Medication reconciliation to solve discrepancies in discharge documents after discharge from the hospital

Background When patients are admitted to, and discharged from hospital there is a high chance of discrepancies and errors occurring during the transfer of patients’ medication information. This often causes drug related problems. Correct and fast communication of patients’ medication information between community pharmacy and hospital is necessary. Objective To investigate the number, type, and origin of discrepancies within discharge documents and between discharge documents and information in the pharmacy computer system, concerning the medication of patients living independently when they are discharged from hospital. Second, to test which variables have an impact on the number of discrepancies found and to study the time spent on the medication reconciliation process. Setting One quality-certified community pharmacy in the Netherlands. Methods Pharmacists reviewed discharge documents of patients discharged over one year. This information was compared to information available in the pharmacy computer system. Discrepancies were discussed with medical specialists and/or general practitioners. Type and origin of discrepancies were classified. Differences in variables between hospitals were tested using Independent-Samples Mann–Whitney U Test and Pearson Chi Square test. Poisson regression analysis was performed to test the impact of variables on the number of discrepancies found. Main outcome measure Number, type and origin of discrepancies for all independently living patients discharged from the hospital. Results During the study period, 100 discharges took place and were analyzed. No differences were found between the two main hospitals, a university hospital and a teaching hospital. In total, 223 discrepancies were documented. Sixty-nine discharges (69.0 %) required consultation with a patients’ medical specialist. A majority of the discrepancies (73.1 %) have their origin in hospital information. The number of discrepancies found increased with the number of medicines prescribed at discharge. The community pharmacist spent, on average, 45 min on the medication review after discharge. This included 11 min for counseling the patient. Conclusion Many discrepancies were found between different information sources at patient discharge from hospital. A majority of the discrepancies had their origin in hospital information. The number of medicines after discharge was related to the number of discrepancies found. The medication reconciliation process took an average of 45 minutes per patient.     

Communicating medication changes to community pharmacy post-discharge: the good, the bad, and the improvements

Background Communication between hospital and community pharmacists when a patient is discharged from hospital can improve the accuracy of medication reconciliation, thus preventing unintentional changes and ensuring continuity of supply. It allows problems to be resolved before a patient requires a further supply of medication post-discharge. Despite evidence demonstrating the benefits of sharing information, community pharmacists’ willingness to receive information and advances in information technology (particularly electronic discharge medication summaries), there is little published evidence to indicate whether communication has improved over the last 15 years. This study aimed to explore community pharmacists’ experience of information sharing by and with their local hospital and GP practices. Objectives (1) To establish the extent to which community pharmacies currently receive discharge medication information, and for which patients.(2)To determine community pharmacy staff opinion on where and how current communication practice could be improved. Setting Community Pharmacies in one Primary Care Organisation (PCO) in England. Method Semi-structured interviews conducted during visits to community pharmacies. Main outcome measure Reported receipt of discharge medication information from hospitals and general practices. Results A total of 14 community pharmacies participated. Current provision of information to community pharmacies from hospitals regarding medication changes at discharge was reported to be inconsistent and lacking in quality. Where information was received it was predominantly for patients who receive their medicines in monitored dosage systems (MDS) rather than for the general population of patients. Some examples of “notable practice” were reported. Conclusion Community pharmacists received post-discharge information rarely and mainly for patients where the hospital perceived the patient’s medication issues as “complex”. Practice was inconsistent overall. These findings suggest that the potential of community pharmacists to improve patient safety after discharge from hospital is not being utilised.     

Clinical and Financial Impact of Pharmacist Involvement in Discharge Medication Reconciliation at an Academic Medical Center: A Prospective Pilot Study

Background:

Medication reconciliation is one of the more challenging aspects of inpatient care, and its accuracy is paramount to safe transitions of care. Studies have shown that pharmacists have a role in medication reconciliation through improving patient safety and avoiding costs associated with medication errors. The wide-scale use of pharmacists in this process has been limited by time constraints, cost, and lack of resources.

Objective:

This study evaluates the impact of pharmacists in resolving medication errors, decreasing readmission rates, and reducing institutional costs during the discharge medication reconciliation process.

Methods:

Pharmacists evaluated discharge medication reconciliation documentation for patients to determine its accuracy, the accuracy of the admission reconciliation documentation, and any potential issues unrelated to accuracy. Analysis of these data determined the time required for pharmacist involvement, the number of errors identified by pharmacists, the quality of pharmacist interventions, the cost avoidance for each error, and the overall impact on hospital readmission.

Results:

During the 7-week study period, pharmacists performed 67 discharge medication reviews and identified 84 errors. Seventy-five percent were considered to be significant and 6% were considered to be serious. The 30-day readmission rate in the study cohort was 18% compared with 20% in the control group. Based on the clinical severity scale and pharmacist salaries, pharmacist interventions resulted in $42,300 in cost avoidance.

Conclusion:

Pharmacists involved in this pilot discharge process identified and resolved significant errors on medication reconciliation orders that resulted in a financial benefit to the institution.     

Assessing the impact of adding pharmacist management services to an existing discharge planning program on 30-day readmissions

BackgroundAlthough hospital readmission rates are declining nationally, avoidable readmissions remain a public health concern. Effective readmission interventions are multifaceted and include discharge planning and transition-of-care coordination. Clinical pharmacists are effective contributors to these processes, bringing expertise to discharge counseling, medication reconciliation, medication adherence, and postdischarge follow-up counseling.ObjectiveWe evaluated the impact of adding health plan clinical pharmacy management services to an existing discharge program on all-cause readmissions and postdischarge primary physician visits.MethodPharmacy management services by health plan clinical pharmacists of a large regional integrated delivery system were added to an existing optimal discharge planning (ODP) program. Criteria for eligibility for these pharmacists’ services included patients who prescribed a new maintenance medication after discharge, received a therapeutic substitution, had a previous discharge within 30 days, or were taking a high-risk medication. A retrospective, observational analysis of a subgroup of patients, who received the pharmacy management services as part of ODP, was performed using a difference-in-difference model, by comparing propensity-matched discharges from February 22, 2016, to January 31, 2017 (preprogram implementation) with discharges from February 22, 2017, to January 31, 2018 (implementation period), to estimate changes in 30-day readmission rates and postdischarge primary physician visits.ResultsA total of 111 of the propensity matched received the pharmacy management services; of these, 73% (ODP) versus 64% (non-ODP) were ≥58 years, 60% were females, and 62% (ODP) versus 52% (non-ODP) were Medicare beneficiaries. There was a 16.7% (P = 0.022) statistically significant reduction in combined inpatient and observation 30-day readmissions and a 19.7% increase in 5-day postdischarge follow-up physician visits (P = 0.037) for the subgroup who also received the pharmacy management services.ConclusionAddition of pharmacist management services to an existing hospital discharge program for select at-risk patients was associated with reduced inpatient and observation 30-day readmissions.     

Optimising patient safety using pharmaceutical intervention in domiciliary hospitalization

Introduction The domiciliary hospitalization unit (DHU) is an innovative model of care provision, where hospital care is transferred to the patients’ home. However, this shift adds a care transition layer to the process, which may increase the probability of medication errors to occur. Method A pharmacist has been integrated into the DHU team to improve medication use. We developed an observational study documenting his intervention for 6 months. Information about the patient’s drug therapy before admission, during hospitalization and after hospital discharge were gathered, enabling comparison of possible discrepancies that may happen during care transitions. The pharmacist evaluated the appropriateness, necessity, effectiveness, and safety of medication and intervened when deemed appropriate. Conclusions Data suggests that a pharmacist involved in the DHU may have a positive impact on medication use. Medication review and reconciliation are examples of pharmaceutical interventions that may lead to increased effectiveness and patient safety.     

Comparing the accuracy of medication order verification between pharmacists and a tech check tech model: A prospective randomised observational study

Background

Medication errors have the potential to cause significant harm and the final verification of dispensed medications is essential to patient safety. There is international evidence to demonstrate that trained pharmacy technicians can safely and accurately undertake the verification of medication orders in ward-based unit dose containers. There is a need for evaluation of pharmacy technician verification of medication orders in broader contexts including the hospital inpatient dispensary.

Medication reconciliation by a pharmacy technician in a mental health assessment unit

Background Medication discrepancies are common when patients cross organisational boundaries. However, little is known about the frequency of discrepancies within mental health and the efficacy of interventions to reduce discrepancies. Objective To evaluate the impact of a pharmacy-led reconciliation service on medication discrepancies on admissions to a secondary care mental health trust. Setting In-patient mental health services. Methods Prospective evaluation of pharmacy technician led medication reconciliation for admissions to a UK Mental Health NHS Trust. From March to June 2012 information on any unintentional discrepancies (dose, frequency and name of medication); patient demographics; and type and cause of the discrepancy was collected. The potential for harm was assessed based on two scenarios; the discrepancy was continued into primary care, and the discrepancy was corrected during admission. Logistic regression identified factors associated with discrepancies. Main outcome measure Mean number of discrepancies per admission corrected by the pharmacy technician. Results Unintentional medication discrepancies occurred in 212 of 377 admissions (56.2 %). Discrepancies involving 569 medicines (mean 1.5 medicines per admission) were corrected. The most common discrepancy was omission (n = 464). Severity was assessed for 114 discrepancies. If the discrepancy was corrected within 16 days the potential harm was minor in 71 (62.3 %) cases and moderate in 43 (37.7 %) cases whereas if the discrepancy was not corrected the potential harm was minor in 27 (23.7 %) cases and moderate in 87 (76.3 %) cases. Discrepancies were associated with both age and number of medications; the stronger association was age. Conclusions Medication discrepancies are common within mental health services with potentially significant consequences for patients. Trained pharmacy technicians are able to reduce the frequency of discrepancies, improving safety.     

Improving medication information transfer between hospitals,skilled-nursing facilities,and long-term-care pharmacies for hospital discharge transitions of care: A targeted needs assessment using the Intervention Mapping framework

Introduction

Patients transitioning from the hospital to a skilled nursing home (SNF) are susceptible to medication-related errors resulting from fragmented communication between facilities. Through continuous process improvement efforts at the hospital, a targeted needs assessment was performed to understand the extent of medication-related issues when patients transition from the hospital into a SNF, and the gaps between the hospital's discharge process, and the needs of the SNF and long-term care (LTC) pharmacy. We report on the development of a logic model that will be used to explore methods for minimizing patient care medication delays and errors while further improving handoff communication to SNF and LTC pharmacy staff.

Evaluation of pharmacy intern-led transition of care service at an academic hospital in Saudi Arabia: A prospective pilot study

ObjectivesThe transition of patients from one setting to another increases the risk of medication errors (MEs). This study aims to assess the implementation of pharmacy intern-led transition of care (TOC) service and to demonstrate its impact on the quality of patient care.MethodA prospective interventional pilot study was carried out from August 2020 to April 2021 at an academic hospital in Saudi Arabia. The TOC team consisted of three pharmacy interns and one pharmacist-in-charge. Daily activities included medication reconciliation, discharge counseling, and follow-up call after 3 days of discharge. The identified discrepancies were categorized according to the National Coordinating Council for Medication Error Reporting Program.Key findingsA total of 182 patients were included in the analysis. During medication reconciliation, 102 discrepancies were detected, with an average of 0.7 discrepancy per patient. The most common discrepancy at admission and discharge was omission (41.7% and 70%, respectively). Category B was the most frequent and accounted for 46% at admission and 93% at discharge. Around 39% of TOC beneficiaries received a follow-up call, and all reported a high level of satisfaction with the service.ConclusionInvolving the pharmacy team in TOC activities was effective in identifying discrepancies and resolving MEs.     

Medication Reconciliation in Pediatric Cardiology Performed by a Pharmacy Technician: A Prospective Cohort Comparison Study

Background:Medication reconciliation reduces potential medication discrepancies and adverse drug events. The role of pharmacy technicians in obtaining best possible medication histories (BPMHs) and performing reconciliation at the admission and transfer interfaces of care for pediatric patients has not been described.Objectives:To compare the completeness and accuracy of BPMHs and reconciliation conducted by a pharmacy technician (pilot study) and by nurses and/or pharmacists (baseline). The severity of identified unintentional discrepancies was rated to determine their clinical importance.Methods:This prospective cohort comparison study involved patients up to 18 years of age admitted to and/or transferred between the Cardiology ward and the Cardiac Critical Care Unit of a pediatric tertiary care teaching hospital. A pharmacy resident conducted two 3-week audits: the first to assess the completeness and accuracy of BPMHs and reconciliation performed by nurses and/or pharmacists and the second to assess the completeness and accuracy of BPMHs and reconciliation performed by a pharmacy technician.Results:The total number of patients was 38 in the baseline phase and 46 in the pilot period. There were no statistically significant differences between the baseline and pilot audits in terms of completion of BPMH (82% [28/34] versus 78% [21/27], p = 0.75) or completion of reconciliation (70% [23/33] versus 75% [15/20], p = 0.76) within 24 h of admission. Completeness of transfer reconciliation was significantly higher during the pilot study than at baseline (91% [31/34] versus 61% [11/18], p = 0.022). No significant differences between the baseline and pilot audits were found in the proportions of patients with at least one BPMH discrepancy (38% [13/34] versus 22% [6/27], p = 0.27), at least one unintentional discrepancy upon admission (21% [7/33] versus 10% [2/20], p = 0.46), or at least one unintentional discrepancy at the transfer interface (6% [1/18] versus 3% [1/34], p = 0.58). None of the 16 unintentional discrepancies were rated as causing severe patient discomfort or clinical deterioration.Conclusions:A trained pharmacy technician can perform admission and transfer medication reconciliation for pediatric patients with completeness and accuracy comparable to those of nurses and pharmacists. Future studies should explore the sustainability and cost-effectiveness of this practice model.     

Post discharge medicines use review service for older patients: recruitment issues in a feasibility study

Background The community pharmacy medicines use review (MUR) service in England has been identified as a way of providing support with medication to recently discharged patients; however initial uptake of post-discharge MUR has been low. Objective To identify barriers to recruitment into a randomised controlled feasibility study of a hospital referral system to older patients’ regular community pharmacists. Method Ward pharmacists at Southport District General Hospital identified patients aged over 65 to be approached by a researcher to assess eligibility and discuss involvement in the trial. Participants were randomised to referral for a post discharge MUR with their regular community pharmacist, or to standard discharge care. Reasons for patients not participating were collected. Results Over a 9-month period 337 potential participants were identified by ward pharmacists. Of these, 132 were eligible and 60 were recruited. Barriers to recruitment included competing priorities among ward pharmacists, and national restrictions placed on MURs e.g. housebound patients and those requiring carer support with medication. Lack of expected benefit resulted in a high proportion of patient refusals. Conclusion The current provisions for post discharge MURs exclude many older people from participation, including those possibly in greatest need. Unfamiliarity with the role of the pharmacist in transitional care may have affected patients’ perceived ‘cost-benefit’ of taking part in this study.