A Quantitative Evaluation of Medication Histories and Reconciliation by Discipline

Background/Objective:

Medication reconciliation at transitions of care decreases medication errors, hospitalizations, and adverse drug events. We compared inpatient medication histories and reconciliation across disciplines and evaluated the nature of discrepancies.

Methods:

We conducted a prospective cohort study of patients admitted from the emergency department at our 760-bed hospital. Eligible patients had their medication histories conducted and reconciled in order by the admitting nurse (RN), certified pharmacy technician (CPhT), and pharmacist (RPh). Discharge medication reconciliation was not altered. Admission and discharge discrepancies were categorized by discipline, error type, and drug class and were assigned a criticality index score. A discrepancy rating system systematically measured discrepancies.

Results:

Of 175 consented patients, 153 were evaluated. Total admission and discharge discrepancies were 1,461 and 369, respectively. The average number of medications per participant at admission was 8.59 (1,314) with 9.41 (1,374) at discharge. Most discrepancies were committed by RNs: 53.2% (777) at admission and 56.1% (207) at discharge. The majority were omitted or incorrect. RNs had significantly higher admission discrepancy rates per medication (0.59) compared with CPhTs (0.36) and RPhs (0.16) (P < .001). RPhs corrected significantly more discrepancies per participant than RNs (6.39 vs 0.48; P < .001); average criticality index reduction was 79.0%. Estimated prevented adverse drug events (pADEs) cost savings were $589,744.

Conclusions:

RPhs committed the fewest discrepancies compared with RNs and CPhTs, resulting in more accurate medication histories and reconciliation. RPh involvement also prevented the greatest number of medication errors, contributing to considerable pADE-related cost savings.Key Words: admission, evaluation study, discharge, medication reconciliationObtaining medication histories and conducting medication reconciliation are challeng ing tasks with the advent of new molecular entities and orphan drugs.¹ As Franklin reported, “Patients who once came into the [physician] office carrying their medications in a purse, or pocket, now need a shopping bag.”² The importance of accurate medication histories cannot be overemphasized; nearly 27% of all hospital prescribing errors originate from incorrect admission medication histories, over 70% of drug-related problems are only discovered through patient interview, and more than 50% of discharge discrepancies are associated with admission discrepancies.^3–6In 2010, an Institute of Medicine report estimated that if hospitals prevented adverse drug events (pADEs) and redundant tests, the associated cost savings would be nearly $25 billion annually.⁷ One organization decreased inpatient care costs by 30% when no medication reconciliation errors were reported over 24 months. ⁷Multiple organizations have supported medication reconciliation to improve quality of care, reduce preventable hospital admissions and readmissions, and decrease the incidence of adverse health care- associated conditions.^8–11 Although The Joint Commission does not indicate the discipline to perform this role, evidence supports the role of registered pharmacists (RPhs), pharmacy students, and pharmacy technicians in collecting accurate medication histories. RPhs should be involved when high-risk medications are identified, more than 5 medications are reported, or patients are elderly.^6,8,11–40 Therefore, our primary study objective was to compare inpatient medication histories and reconciliation processes across disciplines and to evaluate the nature of discrepancies using a novel method.     

Prophylactic high-dose N(omega)-monomethyl-L-arginine prevents the late cardiac dysfunction associated with lethal tumor necrosis factor-alpha challenge in dogs

We investigated nitric oxide (NO) as a possible cause of the cardiac dysfunction associated with high, lethal doses of tumor necrosis factor-alpha (TNF-alpha) in dogs. Eighty-seven awake, 2-year-old (10-12 kg), purpose-bred beagles were randomized to receive an infusion of saline or N-monomethyl-L-arginine (L-NMMA), a nonselective NO synthase (NOS) inhibitor, as a 40 mg kg bolus followed by a 40 mg kg(-1) h(-1) infusion for 3 to 6 h 3 h before (prophylactic) or 3 h after (therapeutic) challenge with TNF-alpha (60 microg kg(-1)) or vehicle. Serial radionuclide-heart scans and thermodilution pulmonary artery catheter hemodynamic measurements were performed. The effects of prophylactic L-NMMA on TNF-alpha-induced cardiac dysfunction as measured by decreases in mean left ventricular (LV) ejection fraction and downward and rightward shifts of LV function plots (peak systolic pressure versus end systolic volume index and LV stroke work index versus end diastolic volume index) were significantly different comparing early (3-6 h) and delayed (24 h) time points (P = 0.02). Prophylactic L-NMMA therapy did not appear to fully prevent early (3-6 h) TNF-alpha-induced cardiac dysfunction, but at 24 h, complete protection was seen. Therapeutic L-NMMA did not appear to fully protect the heart from TNF-alpha-induced early or delayed cardiac dysfunction (P = NS). Similarly, L-NMMA given prophylactically, but not therapeutically, blocked TNF-alpha-induced increases in exhaled NO flow rates and plasma nitrite and nitrate concentrations (both P = 0.02). These data suggest that TNF-alpha initiates two phases of cardiac injury: an early (3-6 h) phase that may be partially NO independent and a delayed (24 h) phase that is NO dependent. The delayed, more persistent dysfunction can be completely blocked by high doses of a nonselective NOS inhibitor administered before TNF-alpha.     

Ethics: the agonizing decisions in mental retardation

Many decisions which were once outside our control are now becoming matters of choice. Amniocentesis can detect severe birth defects and severely defective or crippled persons can be kept alive for long periods of time. Most people believe in adequate medical care and education for those born with physical and/or mental handicaps; the problems arise when the attempt to attain 1 valued goal conflicts with attaining others. There are insufficient resources to attain all goals. Physicians and nurses traditionally value individual human life while ignoring the family and broader society. The question raised now concerns the allocation of resources to individuals with terminal illness or life of limited quality vs. spending on public health measures that might preserve more lives. What part should societal coercion or societal persuasion play in handling cases of pregnancy at high risk of a deformed or retarded fetus, or extraordinary care of a severely deformed child? It is imperative for nurses to take an informed stand on such ethical issues. Many of the decisions to be made have greater bearing on the lives of women, those who will have to undergo the amniocentesis or abortion or raise the retarded child.