Åsa Åb Bondesson

Improved quality in the hospital discharge summary reduces medication errors?LIMM: Landskrona Integrated Medicines Management

PurposeWe have developed a model for integrated medicines management, including tools and activities for medication reconciliation and medication review. In this study, we focus on improving the quality of the discharge summary including the medication report to reduce medication errors in the transition from hospital to primary and community care.MethodsThis study is a longitudinal study with an intervention group and a control group. The intervention group comprised 52 patients, who were included from 1 March 2006 until 31 December 2006, with a break during summer. Inclusion in the control group was performed in the same wards during the period 1 September 2005 until 20 December 2005, and 63 patients were included in the control group. In order to improve the quality of the medication report, clinical pharmacists reviewed and gave feedback to the physician on the discharge summary before patient discharge, using a structured checklist. Medication errors were then identified by comparing the medication list in the discharge summary with the first medication list used in the community health care after the patient had returned home.ResultsBy improving the quality of the discharge summary, patients had on average 45% fewer medication errors per patient (P = 0.012). The proportion of patients without medication errors was 63.5% in the control group and 73.1% in the intervention group. However, this increase was not significant (P = 0.319). Patients who used a specific medication dispensing system (ApoDos) had a 5.9-fold higher risk of suffering from medication errors than those without this medication dispensing system (P < 0.001).ConclusionReview and feedback on errors in the discharge summary, including the medication report and a correct medication list, reduced medication errors during the transfer of information from hospital to primary and community care.

Medication errors when transferring elderly patients between primary health care and hospital care

Objective: The aims were to evaluate the frequency and nature of errors in medication when patients are transferred between primary and secondary care.Method: Elderly primary health care patients (> 65years) living in nursing homes or in their own homes with care provided by the community nursing system, had been admitted to one of two hospitals in southern Sweden, one university hospital and one local hospital. A total of 69 patient-transfers were included. Of these, 34 patients were admitted to hospital whereas 35 were discharged from hospital.Main outcome measure: Percentage medication errors of all medications i.e. any error in the process of prescribing, dispensing, or administering a drug, and whether these had adverse consequences or not.Results: There were 142 medication errors out of 758 transfers of medications. The patients in this study used on an average more than 10 drugs before, during and after hospital stay. On an average, there were two medication errors each time a patient was transferred between primary and secondary care. When patients were discharged from the hospital, the usage of a specific medication dispensing system constituted a significant risk for medication errors. The most common error when patients were transferred to the hospital was inadvertent withdrawal of drugs. When patients left the hospital the most common error was that drugs were erroneously added.Conclusion: Medication errors are common when elderly patients are transferred between primary and secondary care. Improvement in documentation and transferring data about elderly patients’ medications could reduce these errors. The specific medication dispensing system that has been used in order to increase safety in medication dispensing does not seem to be a good instrument to reduce the number of errors in transferring data about medication.

The process of identifying, solving and preventing drug related problems in the LIMM-study

Objective To avoid negative effects of drug treatment and need for additional medical care, drug treatment must be individualised. Our research group has developed a model for clinical pharmacy which improves several aspects of the patient’s drug treatment. This study describes the process behind these improvements, i.e. drug related problems identified by pharmacists within a clinical pharmacy service. Setting Three wards at a department of internal medicine. Method Pharmacists performed systematic interventions during the patient’s hospital stay, aiming to identify, solve and prevent drug related problems in the elderly. Identified drug related problems were put forward to the health care team and discussed. Information on identified problems, and their outcomes was collected and analysed. A questionnaire was used to evaluate the health care personnel’s attitudes towards the process. Main outcome measure The number of drug related problems identified by the clinical pharmacists, the proportion of problems discussed with the physicians, the proportion of problems adjusted by the physicians and whether pharmacists and physicians prioritised any subgroup of drug related problems when choosing which problems to address. Finally, we wanted to evaluate the health care personnel’s attitudes towards the model. Results In total, 1,227 problem were identified in 190 patients. The pharmacists discussed 685 (55.8%) of the identified problems with the physicians who accepted 438 (63.9%) of the suggestions. There was no significant difference in which subgroup to put forward and which to adjust. There was a high response rate (84%) to the questionnaire, and the health care personnel estimated the benefits to be very high, both for the patients and for themselves. Conclusion The process for identifying, solving and preventing drug related problems was good and the different types of problems were considered equally important. The addition of a clinical pharmacy service was considered very useful. This suggests that the addition of our clinical pharmacy service to the hospital setting add skills of great importance.

In-hospital medication reviews reduce unidentified drug-related problems

PurposeTo examine the impact of a new model of care, in which a clinical pharmacist conducts structured medication reviews and a multi-professional team collates systematic medication care plans, on the number of unidentified DRPs in a hospital setting.MethodsIn a prospective two-period study, patients admitted to an internal medicine ward at the University Hospital of Lund, Sweden, were included if they were ≥ 65 years old, used ≥ 3 medications on a regular basis and had stayed on the ward for ≥ 5 weekdays. Intervention patients were given the new model of care and control patients received conventional care. DRPs were then retrospectively identified after study completion from blinded patient records for both intervention and control patients. Two pairs of evaluators independently evaluated and classified these DRPs as having been identified/unidentified during the hospital stay and according to type and clinical significance. The primary endpoint was the number of unidentified DRPs, and the secondary endpoints were the numbers of unidentified DRPs within each type and clinical significance category.ResultsThe study included a total of 141 (70 intervention and 71 control) patients. The intervention group benefited from a reduction in the total number of unidentified DRPs per patient during the hospital stay: intervention group median 1 (1st–3rd quartile 0–2), control group 9 (6–13.5) (p < 0.001), and also in the number of medications associated with unidentified DRPs per patient: intervention group 1 (0–2), control group 8 (5–10) (p < 0.001). All sub-categories of DRPs that were frequent in the control group were significantly reduced in the intervention group. Similarly, the DRPs were less clinically significant in the intervention group.ConclusionsA multi-professional team, including a clinical pharmacist, conducting structured medication reviews and collating systematic medication care plans proved very effective in reducing the number of unidentified DRPs for elderly in-patients.

Acceptance and importance of clinical pharmacists’ LIMM-based recommendations

Objective The objective of this study was to evaluate the quality of the clinical pharmacy service in a Swedish hospital according to the Lund Integrated Medicine Management (LIMM) model, in terms of the acceptance and clinical significance of the recommendations made by clinical pharmacists. Method The clinical significance of the recommendations made by clinical pharmacists was assessed for a random sample of inpatients receiving the clinical pharmacy service in 2007. Two independent physicians retrospectively ranked the recommendations emerging from errors in the patients’ current medication list and actual drug-related problems according to Hatoum, with rankings ranging between 1 (adverse significance) and 6 (extremely significant). Results The random sample comprised 132 patients (out of 800 receiving the service). The clinical significance of 197 recommendations was assessed. The physicians accepted and implemented 178 (90%) of the clinical pharmacists’ recommendations. Most of these recommendations, 170 (83%), were ranked 3 (somewhat significant) or higher. Conclusion This study provides further evidence of the quality of the LIMM model and confirms that the inclusion of clinical pharmacists in a multi-professional team can improve drug therapy for inpatients. The very high level of acceptance by the physicians of the pharmacists’ recommendations further demonstrates the effectiveness of the process.

Clinical implementation of systematic medication reconciliation and review as part of the Lund Integrated Medicines Management model – impact on all‐cause emergency department revisits

What is known and objective:  Interventions involving medication reconciliation and review by clinical pharmacists can reduce drug‐related problems and improve therapeutic outcomes. The objective of this study was to examine the impact of routine admission medication reconciliation and inpatient medication review on emergency department (ED) revisits after discharge. Secondary outcomes included the combined rate of post‐discharge hospital revisits or death.

Health economic evaluation of the Lund Integrated Medicines Management Model (LIMM) in elderly patients admitted to hospital.

Objective To evaluate the cost effectiveness of a multidisciplinary team including a pharmacist for systematic medication review and reconciliation from admission to discharge at hospital among elderly patients (the Lund Integrated Medicines Management (LIMM)) in order to reduce drug-related readmissions and outpatient visits. Method Published data from the LIMM project group were used to design a probabilistic decision tree model for evaluating tools for (1) a systematic medication reconciliation and review process at initial hospital admission and during stay (admission part) and (2) a medication report for patients discharged from hospital to primary care (discharge part). The comparator was standard care. Inpatient, outpatient and staff time costs (Euros, 2009) were calculated during a 3-month period. Dis-utilities for hospital readmissions and outpatient visits due to medication errors were taken from the literature. Results The total cost for the LIMM model was €290 compared to €630 for standard care, in spite of a €39 intervention cost. The main cost offset arose from avoided drug-related readmissions in the Admission part (€262) whereas only €66 was offset in the Discharge part as a result of fewer outpatient visits and correction time. The reduced disutility was estimated to 0.005 quality-adjusted life-years (QALY), indicating that LIMM was a dominant alternative. The probability that the intervention would be cost-effective at a zero willingness to pay for a gained QALY compared to standard care was estimated to 98%. Conclusions The LIMM medication reconciliation (at admission and discharge) and medication review was both cost-saving and generated greater utility compared to standard care, foremost owing to avoided drug-related hospital readmissions. When implementing such a review process with a multidisciplinary team, it may be important to consider a learning curve in order to capture the full advantage.

Healthcare system intervention for safer use of medicines in elderly patients in primary care—a qualitative study of the participants’ perceptions of self-assessment, peer review, feedback and agreement for change

BackgroundThe elderly population is increasing and with advanced age comes a higher risk for contracting diseases and excessive medicine use. Polypharmacy can lead to drug-related problems and an increased need of health care. More needs to be done to help overcome these problems. In order for new models to be successful and possible to implement in health care they have to be accepted by caregivers. The aim of this study was to evaluate participants’ perceptions of the SÄKLÄK project, which aims to enhance medication safety, especially for elderly patients, in primary care.MethodsThis is a qualitative study within the SÄKLÄK project. The SÄKLÄK project is a multi-professional intervention in primary care consisting of self-assessment, peer review, feedback and written agreements for change. A total of 17 participants from the intervention’s primary care units were interviewed. Most of the interviews were done on a one-to-one basis. The interviews were recorded and transcribed verbatim. A survey was also sent to the primary care unit heads. Qualitative content analysis was used to explore the participants’ perceptions.ResultsThe analysis of the interviews yielded six categories: multi-professional co-operation, a focus on areas of improvement, the joy of sharing knowledge, disappointment with the focus of the feedback, spend time to save time and impact on work. From these categories a theme developed: “Medication safety is a large area. In order to make improvements time needs to be invested and different professions must contribute.”ConclusionsThis study shows that our studied intervention method is feasible to use in primary care and that the multi-professional approach was perceived as being very positive by the participants. Multi-professional co-operation was time consuming, but was also deemed as an investment and an opportunity to share knowledge. Some points of improvement of the method were identified such as simplification of the self-assessment form and clearer instructions for reviewers. In addition, to have an impact on work the focus must lie in areas within the primary care units’ scope.

The lund integrated medicines management model, health outcomes and processes development.

Background The effects from medication use in clinical trials are hard to achieve in standard care. Instead of health benefits for the patient there is risk of errors and negative consequences such as morbidity, mortality and costs. The risk is highest among older patients admitted and discharged to and from hospital care. Purpose Develop a systematic model for improved medication use when a patient is admitted to hospital. Materials and methods Systematic analysis of problems and limitations in the standard patient medication care process from admission, during stay, at, and after discharge was performed at Lund University hospital. A structured team based model with tools, checklists and responsibilities were developed and tested for each part and for the total model. The clinical pharmacist was introduced as the catalyst for improvement in the team and was responsible for performing medication reconciliation and medication review. Each part of the model was researched stepwise and compared to standard care in studies powered to detect significant differences in processes and outcomes. Three of the outcomes studies were used as input in a probabilistic decision tree model for cost-utility analyses. Results 18 scientific publications and manuscripts have been produced from the development and is the base for four PhD- and more than 30 MSc-theses. The model improves the process of care, that is identifies and solves drug related problem, reduces medication reconciliation errors, and improves medication appropriateness. It also improves healthcare outcomes. Healthcare contacts and hospital readmissions due to medication errors were reduced by 50 percent. For each hour spent by a pharmacist 2-3 h were saved among physicians and nurses. The total model generated savings of €390 and gained utility of 0.005 for each patient. The model is cost saving at a 98% chance. Finally all involved professionals are very satisfied with the process and the pharmacist professional contribution. Conclusions The model has successfully been implemented, researched and also rewarded as best innovation in Swedish healthcare. In Scania (the south of Sweden) there is a political consensus on the benefit and there are concrete plans to employ 40 additional clinical pharmacists

Effects of an intervention (SäkläK) on prescription of potentially inappropriate medication in elderly patients

Background Polypharmacy is known to increase the risk for drug-related problems, and some drugs, potentially inappropriate medications (PIMs), are especially troublesome. Objective To analyse the effects on prescription of PIMs of the SÄKLÄK project, an intervention model created to improve medication safety for elderly patients in primary care. Method The SÄKLÄK project was a multiprofessional intervention in primary care consisting of self-assessment, peer review, feedback and written agreements for change. Five Swedish primary care centres participated in the intervention and five served as comparison group. Data were collected from the Swedish Prescribed Drug Register on PIMs (long-acting benzodiazepines, anticholinergics, tramadol, propiomazine, antipsychotics and non-steroidal anti-inflammatory drugs) prescribed to patients aged 65 years and older. Total number of patients and change in patients using PIMs before and after intervention with-in groups was analysed as well as differences between intervention and comparison group. Results A total of 32566 prescriptions of PIMs were dispensed before the intervention, 19796 in the intervention group and 12770 in the comparison group. After intervention a decrease was seen in both groups, intervention-22.2% and comparison-8.8%. All groups of PIMs decreased, except for antipsychotics in the comparison group. For the intervention group, a significant decrease in mean dose/patient was seen after the intervention but not in the comparison group. Conclusion Our study shows this method has some effects on prescription of PIMs. The evaluation indicates this is a feasible method for improvement of medication use in primary care and the method should be tested on a larger scale.