Medication Reconciliation During Transitions of Care as a Patient Safety Strategy

Summary Background: Code status (CS) of a patient (part of their end-of-life wishes) can be critical information in healthcare delivery, which can change over time, especially at transitions of care. Although electronic health record (EHR) tools exist for medication reconciliation across transitions of care, much less attention is given to CS, and standard EHR tools have not been implemented for CS reconciliation (CSR). Lack of CSR creates significant potential patient safety and quality of life issues. Objective: To study the tools, workflow, and impact of clinical decision support (CDS) for CSR. Methods: We established rules for CS implementation in our EHR. At admission, a CS is required as part of a patient’s admission order set. Using standard CDS tools in our EHR, we built an interruptive alert for CSR at discharge if a patient did not have the same inpatient (current) CS at discharge as that prior to admission CS. Results: Of 80,587 admissions over a four year period (2 years prior to and post CSR implementation), CS discordance was seen in 3.5% of encounters which had full code status prior to admission, but Do Not Resuscitate (DNR) CS at discharge. In addition, 1.4% of the encounters had a different variant of the DNR CS at discharge when compared with CS prior to admission. On pre-post CSR implementation analysis, DNR CS per 1000 admissions per month increased significantly among patients discharged and in patients being admitted (mean ± SD: 85.36 ± 13.69 to 399.85 ± 182.86, p<0.001; and 1.99 ± 1.37 vs 16.70 ± 4.51, p<0.001, respectively). Conclusion: EHR enabled CSR is effective and represents a significant informatics opportunity to help honor patients’ end-of-life wishes. CSR represents one example of non-medication reconciliation at transitions of care that should be considered in all EHRs to improve care quality and patient safety.

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5PSQ-216 Implementation of a medication reconciliation programme as a patient safety strategy

10.1136/ejhpharm-2021-eahpconf.335 ◽

2021 ◽

Author(s):

M Mañes Sevilla ◽

B Rubio-Cebrian ◽

ML De La Cruz Conty ◽

B Bertran De Lis Bartolome ◽

C Moriel-Sanchez

Keyword(s):

Patient Safety ◽

Medication Reconciliation ◽

Safety Strategy

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Pharmacy student-assisted medication reconciliation: Number and types of medication discrepancies identified by pharmacy students

Pharmacy Practice ◽

10.18549/pharmpract.2021.3.2471 ◽

2021 ◽

Vol 19 (3) ◽

pp. 2471

Author(s):

Louise Deep ◽

Carl R. Schneider ◽

Rebekah Moles ◽

Asad E. Patanwala ◽

Linda L. Do ◽

...

Keyword(s):

Patient Safety ◽

Medication Reconciliation ◽

Alimentary Tract ◽

Common Type ◽

Pharmacy Students ◽

Transitions Of Care ◽

Patient Harm ◽

Medication Discrepancies ◽

Retrospective Audit ◽

Hospital Inpatients

Background: Medication reconciliation aims to prevent unintentional medication discrepancies that can result in patient harm at transitions of care. Pharmacist-led medication reconciliation has clear benefits, however workforce limitations can be a barrier to providing this service. Pharmacy students are a potential workforce solution. Objective: To evaluate the number and type of medication discrepancies identified by pharmacy students. Methods: Fourth year pharmacy students completed best possible medication histories and identified discrepancies with prescribed medications for patients admitted to hospital. A retrospective audit was conducted to determine the number and type of medication discrepancies identified by pharmacy students, types of patients and medicines involved in discrepancies. Results: There were 294 patients included in the study. Overall, 72% (n=212/294) had medication discrepancies, the most common type being drug omission. A total of 645 discrepancies were identified, which was a median of three per patient. Patients with discrepancies were older than patients without discrepancies with a median (IQR) age of 74 (65-84) vs 68 (53-77) years (p=0.001). They also took more medicines with a median (IQR) number of 9 (6-3) vs 7 (2-10) medicines per patient (p<0.001). The most common types of medicines involved were those related to the alimentary tract and cardiovascular system. Conclusions: Pharmacy students identified medication discrepancies in over 70% of hospital inpatients, categorised primarily as drug omission. Pharmacy students can provide a beneficial service to the hospital and contribute to improved patient safety by assisting pharmacists with medication reconciliation.

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Facilitating Home Hospice Transitions of Care in Oncology: Evaluation of Clinical Pharmacists’ Interventions, Hospice Program Satisfaction, and Patient Representation Rates

American Journal of Hospice and Palliative Medicine® ◽

10.1177/1049909118765944 ◽

2018 ◽

Vol 35 (9) ◽

pp. 1181-1187 ◽

Cited By ~ 2

Author(s):

Alison P. Duffy ◽

Nina M. Bemben ◽

Jueli Li ◽

James Trovato

Keyword(s):

Medication Reconciliation ◽

Transitions Of Care ◽

Cancer Center ◽

Discharge Process ◽

Program Satisfaction ◽

Discharge Medication ◽

Pharmacist Interventions ◽

Center Care ◽

Discharge Readiness

Background: The importance of medication reconciliation and the pharmacist’s role within the interdisciplinary team at the point of transition to home hospice is understudied. A transitions of care pilot initiative was developed to streamline the transition for patients at end of life from inpatient cancer center care to home hospice. The initiative consisted of using a hospice discharge checklist, pharmacist-led discharge medication reconciliation in consultation with the primary team responsible for inpatient care, review of discharge prescriptions, and facilitation of bedside delivery of discharge medications. Methods: This was a single-center, prospective, pilot initiative. The objectives of this study were to characterize pharmacist interventions at the time of transition, to assess changes in hospice organizations’ perceptions of discharge readiness, and to evaluate differences in representation rates with the implementation of the pilot discharge process. Results: Fifteen patients in the preimplementation period and 12 patients in the postimplementation period were included. One hundred eleven pharmacist interventions were captured, an average of 9.3 interventions per patient, with an acceptance rate of 82.9% by providers. There was a statistically significant ( P = .035) improvement in hospice organizations’ perceptions of discharge readiness. There was no difference in 30-day representation rates postdischarge ( P = 1). Conclusion: This well-received pilot initiative demonstrated an improvement in local hospice’s perception of patient readiness for discharge and a high percentage of accepted pharmacist interventions during discharge medication reconciliation. A larger sample size of patients and longer follow-up period may be needed to demonstrate statistically significant improvements in representation rates postintervention.

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Residents' Perspectives on Patient Safety in University and Community Teaching Hospitals

Journal of Graduate Medical Education ◽

10.4300/jgme-d-14-00350.1 ◽

2014 ◽

Vol 6 (3) ◽

pp. 603-607 ◽

Cited By ~ 8

Author(s):

Deborah L. Jones

Keyword(s):

Internal Medicine ◽

Patient Safety ◽

General Surgery ◽

Health Care Professionals ◽

Diagnostic Radiology ◽

Transitions Of Care ◽

Teaching Hospitals ◽

Safety Issues ◽

Communication Problems ◽

Community Teaching

Abstract Background Patient safety is an important concept in resident education. To date, few studies have assessed resident perceptions of patient safety across different specialties. Objective The study explored residents' views on patient safety across the specialties of internal medicine, general surgery, and diagnostic radiology, focusing on common themes and differences. Methods In fall 2012, interviews of small groups of senior residents in internal medicine, general surgery, and diagnostic radiology were conducted at 3 academic medical centers and 3 community teaching hospitals in 3 major US metropolitan areas. In total, 33 residents were interviewed. Interviews used interactive discussion to explore multiple facets of patient safety. Results Residents identified lack of information, common errors, volume and acuity of patients, and inadequate supervision as major risks to patient safety. Specific threats to patient safety included communication problems, transitions of care, information technology interface issues, time constraints, and work flow. Residents disclosed that reporting safety issues was viewed as burdensome and carrying some degree of risk. There was variability as to whether residents would report safety threats they encountered. Conclusions Residents are aware of threats to patient safety and have a unique perspective compared with other health care professionals. Transitions of care and communication problems were the most common safety threats identified by the residents interviewed.

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Creating a foundation for implementing an electronic health records (EHR)-integrated Social Knowledge Networking (SKN) system on medication reconciliation

Journal of Hospital Administration ◽

10.5430/jha.v7n2p36 ◽

2018 ◽

Vol 7 (2) ◽

pp. 36

Author(s):

Rangachari P. ◽

Dellsperger K.C. ◽

Fallaw D. ◽

Davis I. ◽

Sumner M. ◽

...

Keyword(s):

Electronic Health Records ◽

Medication Reconciliation ◽

Phase 1 ◽

Transitions Of Care ◽

Social Knowledge ◽

Importance Rating ◽

Health Records ◽

Professional Affiliation ◽

Inpatient Medicine ◽

Electronic Health

Background: In fall 2016, Augusta University received a two-year grant from AHRQ, to implement a Social Knowledge Networking (SKN) system for enabling its health system, AU-Health, to progress from “limited use” of electronic health records (EHR) Medication Reconciliation (MedRec) Technology, to “meaningful use”. Phase 1 sought to identify a comprehensive set of issues related to EHR MedRec encountered by practitioners at AU-Health. These efforts helped develop a Reporting Tool, which, along with a Discussion Tool, was incorporated into the AU-Health EHR, at the end of Phase 1. Phase 2 (currently underway), comprises a 52-week pilot of the EHR-integrated SKN system in outpatient and inpatient medicine units. The purpose of this paper is to describe the methods and results of Phase 1.Methods: Phase 1 utilized an exploratory mixed-method approach, involving two rounds of data collection. This included 15 individual interviews followed by a survey of 200 practitioners, i.e., physicians, nurses, and pharmacists, based in the outpatient and inpatient medicine service at AU Health.Results: Thematic analysis of interviews identified 55 issue-items related to EHR MedRec under 9 issue-categories. The survey sought practitioners’ importance-rating of all issue-items identified from interviews. A total of 127 (63%) survey responses were received. Factor analysis served to validate the following 6 of the 9 issue-categories, all of which, were rated “Important” or higher (on average), by over 70% of all respondents: 1) Care-Coordination (CCI); 2) Patient-Education (PEI); 3) Ownership-and-Accountability (OAI); 4) Processes-of-Care (PCI); 5) IT-Related (ITRI); and 6)Workforce-Training (WTI). Significance-testing of importance-rating by professional affiliation revealed no statistically significant differences for CCI and PEI; and some statistically significant differences for OAI, PCI, ITRI, and WTI.Conclusions: There were two key gleanings from the issues related to EHR MedRec unearthed by this study: 1) there was an absence of shared understanding among practitioners, of the value of EHR MedRec in promoting patient safety, which contributed to workarounds, and suboptimal use of the EHR MedRec system; and 2) there was a socio-technical dimension to many of the issues, creating an added layer of complexity. These gleanings in turn, provide insights into best practices for managing both clinical transitions-of-care in the EHR MedRec process; and socio-technical challenges encountered in EHR MedRec implementation.

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Bridging the Gap for Patient Safety: Medication Reconciliation

Hospital Pharmacy ◽

10.1177/001857870403900801 ◽

2004 ◽

Vol 39 (8) ◽

pp. 724-724 ◽

Cited By ~ 4

Author(s):

Joyce A. Generali

Keyword(s):

Patient Safety ◽

Medication Reconciliation

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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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