5PSQ-134 Analysis of medication discrepancies as part of the clinical pharmacy medication 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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Development of a Student-Led Ambulatory Medication Reconciliation Program at an Academic Institution

Journal of Pharmacy Practice ◽

10.1177/0897190017712175 ◽

2017 ◽

Vol 31 (3) ◽

pp. 342-346 ◽

Cited By ~ 1

Author(s):

Aimon C. Miranda ◽

Jaclyn D. Cole ◽

Melissa J. Ruble ◽

Erini S. Serag-Bolos

Keyword(s):

Medication Reconciliation ◽

Pharmacy Practice ◽

Successful Implementation ◽

Medication Discrepancies ◽

Interdisciplinary Practice ◽

Practice Experience ◽

Innovative Program ◽

Similar Program ◽

Time Required ◽

Reconciliation Process

Objectives: To integrate fourth-year student pharmacists on advanced pharmacy practice experience (APPE) rotations within several different ambulatory clinics to perform medication reconciliations and enhance interdisciplinary practice. Methods: The study design was a descriptive, prospective multisite study among a variety of ambulatory care outpatient clinics. Student pharmacists were partnered with physicians to conduct medication reconciliations during clinic visits for 4 hours per week, with data collection from January 2016 to September 2016. This program originated from physician requests for additional pharmacy involvement and led to the development of a successful implementation strategy to involve student pharmacists in the medication reconciliation process. Results: Student pharmacists identified 537 medication discrepancies among 491 patients, including commission of medications (36%), documentation of previously omitted medications (27%), and incomplete patient allergy information (11%). Students spent an average of 10 minutes on each encounter. Conclusion: Documentation from this innovative program suggests improvement in medication reconciliation and enhanced patient care with limited time required of student pharmacists. A similar program could be developed and utilized at other clinical sites.

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147 Prevalence and Drug Classes of Medication Discrepancies among Elderly Patients Discharged from a Tertiary Hospital

Age and Ageing ◽

10.1093/ageing/afz164.147 ◽

2019 ◽

Vol 48 (Supplement_4) ◽

pp. iv34-iv39

Author(s):

Izzati Abdul Halim Zaki ◽

Rizah Mazzuin Razali ◽

Mahmathi Karuppannan ◽

Shubashini Gnanasan ◽

Rosmaliah Alias

Keyword(s):

Elderly Patients ◽

Medication Reconciliation ◽

Tertiary Hospital ◽

Geriatric Ward ◽

Medication History ◽

Medication Discrepancies ◽

Mortality And Morbidity ◽

Drug Classification ◽

Reconciliation Process

Abstract Introduction Medication-related hospital admission may lead to the development of harmful and unwanted side effects that increase the risk of mortality and morbidity. Multiple steps are being executed to overcome the medication errors and one of the strategies is through conducting the medication reconciliation process. This process involves creating an accurate list of patient’s medications which to be compared with the current medications list upon transfer from different point of care or discharge. Any differences detected are categorized as medication discrepancies either being intentional or unintentional. This study aims to determine the prevalence and drug classification of medications discrepancies among patient discharged from a geriatric ward. Method This study was conducted retrospectively for three months in a geriatric ward. Comparisons were made between medications list on admission from the Medication History Assessment Form with the in-patient medication chart and medications upon discharge by a pharmacist to detect any discrepancies. Descriptive analysis was used to identify prevalence and the drug classification of medication discrepancies among elderly patients discharged from tertiary hospital. Results 1056 medications for 74 patients were screened for discrepancies. 689 (65.3%) discrepancies were detected with a mean of 9.31 ± SD 4.02. The highest number of intentional and unintentional medication discrepancies were detected in cardiovascular drugs (29.1%, n = 155) and (36.5%, n = 57). The drugs on admission and upon discharged that involved in discrepancies were diuretics, antihypertensives and antilipemic agents. Conclusion The number of medication discrepancies was found to be common among elderly patients discharged from the geriatric wards. Findings from this study have highlighted the importance of comprehensive medication reconciliation process prior to discharge in preventing medication discrepancies.

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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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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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Evaluation of an Electronic Module for Reconciling Medications in Home Health Plans of Care

Applied Clinical Informatics ◽

10.4338/aci-2015-11-ra-0154 ◽

2016 ◽

Vol 07 (02) ◽

pp. 412-424 ◽

Cited By ~ 2

Author(s):

Bryan Gibson ◽

Yarden Livnat ◽

Iona Thraen ◽

Abraham Brody ◽

Randall Rupper ◽

...

Keyword(s):

Repeated Measures ◽

Medication Reconciliation ◽

Confidence Score ◽

Electronic System ◽

Home Health ◽

Home Healthcare ◽

Medication Discrepancies ◽

Increased Risk ◽

Perceived Usability ◽

Improved Accuracy

SummaryTransitions in patient care pose an increased risk to patient safety. One way to reduce this risk is to ensure accurate medication reconciliation during the transition. Here we present an evaluation of an electronic medication reconciliation module we developed to reduce the transition risk in patients referred for home healthcare.Nineteen physicians with experience in managing home health referrals were recruited to participate in this within-subjects experiment. Participants completed medication reconciliation for three clinical cases in each of two conditions. The first condition (paper-based) simulated current practice – reconciling medication discrepancies between a paper plan of care (CMS 485) and a simulated Electronic Health Record (EHR). For the second condition (electronic) participants used our medication reconciliation module, which we integrated into the simulated EHR.To evaluate the effectiveness of our medication reconciliation module, we employed repeated measures ANOVA to test the hypotheses that the module will: 1) Improve accuracy by reducing the number of unaddressed medication discrepancies, 2) Improve efficiency by reducing the reconciliation time, 3) have good perceived usability.The improved accuracy hypothesis is supported. Participants left more discrepancies unaddressed in the paper-based condition than the electronic condition, F (1,1) = 22.3, p < 0.0001 (Paper Mean = 1.55, SD = 1.20; Electronic Mean = 0.45, SD = 0.65). However, contrary to our efficiency hypothesis, participants took the same amount of time to complete cases in the two conditions, F (1, 1) =0.007, p = 0.93 (Paper Mean = 258.7 seconds, SD = 124.4; Electronic Mean = 260.4 seconds, SD = 158.9). The usability hypothesis is supported by a composite mean ability and confidence score of 6.41 on a 7-point scale, 17 of 19 participants preferring the electronic system and an SUS rating of 86.5.We present the evaluation of an electronic medication reconciliation module that increases detection and resolution of medication discrepancies compared to a paper-based process. Further work to integrate medication reconciliation within an electronic medical record is warranted.

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A web application to involve patients in the medication reconciliation process: a user-centered usability and usefulness study

Journal of the American Medical Informatics Association ◽

10.1093/jamia/ocy107 ◽

2018 ◽

Vol 25 (11) ◽

pp. 1488-1500

Author(s):

Sophie Marien ◽

Delphine Legrand ◽

Ravi Ramdoyal ◽

Jimmy Nsenga ◽

Gustavo Ospina ◽

...

Keyword(s):

Web Application ◽

Medication Reconciliation ◽

Qualitative Data ◽

Improve Patient Safety ◽

Three Dimensions ◽

Medication List ◽

Medication History ◽

Medication Discrepancies ◽

System Usability Scale ◽

User Centered

Abstract Objective Medication reconciliation (MedRec) can improve patient safety by resolving medication discrepancies. Because information technology (IT) and patient engagement are promising approaches to optimizing MedRec, the SEAMPAT project aims to develop a MedRec IT platform based on two applications: the “patient app” and the “MedRec app.” This study evaluates three dimensions of the usability (efficiency, satisfaction, and effectiveness) and usefulness of the patient app. Methods We performed a four-month user-centered observational study. Quantitative and qualitative data were collected. Participants completed the system usability scale (SUS) questionnaire and a second questionnaire on usefulness. Effectiveness was assessed by measuring the completeness of the medication list generated by the patient application and its correctness (ie medication discrepancies between the patient list and the best possible medication history). Qualitative data were collected from semi-structured interviews, observations and comments, and questions raised by patients. Results Forty-two patients completed the study. Sixty-nine percent of patients considered the patient app to be acceptable (SUS Score ≥ 70) and usefulness was high. The medication list was complete for a quarter of the patients (7/28) and there was a discrepancy for 21.7% of medications (21/97). The qualitative data enabled the identification of several barriers (related to functional and non-functional aspects) to the optimization of usability and usefulness. Conclusions Our findings highlight the importance and value of user-centered usability testing of a patient application implemented in “real-world” conditions. To achieve adoption and sustained use by patients, the app should meet patients’ needs while also efficiently improving the quality of MedRec.

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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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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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