Kristine M. Gleason

Results of the Medications At Transitions and Clinical Handoffs (MATCH) Study: An Analysis of Medication Reconciliation Errors and Risk Factors at Hospital Admission

BackgroundThis study was designed to determine risk factors and potential harm associated with medication errors at hospital admission.MethodsStudy pharmacist and hospital-physician medication histories were compared with medication orders to identify unexplained history and order discrepancies in 651 adult medicine service inpatients with 5,701 prescription medications. Discrepancies resulting in order changes were considered errors. Logistic regression was used to analyze the association of patient demographic and clinical characteristics including patients’ number of pre-admission prescription medications, pharmacies, prescribing physicians and medication changes; and presentation of medication bottles or lists. These factors were tested after controlling for patient demographics, admitting service and severity of illness.ResultsOver one-third of study patients (35.9%) experienced 309 order errors; 85% of patients had errors originate in medication histories, and almost half were omissions. Cardiovascular agents were commonly in error (29.1%). If undetected, 52.4% of order errors were rated as potentially requiring increased monitoring or intervention to preclude harm; 11.7% were rated as potentially harmful. In logistic regression analysis, patient’s age ≥65 [odds ratio (OR), 2.17; 95% confidence interval (CI), 1.09–4.30] and number of prescription medications (OR, 1.21; 95% CI, 1.14–1.29) were significantly associated with errors potentially requiring monitoring or causing harm. Presenting a medication list (OR, 0.35; 95% CI, 0.19–0.63) or bottles (OR, 0.55; 95% CI, 0.27–1.10) at admission was beneficial.ConclusionOver one-third of the patients in our study had a medication error at admission, and of these patients, 85% had errors originate in their medication histories. Attempts to improve the accuracy of medication histories should focus on older patients with a large number of medications. Primary care physicians and other clinicians should help patients utilize and maintain complete, accurate and understandable medication lists.

Teaching Medication Reconciliation Through Simulation: A Patient Safety Initiative for Second Year Medical Students

Errors in medication reconciliation constitute a large area of potential injury to patients. Medication reconciliation is rarely incorporated into medical school curriculums so students learn primarily from observing clinical care. To design and implement an interactive learning exercise to teach second year medical students about medication reconciliation Northwestern University Feinberg School of Medicine, Chicago, IL The Medication Reconciliation Simulation teaches medical students how to elicit information from active real-world sources to reconcile a medication history. At the conclusion of the session, students completed a Likert scale survey rating the level of improvement in their knowledge and comfort in obtaining medication histories. Students rated their knowledge level as having increased by 27% and their comfort level as having increased by 20%. A full 91% of the 158 students felt that it should be performed again for the following medical student class. The Medication Reconciliation Simulation is the first to specifically target medication reconciliation as a curriculum topic for medical students. Students praised the entertaining simulation and felt it provided a very meaningful experience on the patient safety topic. This simulation is generalizable to other institutions interested in teaching medication reconciliation and improving medication safety.IntroductionErrors in medication reconciliation constitute a large area of potential injury to patients. Medication reconciliation is rarely incorporated into medical school curriculums so students learn primarily from observing clinical care.AimTo design and implement an interactive learning exercise to teach second year medical students about medication reconciliationSettingNorthwestern University Feinberg School of Medicine, Chicago, ILProgram DescriptionThe Medication Reconciliation Simulation teaches medical students how to elicit information from active real-world sources to reconcile a medication history.Program EvaluationAt the conclusion of the session, students completed a Likert scale survey rating the level of improvement in their knowledge and comfort in obtaining medication histories. Students rated their knowledge level as having increased by 27% and their comfort level as having increased by 20%. A full 91% of the 158 students felt that it should be performed again for the following medical student class.DiscussionThe Medication Reconciliation Simulation is the first to specifically target medication reconciliation as a curriculum topic for medical students. Students praised the entertaining simulation and felt it provided a very meaningful experience on the patient safety topic. This simulation is generalizable to other institutions interested in teaching medication reconciliation and improving medication safety.

Physician Report Cards and Implementing Standards of Practice Are Both Significantly Associated With Improved Screening Colonoscopy Quality

OBJECTIVES:Adenoma-detection rates (ADRs) are associated with decreased interval colorectal cancer (CRC) rates and CRC mortality; quality improvement strategies focus on improving physician ADRs. The objective of this study was to examine the sequential effect of physician report cards and implementing institutional standards of practice (SOP) on ADRs.METHODS:Colonoscopy metrics were prospectively evaluated at a single academic medical center over a 23-month period (November 2012 to October 2014). ADRs were evaluated over three time periods—Period 1: Before initial report card distribution or SOP (November 2012 to March 2013); Period 2: After individualized report card distribution detailing physician and institutional ADRs (April 2013 to March 2014); Period 3: After second report card and SOP implementation (April 2014 to October 2014). The SOP required physicians to have a minimum 5-min withdrawal time in normal colonoscopies (WT) and an ADR minimum of 20%; those who did not meet benchmarks would require further training or endoscopy block time alterations. Only endoscopists averaging >15 colonoscopies/month were included in this analysis.RESULTS:Twenty endoscopists met the inclusion criteria, performing 12,894 screening colonoscopies over the 23-month period. Following report card distribution, physician ADRs increased by 3% (P<0.001). SOP implementation resulted in a further significant increase in mean physician ADR of 8% (P<0.0001). Overall, mean ADR increased by 11% from Period 1 to Period 3 (P<0.0001). All physicians met the minimum 20% ADR benchmark during Period 3. Although ADRs significantly correlated with WT overall (r=0.45; 95% CI 0.01, 0.75; P=0.04), mean WT did not significantly increase from Period 1 to Period 3.CONCLUSIONS:Our data suggest that distributing colonoscopy quality report cards resulted in a significant ADR improvement. Further, we report evidence that implementing SOP significantly improved ADRs beyond report card distribution and resulted in all endoscopists meeting minimum benchmarks. This suggests that report cards and SOPs may have an additive effect in improving colonoscopy quality, and their implementation in endoscopy labs should be encouraged.

Educating future physicians to track health care quality: feasibility and perceived impact of a health care quality report card for medical students.

Purpose Quality improvement (QI) requires measurement, but medical schools rarely provide opportunities for students to measure their patient outcomes. The authors tested the feasibility and perceived impact of a quality metric report card as part of an Education-Centered Medical Home longitudinal curriculum. Method Student teams were embedded into faculty practices and assigned a panel of patients to follow longitudinally. Students performed retrospective chart reviews and reported deidentified data on 30 nationally endorsed QI metrics for their assigned patients. Scorecards were created for each clinic team. Students completed pre/post surveys on self-perceived QI skills. Results A total of 405 of their patients’ charts were abstracted by 149 students (76% response rate; mean 2.7 charts/student). Median abstraction time was 21.8 (range: 13.1–37.1) minutes. Abstracted data confirmed that the students had successfully recruited a “high-risk” patient panel. Initial performance on abstracted quality measures ranged from 100% adherence on the use of beta-blockers in postmyocardial infarction patients to 24% on documentation of dilated diabetic eye exams. After the chart abstraction assignment, grand rounds, and background readings, student self-assessment of their perceived QI skills significantly increased for all metrics, though it remained low. Conclusions Creation of an actionable health care quality report card as part of an ambulatory longitudinal experience is feasible, and it improves student perception of QI skills. Future research will aim to use statistical process control methods to track health care quality prospectively as our students use their scorecards to drive clinic-level improvement efforts.

Perspectives on communication in labor and delivery: A focus group analysis

Objective:The objective of this study was to elicit and explore perceptions of barriers to optimal communication among clinicians on a labor and delivery unit, and to use this information to select and design approaches to improve communication.Study Design:A qualitative research design using a focus group format was utilized. Attending and resident obstetricians and anesthesiologists, as well as staff nurses, pharmacists and unit secretaries participated in the focus groups, which were recorded and transcribed. Data were analyzed using a framework analysis approach.Result:In total, 18 focus groups with a total of 92 participants were conducted. Eight key themes emerged regarding specific barriers to effective communication among clinicians in the labor and delivery setting. The most prominent of these themes included issues with inter-departmental coordination, clinical accessibility (the ability to reach other clinicians), lack of a consistent approach for clinical documentation, and the involvement of multiple care providers. On the basis of these themes, multiple interventions were designed to enhance communication.Conclusion:Focus group methodology can be used to elicit a detailed description of communication practices of clinicians on a labor and delivery unit, permitting an exploration of specific barriers to communication and the identification of potential solutions to those barriers.

Immediate and long-term effects of a team-based quality improvement training programme

Background Although many studies of quality improvement (QI) education programmes report improvement in learners’ knowledge and confidence, the impact on learners’ future engagement in QI activities is largely unknown and few studies report project measures beyond completion of the programme. Method We developed the Academy for Quality and Safety Improvement (AQSI) to prepare individuals, across multiple departments and professions, to lead QI. The 7-month programme consisted of class work and team-based project work. We assessed participants’ knowledge using a multiple choice test and an adapted Quality Improvement Knowledge Assessment Test (QIKAT) before and after the programme. We evaluated participants’ postprogramme QI activity and project status using surveys at 6 and 18 months. Results Over 5 years, 172 individuals and 32 teams participated. Participants had higher multiple choice test (71.9±12.7 vs 79.4±13.2; p<0.001) and adapted QIKAT scores (55.7±16.3 vs 61.8±14.7; p<0.001) after the programme. The majority of participants at 6 months indicated that they had applied knowledge and skills learnt to improve quality in their clinical area (129/148; 87.2%) and to implement QI interventions (92/148; 62.2%). At 18 months, nearly half (48/101; 47.5%) had led other QI projects and many (41/101; 40.6%) had provided QI mentorship to others. Overall, 14 (43.8%) teams had positive postintervention results at AQSI completion and 20 (62.5%) had positive results at some point (ie, completion, 6 months or 18 months after AQSI). Conclusions A team-based QI training programme resulted in a high degree of participants’ involvement in QI activities beyond completion of the programme. A majority of team projects showed improvement in project measures, often occurring after completion of the programme.