Effect of Admission Medication Reconciliation on Adverse Drug Events From Admission Medication Changes

ObjectivesTo identify root causes of preventable adverse drug events (pADEs) contributing to hospital admission; to develop key messages which identify actions patients/families and healthcare providers can take to prevent common pADEs found; to develop a surveillance learning system for the community.MethodsCross-sectional observational study; 120 patients and families, 61 associated healthcare providers were interviewed then root cause analysis was performed to develop key learning messages and an electronic reporting tool was designed. Most common pADE-related medical conditions and their root causes and most common pADE root causes of entire cohort are reported.ResultsMost common pADE-related medical conditions: chronic obstructive pulmonary disease/asthma (13.3%), bleeding (12.5%), hypotension (12%), heart failure (10%), acute kidney injury (5%) and pneumonia (5%). Most common root causes were: providers not confirming that the patient/family understands information given (29.2%), can identify how a medication helps them/have their concerns addressed (16.7%), can identify if a medication is working (14.1%) or causing a side effect (23.3%); can enact medication changes (7.5%); absence of a sick day management plan (12.5%), and other action plans to help patients respond to changes in their clinical status (10.8%); providers not assessing medication use and monitoring competency (19.2%). Ten key learning messages were developed and a pADE surveillance learning system was implemented.ConclusionsTo prevent pADEs, providers need to confirm that patients/families understand information given, how a medication helps them, how to recognise and respond to side effects, how to enact medication changes and follow action plans; providers should assess patient’s/families’ medication use and monitoring competency.

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A Critical Analysis of the Specific Pharmacist Interventions and Risk Assessments During the 12-Month TRANSAFE Rx Randomized Controlled Trial

Annals of Pharmacotherapy ◽

10.1177/10600280211044792 ◽

2021 ◽

pp. 106002802110447

Author(s):

Haley M. Gonzales ◽

James N. Fleming ◽

Mulugeta Gebregziabher ◽

Maria Aurora Posadas Salas ◽

John W. McGillicuddy ◽

...

Keyword(s):

High Risk ◽

Medication Reconciliation ◽

Controlled Trial ◽

Therapy Monitoring ◽

Pharmacist Intervention ◽

Risk Levels ◽

Medication Therapy ◽

Risk Patients ◽

The Impact ◽

Medication Changes

Background Medication safety issues have detrimental implications on long-term outcomes in the high-risk kidney transplant (KTX) population. Medication errors, adverse drug events, and medication nonadherence are important and modifiable mechanisms of graft loss. Objective To describe the frequency and types of interventions made during a pharmacist-led, mobile health–based intervention in KTX recipients and the impact on patient risk levels. Methods This was a secondary analysis of data collected during a 12-month, parallel-arm, 1:1 randomized clinical controlled trial including 136 KTX recipients. Participants were randomized to receive either usual care or supplemental, pharmacist-driven medication therapy monitoring and management using a smartphone-enabled app integrated with telemonitoring of blood pressure and glucose (when applicable) and risk-based televisits. The primary outcome was pharmacist intervention type. Secondary outcomes included frequency of interventions and changes in risk levels. Results A total of 68 patients were randomized to the intervention and included in this analysis. The mean age at baseline was 50.2 years; 51.5% of participants were male, and 58.8% were black. Primary pharmacist intervention types were medication reconciliation and patient education, followed by medication changes. Medication reconciliation remained high throughout the study period, whereas education and medication changes trended downward. From baseline to month 12, we observed an approximately 15% decrease in high-risk patients and a corresponding 15% increase in medium- or low-risk patients. Conclusion and Relevance A pharmacist-led mHealth intervention may enhance opportunities for pharmacological and nonpharmacological interventions and mitigate risk levels in KTX recipients.

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Engaging hospital patients in the medication reconciliation process using tablet computers

Journal of the American Medical Informatics Association ◽

10.1093/jamia/ocy115 ◽

2018 ◽

Vol 25 (11) ◽

pp. 1460-1469 ◽

Cited By ~ 5

Author(s):

Jennifer E Prey ◽

Fernanda Polubriaginof ◽

Lisa V Grossman ◽

Ruth Masterson Creber ◽

Demetra Tsapepas ◽

...

Keyword(s):

Medication Review ◽

Medication Safety ◽

Medication Reconciliation ◽

Adverse Drug Events ◽

Medication List ◽

Medication Discrepancies ◽

Home Medication ◽

Verbal Participation ◽

Hospital Patients ◽

Home Medication Review

Abstract Objective Unintentional medication discrepancies contribute to preventable adverse drug events in patients. Patient engagement in medication safety beyond verbal participation in medication reconciliation is limited. We conducted a pilot study to determine whether patients’ use of an electronic home medication review tool could improve medication safety during hospitalization. Materials and Methods Patients were randomized to use a toolbefore orafter hospital admission medication reconciliation to review and modify their home medication list. We assessed the quantity, potential severity, and potential harm of patients’ and clinicians’ medication changes. We also surveyed clinicians to assess the tool’s usefulness. Results Of 76 patients approached, 65 (86%) participated. Forty-eight (74%) made changes to their home medication list [before: 29 (81%),after: 19 (66%),p = .170].Before group participants identified 57 changes that clinicians subsequently missed on admission medication reconciliation. Thirty-nine (74%) had a significant or greater potential severity, and 19 (36%) had a greater than 50-50 chance of harm.After group patients identified 68 additional changes to their reconciled medication lists. Fifty-one (75%) had a significant or greater potential severity, and 33 (49%) had a greater than 50-50 chance of harm. Clinicians reported believing that the tool would save time, and patients would supply useful information. Discussion The results demonstrate a high willingness of patients to engage in medication reconciliation, and show that patients were able to identify important medication discrepancies and often changes that clinicians missed. Conclusion Engaging patients in admission medication reconciliation using an electronic home medication review tool may improve medication safety during hospitalization.

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Ambulatory Medication Reconciliation in Dialysis Patients: Benefits and Community Practitioners’ Perspectives

The Canadian Journal of Hospital Pharmacy ◽

10.4212/cjhp.v70i6.1719 ◽

2017 ◽

Vol 70 (6) ◽

Author(s):

Jo-Anne S Wilson ◽

Matthew A Ladda ◽

Jaclyn Tran ◽

Marsha Wood ◽

Penelope Poyah ◽

...

Keyword(s):

Medication Reconciliation ◽

Adverse Drug Events ◽

Quality Care ◽

Community Pharmacists ◽

Family Physicians ◽

Dialysis Patients ◽

Medication Discrepancies ◽

Personnel Infirmier ◽

Étude De Cohorte ◽

Potential Level

ABSTRACTBackground: Ambulatory medication reconciliation can reduce the frequency of medication discrepancies and may also reduce adverse drug events. Patients receiving dialysis are at high risk for medication discrepancies because they typically have multiple comorbid conditions, are taking many medications, and are receiving care from many practitioners. Little is known about the potential benefits of ambulatory medication reconciliation for these patients.Objectives: To determine the number, type, and potential level of harm associated with medication discrepancies identified through ambulatory medication reconciliation and to ascertain the views of community pharmacists and family physicians about this service.Methods: This retrospective cohort study involved patients initiating hemodialysis who received ambulatory medication reconciliation in a hospital renal program over the period July 2014 to July 2016. Discrepanciesidentified on the medication reconciliation forms for study patients were extracted and categorized by discrepancy type and potential level of harm. The level of harm was determined independently by a pharmacist and a nurse practitioner using a defined scoring system. In the event of disagreement, a nephrologist determined the final score. Surveys were sent to 52 community pharmacists and 44 family physicians involved in the care of study patients to collect their opinions and perspectives on ambulatory medication reconciliation.Results: Ambulatory medication reconciliation was conducted 296 times for a total of 147 hemodialysis patients. The mean number of discrepancies identified per patient was 1.31 (standard deviation 2.00). Overall, 30% of these discrepancies were deemed to have the potential to cause moderate to severe patient discomfort or clinical deterioration. Survey results indicated that community practitioners found ambulatory medication reconciliation valuable for providing quality care to dialysis patients.Conclusions: This study has provided evidence that ambulatory medication reconciliation can increase patient safety and potentially prevent adverse events associated with medication discrepancies.RÉSUMÉContexte : Le bilan comparatif des médicaments en soins ambulatoires peut réduire les divergences au chapitre des médicaments et les événements indésirables liés aux médicaments. Les divergences relatives aux médicaments représentent un risque élevé pour les patients dialysés, car ils souffrent normalement de multiples troubles comorbides, ils prennent souvent de nombreux médicaments et ils sont soignés par bon nombre de praticiens. Peu d’information existe sur les possibles avantages du bilan comparatif des médicaments en soins ambulatoires pour ces patients.Objectifs : Déterminer le nombre et la catégorie des divergences concernant les médicaments constatées lors d’un bilan comparatif des médicaments en soins ambulatoires ainsi que la gravité potentielle des préjudices consécutifs. De plus, établir la position des pharmaciens communautaires et des médecins de famille sur cette modalité du bilan comparatif des médicaments.Méthodes : La présente étude de cohorte rétrospective a été menée auprès de patients amorçant un traitement par hémodialyse pour qui un bilan comparatif des médicaments en soins ambulatoires a été réalisé dans le cadre d’un programme hospitalier des maladies du rein, entre juillet 2014 et juillet 2016. Les divergences trouvées dans les formulaires de bilan comparatif des médicaments ont été classées par catégorie et selon la gravité potentielle des préjudices. Le niveau du préjudice a été déterminé de manière indépendante par un pharmacien et un membre du personnel infirmier praticien à l’aide d’un système de notation défini. En cas de désaccord, le score final était établi par un néphrologue. Des sondages ont été envoyés à 52 pharmaciens communautaires et à 44 médecins de famille prodiguant des soins aux participants afin qu’ils expriment leurs opinions et leurs points de vue sur le bilan comparatif des médicaments en soins ambulatoires.Résultats : En tout, 296 bilans comparatifs des médicaments en soins ambulatoires ont été effectués auprès de 147 patients hémodialysés. Le nombre moyen de divergences constatées par patient était de 1,31 (écart-type de 2,00). Dans l’ensemble, 30 % de ces divergences ont été considérées comme une source potentielle d’un inconfort allant de modéré à grave ou de dégradation clinique. Selon les résultats du sondage, les praticiens communautaires ont jugé le bilan comparatif des médicaments en soins ambulatoires utile à la prestation de soins de qualité aux patients dialysés.Conclusions : D’après les résultats de l’étude, le bilan comparatif des médicaments en soins ambulatoires augmenterait la sécurité des patients et pourrait prévenir les événements indésirables liés aux divergences relatives aux médicaments.

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Evaluation of Adverse Drug Events and Medication Discrepancies in Transitions of Care Between Hospital Discharge and Primary Care Follow-Up

Journal of Pharmacy Practice ◽

10.1177/0897190014549836 ◽

2014 ◽

Vol 29 (2) ◽

pp. 132-137 ◽

Cited By ~ 21

Author(s):

Becky L. Armor ◽

Avery J. Wight ◽

Sandra M. Carter

Keyword(s):

Primary Care ◽

Hospital Discharge ◽

Medication Reconciliation ◽

Adverse Drug Events ◽

Medication Management ◽

Transitions Of Care ◽

Therapeutic Monitoring ◽

Medication List ◽

Medication Discrepancies

Approximately two-thirds of adverse events posthospital discharge are due to medication-related problems. Medication reconciliation is a strategy to reduce medication errors and improve patient safety. Objective: To evaluate adverse drug events (ADEs), potential ADEs (pADEs), and medication discrepancies occurring between hospital discharge and primary care follow-up in an academic family medicine clinic. Adult patients recently discharged from the hospital were seen by a pharmacist for medication reconciliation between September 1, 2011, and November 30, 2012. The pharmacist identified medication discrepancies and pADEs or ADEs from a best possible medication history obtained from the electronic medical record (EMR) and hospital medication list. In 43 study participants, an average of 2.9 ADEs or pADEs was identified ( N = 124). The most common ADEs/pADEs identified were nonadherence/underuse (18%), untreated medical problems (15%), and lack of therapeutic monitoring (13%). An average of 3.9 medication discrepancies per participant was identified (N = 171), with 81% of participants experiencing at least 1 discrepancy. The absence of a complete and accurate medication list at hospital discharge is a barrier to comprehensive medication management. Strategies to improve medication management during care transitions are needed in primary care.

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Pharmacist- Versus Physician-Initiated Admission Medication Reconciliation: Impact on Adverse Drug Events

The American Journal of Geriatric Pharmacotherapy ◽

10.1016/j.amjopharm.2012.06.001 ◽

2012 ◽

Vol 10 (4) ◽

pp. 242-250 ◽

Cited By ~ 31

Author(s):

Kari A. Mergenhagen ◽

Sharon S. Blum ◽

Anne Kugler ◽

Elayne E. Livote ◽

Jonathan R. Nebeker ◽

...

Keyword(s):

Medication Reconciliation ◽

Adverse Drug Events

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A FORMAL MEDICATION RECONCILIATION PROGRAMME IN A HAEMODIALYSIS UNIT CAN IDENTIFY MEDICATION DISCREPANCIES AND POTENTIALLY PREVENT ADVERSE DRUG EVENTS

Journal of Renal Care ◽

10.1111/jorc.12107 ◽

2015 ◽

Vol 41 (2) ◽

pp. 104-109 ◽

Cited By ~ 3

Author(s):

Winnie WY Chan ◽

Geetha Mahalingam ◽

Robert MA Richardson ◽

Olavo A Fernandes ◽

Marisa Battistella

Keyword(s):

Medication Reconciliation ◽

Adverse Drug Events ◽

Medication Discrepancies

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

Journal of General Internal Medicine ◽

10.1007/s11606-012-2168-4 ◽

2012 ◽

Vol 27 (11) ◽

pp. 1513-1520 ◽

Cited By ~ 53

Author(s):

Boback Ziaeian ◽

Katy L. B. Araujo ◽

Peter H. Van Ness ◽

Leora I. Horwitz

Keyword(s):

Hospital Discharge ◽

Medication Reconciliation ◽

Patient Understanding ◽

Medication Changes

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Impact of a Pharmacy-Driven Transitions of Care Medication Reconciliation Following Hospitalization

Journal of Pharmacy Technology ◽

10.1177/8755122519900507 ◽

2020 ◽

Vol 36 (2) ◽

pp. 68-71

Author(s):

Rebecca L. Stauffer ◽

Abigail Yancey

Keyword(s):

Medication Reconciliation ◽

Intervention Group ◽

Emergency Department Visits ◽

Transitions Of Care ◽

Control Group ◽

Medication Discrepancies ◽

Institutional Review ◽

The Impact ◽

Medication Changes

Background: Medication changes are common after hospitalizations, and medication reconciliations are one tool to help identify potential medication discrepancies. Objective: To determine the impact of a pharmacy-driven medication reconciliation service on number of medication discrepancies identified. Methods: This was a retrospective cohort, chart-review study conducted at an internal medicine outpatient clinic. Patients at least 18 years of age were eligible for inclusion if they presented for a hospital follow-up appointment within 14 days of discharge between September 1, 2015, and May 31, 2016, from a system hospital. The 2 cohorts were patients with a pharmacist-completed medication reconciliation note written in the electronic health record on the date of their hospital follow-up appointment and those without. The primary outcome was number of medication discrepancies identified during medication reconciliation. Secondary outcomes included types of discrepancies, 30-day hospital readmission, and 30-day emergency department visits. This study was approved by the facility institutional review board. Results: Seventy-nine patients were included, and 38 patients had a pharmacist-completed medication reconciliation (48%). A total of 64 medication discrepancies were identified in 26 patients; of these, 49 discrepancies were resolved during the appointment (77%). There was an average of 2.46 medication discrepancies (±2.34) per patient. The most common discrepancy was missing medications. Thirty-day readmission rate was 5.3% in the intervention group and 19.5% in the control group ( P = .054). Conclusions: A pharmacist-completed medication reconciliation identified many medication discrepancies that were then resolved. From this study, pharmacist-led medication reconciliations following hospital discharge appear valuable.

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Improving medication reconciliation in ambulatory cancer care.

Journal of Clinical Oncology ◽

10.1200/jco.2020.38.29_suppl.224 ◽

2020 ◽

Vol 38 (29_suppl) ◽

pp. 224-224

Author(s):

Carissa Milley-Daigle ◽

Celina Dara ◽

Genevieve Bouchard-Fortier ◽

Anet Julius ◽

Vishal Kukreti ◽

...

Keyword(s):

Medication Reconciliation ◽

Adverse Drug Events ◽

Medication Management ◽

Median Number ◽

Medication History ◽

Time Motion ◽

Motion Study ◽

Study Results ◽

Ambulatory Oncology ◽

Medication Documentation

224 Background: Adverse drug events are common in ambulatory oncology where care spans multiple providers and medication documentation is often poor. We undertook a QI project with the aim of having 30% of patients have a best possible medication history (BPMH) or medication reconciliation (MedRec) documented within 30 days of starting systemic therapy. Methods: An Electronic Medical record-Integrated Tool (EMITT) was developed to facilitate documentation. 2 Plan-Do-Study-Act (PDSA) cycles have been completed to date; PDSA 1 consisted of piloting EMITT in 3 clinics run by physician champions. PDSA 2 which consisted of expanding pharmacy support and addition of a 4th clinic was impacted by care changes related to COVID. The proportion of patients with BPMH/MedRec documented in EMITT was calculated monthly for each period (PDSA 1, PDSA 2 pre-COVID and PDSA 2 post-COVID). The balancing measure of time to complete an entry was evaluated through a time motion study. Results: Between 9/9/2019 and 31/5/2020, 9.4% (233/2488) of patients had BPMH/MedRec completed; Table shows proportion of patients by month. BPMH and MedRec were most frequently performed by pharmacists followed by pharmacy students and nurses. On average, it took 5.5 minutes to complete an entry (n = 10; median number of medications per patient = 12.3). Conclusions: BPMH was documented more often than MedRec. While some usage was sustained, the changes to care as a result of COVID-19 negatively impacted ambulatory medication reconciliation. Future PDSA cycles will involve engaging patients in MedRec and extending EMITT to all ambulatory cancer clinics where medication management is a major component of care. [Table: see text]

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