Olavo Fernandes

Medication Reconciliation at Hospital Discharge: Evaluating Discrepancies

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.

Drug-Related Problems on Hospital Admission: Relationship to Medication Information Transfer

Background: Patients with end-stage renal disease (ESRD) are at risk for drug-related problems (DRPs), especially on hospital admission. Objective: To identify and characterize the DRPs experienced by patients with ESRD on admission and Investigate how these DRPs could be related to gaps in medication information transfer. Methods: Patients with ESRD admitted to the hospital were prospectively identified and clinically assessed by a pharmacist to identify and categorize DRPs on admission. Each DRP was evaluated to determine whether it could have been caused by a gap in medication information transfer. For DRPs caused in this manner, the interface in the information transfer process where the gap may have occurred was determined. Results: A total of 199 DRPs were identified in 47 patients with ESRD over a 12 week period. Ninety-two percent of patients had at least one DRP on admission, with an average of 4.2 ± 2.2 DRPs per patient. The most common DRP identified was indication for drug therapy—patient requires drug but is not receiving it (51.3%). Of the total DRPs, 130 (65%) were related to gaps in medication information transfer, with 21.5% occurring between the inpatient hospital and the ambulatory clinic pharmacists and 17.7% between the admitting physician and the patient. Conclusions: Results of this study demonstrate that, in patients with ESRD, DRPs on admission are frequently related to gaps in medication information transfer between healthcare professionals and also between healthcare providers and patients. Improved communication is required at medication information transfer interfaces to prevent these DRPs.

Medication Reconciliation During Internal Hospital Transfer and Impact of Computerized Prescriber Order Entry

Background: Internal hospital transfer is a vulnerable time during which patients are at high risk of medication discrepancies that can result in clinically significant harm, medication errors, and adverse drug events. Objective: To identify, characterize, and assess the clinical impact of unintentional medication discrepancies during internal hospital transfer and to investigate the influence of computerized prescriber order entry (CPOE) on medication discrepancies. Methods: All patients transferred between 10 inpatient units at 2 tertiary care hospitals were prospectively assessed to identify discrepancies. Interfaces included transfers between (1) units that both used paper-based medication ordering systems; (2) units that both used CPOE-based systems; and (3) units that used both paper-based and CPOE-based systems (hybrid transfer). The primary endpoint was the number of patients with at least 1 unintentional medication discrepancy during internal hospital transfer. Discrepancies were identified through assessment and comparison of a best possible medication transfer list with the actual transfer orders. A multidisciplinary team of clinicians assessed the potential clinical impact and severity of unintentional discrepancies. Results: Overall, 190 patients were screened and 129 patients were included. Eighty patients (62.0%) had at least 1 unintentional medication discrepancy at the time of transfer, and the most common discrepancy was medication omission (55.6%). Factors that independently increased the risk of a patient experiencing at least 1 unintentional discrepancy included lack of best possible medication history, increasing number of home medications, and increasing number of transfer medications. Forty-seven patients (36.4%) had at least 1 unintentional discrepancy with the potential to cause discomfort and/or clinical deterioration. The risk of discrepancies was present regardless of the medication-ordering system (paper, CPOE, or hybrid). Conclusions: Clinically significant medication discrepancies occur commonly during internal hospital transfer. A structured, collaborative, and clearly defined medication reconciliation process is needed to prevent internal transfer discrepancies and patient harm.

The EMITT Study: Development and Evaluation of a Medication Information Transfer Tool

Background: Continuity of care is required as patients move from the care of one pharmacist to another. The appropriate transfer of medication information between pharmacists as well as to patients at these times is essential in order to prevent drug-related problems (DRPs). Objective: To develop a tool to transfer medication information between various pharmacists caring for the same patients. Secondary objectives were to evaluate the tool based on utility in practice and satisfaction of pharmacists. Methods: The project consisted of a needs assessment involving in-depth interviews with patients and pharmacists and a literature review. These data were used to develop an optimal tool for medication information transfer between pharmacists in different practice settings. The tool was evaluated in a feasibility pilot for potential utility and pharmacist satisfaction. Results: The tool created called EMITT (electronic medication information transfer tool) facilitates the communication of information to outpatient pharmacists including a letter and an up-to-date list of the patients drugs. A total of 187 medication issues were communicated within 40 transferred letters, 61 of which required active follow-up, which potentially prevented 348 DRPs if the receiver of the information acted on the information that was provided. The 3 most common issues that required follow-up were restarting a held medication (n = 13), adjustment of doses based on laboratory results (n = 11), and starting a new indicated medication in the future (n = 7). Conclusions: A tool can be created to help address the gap in communication between pharmacists when patients move between interfaces of care by evaluating the needs of healthcare professionals involved in the information transfer process. It is envisioned that the elements of our tool can be easily adapted to other institutions to improve medication information transfer.

Effects of Smartphones on Pharmacist-Physician Clinical Communication

Background: Clinical pharmacist interventions are associated with improved patient outcomes and cost savings. Expanded interprofessional communication strategies may improve the efficiency and quality of the communication of these interventions. Objective: To determine the impact of smartphone device use on pharmacists efficiency when communicating clinical interventions and to determine factors related to smartphone use that improve and impede communication. Methods: A prospective, 2-phase, observational study was completed. In phase 1, work shadowing observations involved general internal medicine (GIM) pharmacists who communicated interventions to a physicians smartphone (BlackBerry device) and multiorgan transplant (MOT) pharmacists who used traditional modes of communication (paging, phone call, face-to-face). On each ward, various aspects of the interventions were documented for a total of 20 hours. In phase 2, 10 interviews were conducted with GIM pharmacists and physicians to gain their perspectives on BlackBerry device communication. Results: In phase 1, no significant difference was found in median time to resolution (order change or drug information response given) between accepted interventions from the smartphone group (15.5 minutes) versus traditional modes of communication in the GIM group (4 minutes) and the MOT group (8.5 minutes) (p = 0.74). In phase 2, themes that emerged across the different clinical groups included perceived improvements in communication processes (efficiency, decreased wait times, and triaging of issues), concerns for potential miscommunication (use of tone in the emails), and recommendations regarding BlackBerry best practices (dealing with urgent/nonurgent issues and establishment of pharmacist-physician interprofessional relationships). Conclusions: Despite no significant difference in median time to resolution of pharmacists interventions communicated through physician BlackBerry devices compared to traditional modes, the majority of interviewees perceived this device to be a positive communication tool resulting in improved efficiency of team communication.

Audit on the Use of Dangerous Abbreviations, Symbols, and Dose Designations in Paper Compared to Electronic Medication Orders: A Multicenter Study

Background: Dangerous abbreviations on the Institute for Safe Medication Practices Canada’s “Do Not Use” list have resulted in medication errors leading to harm. Data comparing rates of use of dangerous abbreviations in paper and electronic medication orders are limited. Objective: To compare rates of use of dangerous abbreviations from the “Do Not Use” list, in paper and electronic medication orders. Secondary objectives include determining the proportion of patients at risk for medication errors due to dangerous abbreviations and the most commonly used dangerous abbreviations. Methods: One-day cross-sectional audits of medication orders were conducted at a 6-site hospital network in Toronto, Canada, between December 2013 and January 2014. Proportions of paper and electronic medication orders containing dangerous abbreviation(s) were compared using a χ2 test. The proportion of patients with at least 1 medication order containing dangerous abbreviation(s) and the top 5 dangerous abbreviations used were described. Results: Overall, 255 patient charts were reviewed. The proportions of paper and electronic medication orders containing dangerous abbreviation(s) were 172/714 (24.1%) and 9/2207 (0.4%), respectively (P < 0.001). Almost one-third of patients had medication order(s) containing dangerous abbreviation(s). The proportions of patients with at least 1 medication order during the audit period containing dangerous abbreviation(s) for patients with paper only, electronic only, or a hybrid of paper and electronic medication orders were 50.5%, 5%, and 47.2%, respectively. Those most commonly used were “D/C”, drug name abbreviations, “OD,” “cc,” and “U.” Conclusions: Electronic medication orders have significantly lower rates of dangerous abbreviation use compared to paper medication orders.