Medication Reconciliation at Hospital Discharge: Evaluating Discrepancies

2008 ◽  
Vol 42 (10) ◽  
pp. 1373-1379 ◽  
Author(s):  
Jacqueline D Wong ◽  
Jana M Bajcar ◽  
Gary G Wong ◽  
Shabbir MH Alibhai ◽  
Jin-Hyeun Huh ◽  
...  
Keyword(s):  
Hospital Discharge ◽  
Medication Reconciliation ◽  
Adverse Drug Events ◽  
Tertiary Care ◽  
Clinical Impact ◽  
Medication Discrepancies ◽  
Medication Discrepancy ◽  
General Internal ◽  
Discharge Medication ◽  
Number Of Patients

Background: Hospital discharge is an interlace of care when patients are at a high risk of medication discrepancies as they transition from hospital to home. These discrepancies are important, as they may contribute to drug-related problems, medication errors, and adverse drug events. Objective: To Identify, characterize, and assess the clinical impact of unintentional medication discrepancies at hospital discharge. Methods: All consecutive general internal medicine patients admitted for at least 72 hours to a tertiary care teaching hospital were prospectively assessed. Patients were excluded if they were discharged with verbal prescriptions; died during hospitalization; or transferred from or to a nursing home, another institution, or another unit within the same hospital. The primary endpoint was to determine the number of patients with at least one unintended medication discrepancy on hospital discharge. Medication discrepancies were assessed through comparison of a best possible medication discharge list with the actual discharge prescriptions. Secondary objectives were to characterize and assess the potential clinical impact of the unintentional discrepancies. Results: From March 14,2006, to June 2,2006,430 patients were screened for eligibility; 150 patients were included in the study. Overall, 106 (70.7%) patients had at least one actual or potential unintentional discrepancy. Sixty-two patients (41.3%) had at least one actual unintentional medication discrepancy al hospital discharge and 83 patients (55.3%) had at least one potential unintentional discrepancy. The most common unintentional discrepancies were an incomplete prescription requiring clarification, which could result in a patient delay in obtaining medications (49.5%), and the omission of medications (22.9%). Of the 105 unintentional discrepancies, 31 (29.5%) had the potential to cause possible or probable patient discomfort and/or clinical deterioration. Conclusions: Medication discrepancies occur commonly on hospital discharge. Understanding the type and frequency of discrepancies can help clinicians better understand ways to prevent them. Structured medication reconciliation may help to prevent discharge medication discrepancies.

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

2014 ◽  
Vol 29 (2) ◽  
pp. 132-137 ◽  
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.

scholarly journals Diabetes Medication Reconciliation at Hospital Discharge

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A424-A424
Author(s):  
Nandi Shah ◽  
Kristen Kulasa
Keyword(s):  
Hospital Discharge ◽  
Educational Intervention ◽  
Medication Reconciliation ◽  
Medical Center ◽  
Hospital Medicine ◽  
Inpatient Diabetes ◽  
Discharge Medication ◽  
Medicine Service ◽  
Number Of Patients ◽  
Primary Service

Abstract Background: During hospital discharge, patients are at high risk for medication discrepancies as they transition from hospital to home. This study aims to evaluate the prevalence of medication errors at hospital discharge for diabetes medications in patients who received an endocrinology consultation for diabetes and explore interventions to improve the accuracy of discharge medication reconciliation. Methods: All patients (n=3018) who received an endocrinology consultation for diabetes at a tertiary care medical center from October 2017 to December 2019 were included. A retrospective chart review was performed to collect the following information on each patient: primary service from which the patient was discharged, hospital site, month and year of discharge date, and whether each patient’s medication reconciliation for diabetes medications at hospital discharge was in agreement with the inpatient diabetes team’s recommendations. Patients who were discharged on medications discordant from those recommended by the inpatient diabetes service were subcategorized into three groups: 1) one medication incorrect 2) more than one medication incorrect and 3) the primary service did not notify the consult team of patient’s discharge or request final recommendations for diabetes medications prior to discharge. Based on the findings of this study, an educational intervention was implemented in November 2019 to the Hospital Medicine services regarding diabetes discharge medication reconciliation. Results: Of the 3018 patients who received an endocrinology consultation for diabetes at a tertiary university medical center, 2279 patients (76%) were discharged on correct medications, 165 patients (5%) were discharged with one incorrect medication, 443 patients (15%) were discharged with more than one incorrect medication, and 121 patients (4%) were discharged without final discharge recommendations from the diabetes service. There was no significant variation based on discharging service or month of the year. After an educational intervention was implemented in November 2019 to the Hospital Medicine service on the existence and use of a comprehensive diabetes discharge order set, the percentage of patients discharged on correct medications improved to 92% (11/12 patients) compared to prior 81% (44/54 patients). Conclusion: Despite detailed discharge medication recommendations including patient education detailing the recommended regimen by the endocrinology diabetes service, a significant number of patients were discharged by providers across all services on diabetes medications discrepant with the diabetes service’s recommendations. Educational efforts improved the rate of correct medications at discharge on the Hospital Medicine service, and additional educational interventions with other services may be helpful in improving medication reconciliation accuracy.

scholarly journals Engaging hospital patients in the medication reconciliation process using tablet computers

2018 ◽  
Vol 25 (11) ◽  
pp. 1460-1469 ◽  
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.

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

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

<p><strong>ABSTRACT</strong></p><p><strong>Background: </strong>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.</p><p><strong>Objectives: </strong>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.</p><p><strong>Methods: </strong>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.</p><p><strong>Results:</strong> 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.</p><p><strong>Conclusions: </strong>This study has provided evidence that ambulatory medication reconciliation can increase patient safety and potentially prevent adverse events associated with medication discrepancies.</p><p><strong>RÉSUMÉ</strong></p><p><strong>Contexte : </strong>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.</p><p><strong>Objectifs : </strong>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.</p><p><strong>Méthodes : </strong>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.</p><p><strong>Résultats : </strong>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.</p><p><strong>Conclusions : </strong>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.</p>

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

2015 ◽  
Vol 41 (2) ◽  
pp. 104-109 ◽  
Author(s):  
Winnie WY Chan ◽  
Geetha Mahalingam ◽  
Robert MA Richardson ◽  
Olavo A Fernandes ◽  
Marisa Battistella
Keyword(s):  
Medication Reconciliation ◽  
Adverse Drug Events ◽  
Medication Discrepancies

scholarly journals Identifying Unintentional Medication Discrepancies at Admission among Elderly Inpatients in Vietnam

2021 ◽  
Author(s):  
Phuong Thi Xuan Dong ◽  
Van Thi Thuy Pham ◽  
Linh Thi Nguyen ◽  
Thao Thi Nguyen ◽  
Huong Thi Lien Nguyen ◽  
...  
Keyword(s):  
Risk Factors ◽  
Logistic Regression ◽  
Hospital Admission ◽  
Medication Reconciliation ◽  
Negative Impact ◽  
Medication History ◽  
Medication Discrepancies ◽  
Medication Discrepancy ◽  
Chronic Medication ◽  
Elderly Inpatients

Abstract Background Elderly patients are at high risk of unintentional medication discrepancies during transition care as they are more likely to have multiple comorbidities and chronic diseases that require multiple medications. The main objective of the study was to measure the occurrence and identify risk factors for unintentional medication discrepancies in elderly inpatients during hospital admission.Methods A prospective observational study was conducted from July to December 2018 in a 800-bed geriatric hospital in Hanoi, North Vietnam. Patients over 60 years of age, admitted to one of selected internal medicine wards, taking at least one chronic medication before admission, and staying at least 48 hours were eligible for enrolment. Medication discrepancies of chronic medications before and after admission of each participant were identified by a pharmacist using a step-by-step protocol for the medication reconciliation process. The identified discrepancies were then classified as intentional or unintentional by an assessment group comprised of a pharmacist and a physician. A logistic regression model was used to identify risk factors of medication discrepancies.Results Among 192 enrolled patients, 328 medication discrepancies were identified; of which 87 (26.5%) were unintentional. 32.3% of patients had at least one unintentional medication discrepancy. The most common unintentional medication discrepancy was omission of drugs (75.9% of 87 medication discrepancies). The logistic regression analysis revealed a positive association between the number of discrepancies at admission and the type of treatment wards. Conclusions Medication discrepancies are common at admission among Vietnamese elderly inpatients. This study confirms the importance of obtaining a comprehensive medication history at hospital admission and supports implementing a medication reconciliation program to reduce the negative impact of medication discrepancy, especially for the elderly population.

Safety and tolerability of immune checkpoint therapies and related adverse effects at a tertiary care hospital in Saudi Arabia.

2019 ◽  
Vol 37 (15_suppl) ◽  
pp. e14082-e14082
Author(s):  
Mohammed Al Nuhait ◽  
Yousef Al Awlah ◽  
Eshtyag Bajnaid
Keyword(s):  
Adverse Effects ◽  
Adverse Events ◽  
Immune Checkpoint ◽  
Adverse Drug Events ◽  
Tertiary Care ◽  
Adult Patients ◽  
Care Hospital ◽  
Inclusion Criteria ◽  
Number Of Patients ◽  
Grade 3

e14082 Background: Immunotherapies associated with many toxicities with a potential immune-mediated cause and has been associated with many adverse events in the literature. As the incidence of emergency room (ER) visits in adult patients receiving immune checkpoint therapies and most frequent immune-related adverse events are not yet established well for our population since this class of medications is newly introduced in the oncology field. This research is aimed to shed the light on this new class of medications. Methods: This is a single-center retrospective cohort study to determine incidence of ER visits in adult patients receiving immune checkpoint therapies and to explore most frequent related adverse events. The study involved adult patients who were treated at King Abdulaziz Medical City. Study participants were identified by identified using our electronic health care system to identify patients who were treated with immunotherapies during the study period (January 2016 to December 2018). Inclusion criteria was patients aged more than 18 years who had received immunotherapies. Results: A total of 53 patients met the specified inclusion criteria for our study. The number of patients in each treatment group were as follows: Nivolumab 37, Atezolizumab 10 and Pembrolizumab 6. Average age was 59 years. The percentages of cancer patients presenting to the ER with various related adverse effects after beginning immune checkpoint therapy were (65%) Nivolumab, (80%) Atezolizumab and (83%) Pembrolizumab. The average number of ER visits after beginning immune checkpoint therapy was 3 visits (SD = 2.8). Renal adverse events were occurred following the immunotherapy use, 9 patients (17%) and none of cases experienced a grade≧3 event. 13 patients (24.5%) experienced hepatic adverse event. Only one patient experienced a grade≧3 event that lead to discontinuation of treatment. For diarrhea, among all patients received the immunotherapies, 14 (26%) experience diarrhea and five of them experience grade≧3 event. Thyroxine abnormalities occurred in 7 patients (13%) after use of immunotherapies. (7.5 %) of patients had pneumonitis with immunotherapy. Other adverse events were noted with immune therapies (skin reaction, nausea, vomiting, thrombocytopenia, neutropenia and neurological adverse events). All others adverse events that is reported had a grade 1-2 adverse events. Conclusions: Patients treated with immunotherapies may have a spectrum of adverse drug events that might lead to discontinue the treatment and increase ER visits.

scholarly journals Electronic tools to support medication reconciliation: a systematic review

2016 ◽  
Vol 24 (1) ◽  
pp. 227-240 ◽  
Author(s):  
Sophie Marien ◽  
Bruno Krug ◽  
Anne Spinewine
Keyword(s):  
User Satisfaction ◽  
Medication Reconciliation ◽  
Adverse Drug Events ◽  
Cochrane Library ◽  
Future Research ◽  
Successful Implementation ◽  
Multiple Sources ◽  
Medication History ◽  
Quality Of Reporting ◽  
Medication Discrepancies

Objectives: Medication reconciliation (MedRec) is essential for reducing patient harm caused by medication discrepancies across care transitions. Electronic support has been described as a promising approach to moving MedRec forward. We systematically reviewed the evidence about electronic tools that support MedRec, by (a) identifying tools; (b) summarizing their characteristics with regard to context, tool, implementation, and evaluation; and (c) summarizing key messages for successful development and implementation. Materials and Methods: We searched PubMed, the Cumulative Index to Nursing and Allied Health Literature, Embase, PsycINFO, and the Cochrane Library, and identified additional reports from reference lists, reviews, and patent databases. Reports were included if the electronic tool supported medication history taking and the identification and resolution of medication discrepancies. Two researchers independently selected studies, evaluated the quality of reporting, and extracted data. Results: Eighteen reports relative to 11 tools were included. There were eight quality improvement projects, five observational effectiveness studies, three randomized controlled trials (RCTs) or RCT protocols (ie, descriptions of RCTs in progress), and two patents. All tools were developed in academic environments in North America. Most used electronic data from multiple sources and partially implemented functionalities considered to be important. Relevant information on functionalities and implementation features was frequently missing. Evaluations mainly focused on usability, adherence, and user satisfaction. One RCT evaluated the effect on potential adverse drug events. Conclusion: Successful implementation of electronic tools to support MedRec requires favorable context, properly designed tools, and attention to implementation features. Future research is needed to evaluate the effect of these tools on the quality and safety of healthcare.

Medication Discrepancies Associated With a Medication Reconciliation Program and Clinical Outcomes After Hospital Discharge

2016 ◽  
Vol 36 (4) ◽  
pp. 415-421 ◽  
Author(s):  
Jennifer R. Shiu ◽  
Miriam Fradette ◽  
Raj S. Padwal ◽  
Sumit R. Majumdar ◽  
Erik Youngson ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Hospital Discharge ◽  
Medication Reconciliation ◽  
Medication Discrepancies
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