Rita Shane

Current status of administration of medicines

The literature review was based on searches of knowledge-based resources, journals, and websites. Published studies, reports, conference proceedings, consensus statements, and abstracts published in English were evaluated. Approximately 3000 citations were reviewed. On an international basis, the

The problem with medication reconciliation

‘The Problem with…’ series covers controversial topics related to efforts to improve healthcare quality, including widely recommended but deceptively difficult strategies for improvement and pervasive problems that seem to resist solution. Medication reconciliation (‘med rec’, as it is often called) refers to the ‘process of identifying the most accurate list of all medications a patient is taking … and using this list to provide correct medications for patients anywhere within the health system’.1 Two recent systematic reviews summarised the evidence for med rec interventions, finding that several med rec interventions reduced medication history errors and errors in patients’ admission and discharge medication regimens.2 ,3 Despite documented efficacy in reducing errors, there are caveats. An earlier literature review showed that the clinical significance of medication history errors varies substantially—between 11% and 59%.4 Furthermore, although errors associated with harm were prevented in those studies that examined it,2 adverse drug events (ADEs) have been infrequently examined. Also, only a few studies have shown decreased healthcare usage,5 ,6 and to our knowledge none have shown direct cost savings. Despite imperfect evidence, The US Joint Commission and Accreditation Canada initially mandated universal med rec in 2005.7 ,8 In addition to the subset of aforementioned evidence in existence at that time, these mandates were driven by frequent anecdotes of ADEs related to med rec errors and strong face-validity of preserving and communicating medication information across patient encounters. Unfortunately, although some organisations mobilised substantial resources to comply with these mandates, other organisations undoubtedly improved documentation of med rec (as per the mandate requirements) rather than actual medication safety.9 Although most studies of med rec interventions report positive results, at least one review found publication bias:2 many negative experiences associated with med rec interventions were never reported. …

Risk evaluation and mitigation strategies: Impact on patients, health care providers, and health systems

PURPOSE To describe the impetus for and evolution, components, and potential impact on patients, health care providers, and health systems of risk evaluation and mitigation strategies (REMS) required by the Food and Drug Administration (FDA) for managing known or potential serious drug risks. SUMMARY A 2006 report from the Institute of Medicine criticizing FDA for drug withdrawals due to safety problems provided the impetus for FDA to enhance postmarketing surveillance and to require REMS for medications with actual or potential safety concerns. Components of REMS may include medication guides, patient package inserts, communication plans for health care providers, and elements to ensure safe use (e.g., special training or certification for prescribing or dispensing, dispensing only under certain circumstances, special monitoring, use of patient registries). Recent increases in the number of drugs with REMS requirements, MedWatch alerts, and the development of the new Sentinel Initiative reflect FDAs commitment to drug safety. Patients may be overwhelmed by information about drugs with REMS requirements, which could deter the use of potentially beneficial therapies. Pharmacists can help patients weigh the risks and benefits of drug therapy. Pharmacists, other health care providers, and health systems may find REMS requirements challenging, but FDA is cognizant of the need to balance the goals of ensuring drug safety and providing patient access to drugs without placing an undue burden on the health system. CONCLUSION The goal of improving drug safety is sought by the FDA, patients, health care providers, and health systems alike. Collaboration among health care providers may provide efficiencies in meeting FDA REMS requirements.

Pharmacist interdependent prescribing: A new model for optimizing patient outcomes

The profession of pharmacy has changed dramatically during our practice lifetimes. What we called a clinical pharmacist in the 1970s–80s we regard as the pharmacy generalist of today.[1][1] We have also seen the development of and subsequent increased demand for pharmacy specialists. Pharmacy

Advancing technician roles: An essential step in pharmacy practice model reform

Advancing the role of pharmacy technicians is recognized as an imperative in order for pharmacists to practice “at the top of their license.” This was one of the key themes of the Pharmacy Practice Model Summit.[1][1] In this issue of AJHP , Adams et al.[2][2] provide a timely review of the

Medication adherence as a predictor of 30-day hospital readmissions

Purpose The aim of this study was to test whether patient medication adherence, a modifiable risk factor obtainable at hospital admission, predicts readmission within 30 days. Patients and methods We used a retrospective cohort study design to test whether patient medication adherence to all chronic medications, as determined by the 4-item Morisky Medication Adherence Scale (MMAS-4) administered by a pharmacist at the time of hospital admission, predicts 30-day readmissions. We compared readmission rates among 385 inpatients who had their adherence assessed from February 1, 2013, to January 31, 2014. Multiple logistic regression was used to examine the benefit of adding medication adherence to previously published variables that have been shown to predict 30-day readmissions. Results Patients with low and intermediate adherence (combined) had readmission rates of 20.0% compared to a readmission rate of 9.3% for patients with high adherence (P=0.005). By adding MMAS-4 data to previously published variables that have been shown to predict 30-day readmissions, we found that patients with low and intermediate medication adherence had an adjusted 2.54-fold higher odds of readmission compared to those in patients with high adherence (95% confidence interval [CI]: 1.32–4.90, P=0.005). The model’s predictive power, as measured by the c-statistic, improved from 0.65 to 0.70 after adding adherence. Conclusion Because medication adherence assessed at hospital admission was independently associated with 30-day readmission risk, it offers potential for targeting interventions to improve adherence.

Critical requirements for health-system pharmacy practice models that achieve optimal use of medicines

When evaluating and designing practice models to achieve a preferred vision for health-system pharmacy practice, it is instructive to examine the elements of pharmacy practice that are essential to ensure optimal medication use. These elements include leadership, responsibility and accountability

Improving admission medication reconciliation with pharmacists or pharmacy technicians in the emergency department: a randomised controlled trial

Background Admission medication history (AMH) errors frequently cause medication order errors and patient harm. Objective To quantify AMH error reduction achieved when pharmacy staff obtain AMHs before admission medication orders (AMO) are placed. Methods This was a three-arm randomised controlled trial of 306 inpatients. In one intervention arm, pharmacists, and in the second intervention arm, pharmacy technicians, obtained initial AMHs prior to admission. They obtained and reconciled medication information from multiple sources. All arms, including the control arm, received usual AMH care, which included variation in several common processes. The primary outcome was severity-weighted mean AMH error score. To detect AMH errors, all patients received reference standard AMHs, which were compared with intervention and control group AMHs. AMH errors and resultant AMO errors were independently identified and rated by ≥2 investigators as significant, serious or life threatening. Each error was assigned 1, 4 or 9 points, respectively, to calculate severity-weighted AMH and AMO error scores for each patient. Results Patient characteristics were similar across arms (mean±SD age 72±16 years, number of medications 15±7). Analysis was limited to 278 patients (91%) with reference standard AMHs. Mean±SD AMH errors per patient in the usual care, pharmacist and technician arms were 8.0±5.6, 1.4±1.9 and 1.5±2.1, respectively (p<0.0001). Mean±SD severity-weighted AMH error scores were 23.0±16.1, 4.1±6.8 and 4.1±7.0 per patient, respectively (p<0.0001). These AMH errors led to a mean±SD of 3.2±2.9, 0.6±1.1 and 0.6±1.1 AMO errors per patient, and mean severity-weighted AMO error scores of 6.9±7.2, 1.5±2.9 and 1.2±2.5 per patient, respectively (both p<0.0001). Conclusions Pharmacists and technicians reduced AMH errors and resultant AMO errors by over 80%. Future research should examine other sites and patient-centred outcomes. Trial registration number NCT02026453.

Potential benefit of electronic pharmacy claims data to prevent medication history errors and resultant inpatient order errors

OBJECTIVE We sought to assess the potential of a widely available source of electronic medication data to prevent medication history errors and resultant inpatient order errors. METHODS We used admission medication history (AMH) data from a recent clinical trial that identified 1017 AMH errors and 419 resultant inpatient order errors among 194 hospital admissions of predominantly older adult patients on complex medication regimens. Among the subset of patients for whom we could access current Surescripts electronic pharmacy claims data (SEPCD), two pharmacists independently assessed error severity and our main outcome, which was whether SEPCD (1) was unrelated to the medication error; (2) probably would not have prevented the error; (3) might have prevented the error; or (4) probably would have prevented the error. RESULTS Seventy patients had both AMH errors and current, accessible SEPCD. SEPCD probably would have prevented 110 (35%) of 315 AMH errors and 46 (31%) of 147 resultant inpatient order errors. When we excluded the least severe medication errors, SEPCD probably would have prevented 99 (47%) of 209 AMH errors and 37 (61%) of 61 resultant inpatient order errors. SEPCD probably would have prevented at least one AMH error in 42 (60%) of 70 patients. CONCLUSION When current SEPCD was available for older adult patients on complex medication regimens, it had substantial potential to prevent AMH errors and resultant inpatient order errors, with greater potential to prevent more severe errors. Further study is needed to measure the benefit of SEPCD in actual use at hospital admission.

Need for pharmacist expertise in medication operations and systems

The focus on medication safety over the past decade has directed both health systems and regulatory agencies to critically evaluate each of the elements of the medication-use process. This approach is somewhat different from pharmacy’s efforts over the past several decades to develop clinical