at presentation (5.2%), in the ED (0.6%), and on discharge from the ED (1.2%). Potentially inappropriate medications and adverse drug-disease interactions prescribed in the ED were not associated with higher rates of revisit to the ED, hospitalization, or death, but were correlated with worse physical function and pain. However, confidence intervals were wide for analyses of revisits and death. CONCLUSIONS: Suboptimal medication selection was fairly common and was associated with worse patient-reported health-related quality of life.     

Misdiagnosis of acute appendicitis: Common features discovered in cases after litigation

To identify differences between correctly diagnosed appendicitis and misdiagnosed cases that resulted in litigation between 1982 and 1989 retrospective review of malpractice claims was conducted. A total of emergency department (ED) charts at the time of the initial ED visit were reviewed and compared with 66 concurrent controls. Missed cases appeared less acutely ill, had fewer complaints of right lower quadrant pain, received fewer rectal examinations, received intramuscular (IM) narcotic pain medication for undiagnosed abdominal pain or symptoms, and more often received an ED discharge diagnosis of gastroenteritis. Misdiagnosed patients had a 91% incidence of ruptured appendix, more extensive surgical procedures, and more postoperative complications. Data were analyzed using the Pearson's χ² Test, Mann-Whitney U test, and stepwise discriminant analysis. Significance was defined as P ≤ .05. Misdiagnosis of acute appendicitis is more likely to occur with patients who present atypically, are not thoroughly examined (as indexed by documentation of a rectal examination), are given IM narcotic pain medication and then discharged from the ED, are diagnosed as having gastroenteritis (despite the absence of the typical diagnostic criteria), and with patients who do not receive appropriate discharge or follow-up instructions.     

Restraint Use in the Elderly Emergency Department Patient

Background

The elderly frequently suffer from altered mental status and other medical conditions requiring physical or chemical restraint for safety in the Emergency Department (ED).

Objective

This study examined outcomes of restrained elderly patients in the ED.

Methods

A 2-year retrospective study was conducted in an urban community teaching hospital ED. Included were patients ≥65 years of age who were physically restrained in the ED and hospitalized. Data collected included age, gender, restraint indications, restraint type, restraint duration, adverse outcomes, ED discharge diagnosis, ED disposition, hospital length of stay, and disposition.

Results

There were 83 patients in the study. Forty-seven (56.6%) were nursing home residents. Twenty-seven (32.5%) were admitted to the intensive care unit. Thirty-five (42.2%) received both chemical and physical restraint. The average number of patient medications on arrival to the ED was eight, and 3 patients were on a medication that could adversely interact with a chemical restraint medication. The mean inpatient length of stay was 7.2 days (SD 5.7 days). Ten patients expired, 14 were discharged home, and 59 were discharged to a nursing facility (8 with new behavioral medications). Of the 36 patients originally presenting to the ED from home, only 11 (30.6%) were discharged back to home. There were no significant differences in outcome between patients who received a combination of both chemical and physical restraints and patients who received physical restraint alone.

Conclusion

In this 2-year retrospective study, elderly patients placed in physical restraints in the ED had no recorded adverse outcomes. In addition, there were no adverse outcomes when they received both physical and chemical restraint. Elderly patients who were originally admitted from home and subsequently required physical restraint were unlikely to return home.     

The Incremental Burden of Acute Respiratory Distress Syndrome: Long-term Follow-up of a Population-Based Nested Case-Control Study

Objective

To evaluate the long-term survival of patients at similar risk for hospital-acquired acute respiratory distress syndrome (ARDS) who did and did not develop ARDS.

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.     

Evaluation of the effectiveness of peer pressure to change disposition decisions and patient throughput by emergency physician

ObjectivesThe aim of this study was to develop a strategy for imposing peer pressure on emergency physicians to discharge patients and to evaluate patient throughput before and after intervention.MethodsA before-and-after study was conducted in a medical center with more than 120 000 annual emergency department (ED) visits. All nontraumatic adult patients who presented to the ED between 7:30 and 11:30 am Wednesday to Sunday were reviewed. We created a “team norm” imposed peer-pressure effect by announcing the patient discharge rate of each emergency physician through monthly e-mail reminders. Emergency department length of stay (LOS) and 8-hour (the end of shift) and final disposition of patients before (June 1, 2011–September 30, 2011) and after (October 1, 2011–January 30, 2012) intervention were compared.ResultsPatients enrolled before and after intervention totaled 3305 and 2945. No differences existed for age, sex, or average number of patient visits per shift. The 8-hour discharge rate increased significantly for all patients (53.5% vs 48.2%, P < .001), particularly for triage level III patients (odds ratio, 1.3; 95% confidence interval, 1.09-1.38) after intervention and without corresponding differences in the final disposition (P = .165) or admission rate (33.7% vs 31.6%, P = .079). Patients with a final discharge disposition had a shorter LOS (median, 140.4 min vs 158.3 min; P < .001) after intervention.ConclusionsThe intervention strategy used peer pressure to enhance patient flow and throughput. More patients were discharged at the end of shifts, particularly triage level III patients. The ED LOS for patients whose final disposition was discharge decreased significantly.     

Use of Direct Oral Anticoagulants Versus Traditional Therapies for Acute Venous Thromboembolism After Direct Discharge From the Emergency Department or After Hospitalization: An Audit of 16 Canadian Hospitals

PurposeThis study compares and describes the use of direct oral anticoagulants (DOACs) versus traditional therapies (parenteral anticoagulant with or without warfarin) for acute venous thromboembolism (VTE) between individuals discharged directly from the emergency department (ED) versus those hospitalized. This study also reports patterns based on discharge from an academic, community, or rural-based site.MethodsThis retrospective medical records study included patients discharged with acute VTE (2015–2016) from 16 institutions across 4 provinces. Patients with atypical clots, other indications for anticoagulants, or an anticipated lifespan <3 months or those who were pregnant or breastfeeding were excluded.FindingsOverall, 590 individuals (30.0%) discharged from the ED and 809 (53.8%) discharged after hospitalization were studied. Hospitalized patients were significantly older, had more comorbidities (cancer, pulmonary disease, and heart failure), and were more likely to have pulmonary embolism than deep vein thrombosis. DOAC use was significantly higher in the ED cohort versus the hospitalized cohort (51.4% vs 44.3%; P < 0.004) and more common for those having lower risk of pulmonary embolisms (simplified Pulmonary Embolism Severity Index score of 0 compared with ≥1) in the ED (58.0% and 26.5%; P < 0.0001) and hospitalized cohorts (57.1% and 35.7%; P < 0.0001). Use of DOACs was lowest in academic settings (46.2%) and highest in rural sites (56.7%). Follow-up patterns were different, with specialists and VTE clinics being most common in academic sites and family physicians being most common in rural practices.ImplicationsDOACs were used in less than half of all patients, with more use in EDs and rural sites. Follow-up patterns (VTE clinic or specialist vs family physician) varied and likely contributed to therapy selection. Over time, use of DOACs is likely to increase, and patient factors (eg, those younger with fewer comorbidities) and health care contact (eg, place of discharge or availability of an ambulatory VTE clinic) will likely continue to influence practice patterns.     

Mortality of the users of a hospital emergency department

Objective

To ascertain the annual number of users who were discharged home after visits to the emergency department (ED), grouped by age, sex, and number of visits during the calendar year, and to assess whether a higher number of visits to the department predicted a higher mortality.

Methods

This was a retrospective cohort study, with follow up of cause specific mortality through a national registry, in the Reykjavik area of Iceland. In total, 19 259 patients who visited the ED during the period 1995–2001 and who were discharged home at the Landspítali University Hospital, Reykjavik, Iceland, were enrolled. The main outcome measures were the standardised mortality ratio, with expected number based on national mortality rates, and hazard ratio calculations using time dependent multivariate regression analysis.

Results

The annual increase in visits to the ED among the patients discharged home was 7–14% per age group during the period 1995–2001, with the highest increase among older men. When emergency department users were compared with the general population, the standardised mortality ratio was 1.81 for men and 1.93 for women. Among those attending the ED two, three, or more times in a calendar year, the mortality rate was higher than among those coming only once in a year. The causes of death that led to the highest mortality among frequent users of the ED were neoplasm, ischaemic heart diseases, and external causes, particularly drug intoxication, suicides, and probable suicides.

Conclusions

The mortality of those who had used the ED and been discharged home was found to be higher than that of the general population. Frequent users of the ED had a higher mortality than those visiting the department no more than once a year. As the ED serves general medicine and surgery patients, not injuries, the high mortality due to drug intoxication, suicide, and probable suicide is interesting. Further studies are needed into the diagnosis at discharge of those frequently using the ED, in an attempt to understand and possibly prevent this marked mortality rate.