Medication Errors Avoided by Medication Reconciliation Process at Female Surgery Ward in Ramathibodi Hospital, Thailand

Background: Pharmacists have an important role in implementing drug reconciliation. The implementation of drug reconciliation allows the process of identifying drug administration errors due to information gaps, which we can avoid by optimizing information as early as possible at every shift in the process of providing health services through the reconciliation process. This process is crucial, especially for groups of patients with chronic diseases who have a high risk of changing health care delivery settings. Failure to identify results in errors in administering drugs that lead to worsening clinical conditions, resulting in increased service needs and health costs. Objective: Provides information about the tendency of pharmacists who work at the UPTD Bali Mandara General Hospital to reduce drug use errors through the drug reconciliation program. Methods: Thematic analysis of structured interview results. Results: Almost all participants (6 out of 8 pharmacists) tend to be willing to be involved in the drug reconciliation process. There are three main themes of consideration that underlie the tendency of pharmacists to be willing to be involved in the drug reconciliation process, namely, related to understanding the definition, purpose, and consistency of the implementation of reconciliation. In controlling the incidence of medication errors, the biggest preventable errors through medication reconciliation are drug duplication and drug discrepancy. Conclusion: The tendency for pharmacists to be involved is good, and the tendency to control the risk of medication errors is still lacking in terms of communication and consistency in filling out by all officers. Keywords: Pharmacist’s role, drug reconciliation, risk of medication errors

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Medication Discrepancies Involving Hospitalized Children At A High-Complexity Public Hospital

10.21203/rs.2.17865/v1 ◽

2019 ◽

Author(s):

Divaldo Pereira de Lyra ◽

Thaciana dos Santos Alcântara ◽

Fernando Castro de Araújo Neto ◽

Helena Ferreira Lima ◽

Dyego Carlos S. Anacleto de Araújo ◽

...

Keyword(s):

Medication Errors ◽

Medication Reconciliation ◽

Public Hospital ◽

Hospital Readmissions ◽

High Complexity ◽

Dose Frequency ◽

Cross Sectional ◽

Medication Discrepancies ◽

Internal Transfer ◽

Reconciliation Process

Abstract Background: Children are more susceptible to medication errors and adverse reactions. In addition, variation in body mass and medication discrepancies are the major causes of medication errors, which pose a risk of harm to children. When unresolved, these issues can lead to longer hospital stays, increased hospital readmissions, and emergency room care that burden the healthcare system. Many organizations have struggled to implement medication reconciliation. In this context, studies demonstrated that reliability and improvement science methods can be used to implement a successful and sustained medication reconciliation process. One of the initial steps involved in medication reconciliation process is determining the sector for implementation. Therefore, the aim of this study was to determine the prevalence of medication discrepancies occurring throughout the course of a hospital stay and describe the types of discrepancies and medications most commonly involved in pediatric cases. Methods: A cross-sectional study was carried out from July 2017 to March 2018 in the pediatric department of a high-complexity public hospital in Brazil. Data collection consisted of: collection of sociodemographic data, clinical interview with the patient's caregiver, registration of patient prescriptions, and evaluation of medical records. Discrepancies were classified as intentional or unintentional and included omission of medication, therapeutic duplicity, different dose, frequency, route of administration than prescribed. Study approved by the Research Ethics Committee (CAAE: 36927014.4.0000.5546). Results: During care transitions, 114 children were followed. Patients presented unintentional discrepancies, of which 16 (14.0%) presented discrepancies at hospital admission, 42 (36.8%) during ward transfer, and 52 (45.6%) during discharge. Omission represented 74% (n=20) ofthe errors at admission, 38% (n=26) at ward transfer, and 100% (n=80) at discharge. The most frequent discrepancies in the three transitions were related to antimicrobials, representing 43.3% of discrepancies at admission, 38.8% at internal transfer, and 61.2% during discharge. Conclusion: The results demonstrated that the main transition levels when unintentional discrepancies occurred in children in this hospital were during internal transfer and discharge and indicated difficulties in interprofessional communication and poor documentation. Evaluation of all transition points is essential for determining the most critical point in the quality of care provided at hospitals.

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Impact of pharmacist driven medication reconciliation in psychiatric emergency services on length of stay, medication errors, and medication discrepancies

Drugs & Therapy Perspectives ◽

10.1007/s40267-021-00824-3 ◽

2021 ◽

Vol 37 (4) ◽

pp. 175-180

Author(s):

Megan O’Connell ◽

Amy VandenBerg

Keyword(s):

Length Of Stay ◽

Medication Errors ◽

Medication Reconciliation ◽

Emergency Services ◽

Psychiatric Emergency ◽

Psychiatric Emergency Services ◽

Medication Discrepancies

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Impact of a Clinical Pharmacy Admission Medication Reconciliation Program on Medication Errors in “High-Risk” Patients

Annals of Pharmacotherapy ◽

10.1177/1060028013507428 ◽

2013 ◽

Vol 47 (12) ◽

pp. 1599-1610 ◽

Cited By ~ 44

Author(s):

Mitchell S. Buckley ◽

Lisa M. Harinstein ◽

Kimberly B. Clark ◽

Pamela L. Smithburger ◽

Doug J. Eckhardt ◽

...

Keyword(s):

High Risk ◽

Medication Errors ◽

Clinical Pharmacy ◽

Medication Reconciliation ◽

High Risk Patients ◽

Risk Patients

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Transitions in Care: Medication Reconciliation in the Community Pharmacy Setting After Discharge

INNOVATIONS in pharmacy ◽

10.24926/iip.v4i2.299 ◽

2013 ◽

Vol 4 (2) ◽

Cited By ~ 6

Author(s):

Jeff E. Freund ◽

Beth A. Martin ◽

Mara A. Kieser ◽

Staci M. Williams ◽

Susan L. Sutter

Keyword(s):

Community Pharmacy ◽

Medication Reconciliation ◽

Comfort Level ◽

Original Research ◽

Patient Counseling ◽

Term Care ◽

Medication Discrepancies ◽

Transitions In Care ◽

Pharmacy Setting ◽

Reconciliation Process

Objective: To assess the feasibility of a workflow process in which pharmacists in an independent community pharmacy group conduct medication reconciliation for patients undergoing transitions in care. Methods: Three workflow changes were made to improve the medication reconciliation process in a group of three independent community pharmacies. Analysis of the process included workflow steps performed by pharmacy staff, pharmacist barriers encountered during the medication reconciliation process, number of medication discrepancies identified, and pharmacist comfort level while performing each medication reconciliation service. Key Findings: Sixty patient medication reconciliation services met the inclusion criteria for the study. Pharmacists were involved in all steps associated with the medication reconciliation workflow, and were the sole performer in four of the steps: verifying discharge medications with the pharmacy medication profile, resolving discrepancies, contacting the prescriber, and providing patient counseling. Pharmacists were least involved in entering medications into the pharmacy management system, performing that workflow step 13% of the time. The most common barriers were the absence of a discharge medication list (24%) and patient notpresent during consultation (11%). A total of 231 medication discrepancies were identified, with an average of 3.85 medication discrepancies per discharge. Pharmacists' comfort level performing medication reconciliation improved through the 13 weeks of the study. Conclusions: These findings suggest that medication reconciliation for patients discharged from hospitals and long term care facilities can be successfully performed in an independent community pharmacy setting. Because many medication discrepancies were identified during this transition of care, it is highly valuable for community pharmacists to perform medication reconciliation services. Type: Original Research

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The Prevalence and Nature of Medication Errors and Adverse Events Related to Preadmission Medications When Patients Are Admitted to an Orthopedic Inpatient Unit: An Observational Study

Annals of Pharmacotherapy ◽

10.1177/1060028018802472 ◽

2018 ◽

Vol 53 (3) ◽

pp. 252-260 ◽

Cited By ~ 5

Author(s):

Tim Tran ◽

Simone E. Taylor ◽

Andrew Hardidge ◽

Elise Mitri ◽

Parnaz Aminian ◽

...

Keyword(s):

Adverse Events ◽

Observational Study ◽

Medication Errors ◽

Medication Reconciliation ◽

Median Number ◽

Patient Harm ◽

Prescribing Error ◽

Delayed Treatment ◽

Metropolitan Hospital ◽

Orthopedic Patients

Background: Medication errors commonly occur when patients move from the community into hospital. Whereas medication reconciliation by pharmacists can detect errors, delays in undertaking this can increase the risk that patients receive incorrect admission medication regimens. Orthopedic patients are an at-risk group because they are often elderly and use multiple medications. Objective: To evaluate the prevalence and nature of medication errors when patients are admitted to an orthopedic unit where pharmacists routinely undertake postprescribing medication reconciliation. Methods: A 10-week retrospective observational study was conducted at a major metropolitan hospital in Australia. Medication records of orthopedic inpatients were evaluated to determine the number of prescribing and administration errors associated with patients’ preadmission medications and the number of related adverse events that occurred within 72 hours of admission. Results: Preadmission, 198 patients were taking at least 1 regular medication, of whom 176 (88.9%) experienced at least 1 medication error. The median number of errors per patient was 6 (interquartile range 3-10). Unintended omission of a preadmission medication was the most common prescribing error (87.4%). There were 17 adverse events involving 24 medications in 16 (8.1%) patients that were potentially related to medication errors; 6 events were deemed moderate consequence (moderate injury or harm, increased length of stay, or cancelled/delayed treatment), and the remainder were minor. Conclusion and Relevance: Medication errors were common when orthopedic patients were admitted to hospital, despite postprescribing pharmacist medication reconciliation. Some of these errors led to patient harm. Interventions that ensure that medications are prescribed correctly at admission are required.

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