Medication Reconciliation in Transition Of Care: Broken Telephone or Patient Safety Goal?

2012 ◽  
Vol 13 (3) ◽  
pp. B15
Author(s):  
Liron Danay Sinvani ◽  
Liron Danay Sinvani ◽  
Judith Beizer ◽  
Gisele Wolf-Klein ◽  
Meredith Ackerman ◽  
...  
Keyword(s):  
Patient Safety ◽  
Medication Reconciliation ◽  
Transition Of Care

scholarly journals Patient Harm Resulting From Medication Reconciliation Process Failures: A Study of Serious Events Reported by Pennsylvania Hospitals

2021 ◽  
pp. 10-22
Author(s):  
Amy Harper ◽  
Elizabeth Kukielka ◽  
Rebecca Jones
Keyword(s):  
Patient Safety ◽  
Medication Reconciliation ◽  
Comprehensive Evaluation ◽  
Improve Patient Safety ◽  
Transition Of Care ◽  
Patient Harm ◽  
Reduction Strategies ◽  
Wrong Dose ◽  
Clinically Significant ◽  
Reconciliation Process

Medication reconciliation broadly defined includes both formal and informal processes that involve the comprehensive evaluation of a patient’s medications during each transition of care and change in therapy. The medication reconciliation process is complex, and studies have shown that up to 91% of medication reconciliation errors are clinically significant and 1–2% are serious or potentially life-threatening. We queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) and identified 93 serious events related to the medication reconciliation process reported between January 2015 and August 2020. Serious events related to medication reconciliation were most common among patients 65 years or older (55.9%; 52 of 93). The majority of events (58.1%; 54 of 93) contributed to or resulted in temporary harm and required treatment or intervention. Permanent harm or death occurred as a result of 3.3% (3 of 93) of the events. Admission/triage was the most frequent transition of care associated with events (69.9%; 65 of 93). The most common stage of the medication reconciliation process at which failures most directly contributed to patient harm was order entry/transcription (41.9%; 39 of 93) and resulted most frequently in wrong dose (n=21) or dose omission (n=13). Most events were discovered after the patient had a change in condition (76.3%; 71 of 93), and patients most often required readmission, hospitalization, emergency care, intensive care, or transfer to a higher level of care (58.0%; 54 of 93). Among 128 medications identified across all events, neurologic or psychiatric medications were the most common (39.1%; 50 of 128), and anticonvulsants were the most common pharmacologic class among neurologic or psychiatric medications (42.0%; 21 of 50). Based on our findings, risk reduction strategies that may improve patient safety related to the medication reconciliation process include defined clinician roles for medication reconciliation, listing the indication for each medication prescribed, and for facilities to consider adding anticonvulsants to their processes for medications with a high risk for harm.

scholarly journals P065: Surveying ED transition of care: satisfaction, awareness of risks and barriers to the implementation of a standardized protocol

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S100-S100
Author(s):  
M. Iseppon ◽  
J. Chauny ◽  
A. Cournoyer ◽  
I. Montplaisir ◽  
R. Daoust ◽  
...  
Keyword(s):  
Patient Safety ◽  
Patient Care ◽  
Electronic Version ◽  
Professional Organizations ◽  
Transition Of Care ◽  
Modified Delphi ◽  
Standardized Protocol ◽  
Cause Of Error ◽  
A Prospective Study ◽  
Emergency Doctors

Introduction: Patient handoffs have been identified as the primary cause of error affecting patient safety. The lack of standardization - and the often-avoidable errors that occur as a result - profoundly affect patient care and emergency department (ED) administration. Our study set out to evaluate emergency doctors’ awareness of these safety concerns, as well as their satisfaction with handoff practices currently used in their respective EDs. We also aimed to identify the potential barriers to the use of a standardized approach to patient transition of care. Methods: Guided by a modified Delphi method, a 29-question survey was developed by a panel of experts on patient transition of care. A printed version of the survey was distributed to ED doctors attending a local emergency medicine conference. An electronic version was subsequently distributed to all ED doctors registered as members of our provincial professional organizations. Results: We achieved a 68% response rate. Amongst the 309 participants, 51% (95%CI 44-56%) acknowledged that handoffs between emergency doctors are a frequent cause of error related to patient care. Frequent interruptions (77% (95%CI 72-82%)) and heavy workloads (73% (95%CI 68-79%)) were identified as the main factors negatively influencing the quality of handoffs. Despite 61% (95%CI 56-68%) satisfaction with the currently employed methods, 74% (95%CI 68-79%) of the respondents believe that handoffs would benefit from standardization and 83% (95%CI 79-88%) are open to changing their current practices. In addition, 53% (95%CI 48-60%) believe that the tools used for transition of care can be improved. Apprehension regarding the increase of handoff burden (86% (95%CI 81-90%)) was identified as the primary barrier to the implementation of a standardized handoff protocol. Conclusion: Doctors are generally satisfied with current handoff practices used in the ED. Nevertheless, their awareness of the possible risks associated with transition of care may be driving their openness to adapting their practice, potentially towards a more standardized approach given the conceivable benefits to patient safety. In light of these results, we aim to develop a comprehensive, standardized handoff protocol, and to evaluate its applicability in the ED with a prospective study.

scholarly journals Medication Reconciliation And Inpatient Fall: Identifying Ways To Improve Patient Safety

2016 ◽  
Vol 19 (3) ◽  
pp. A289
Author(s):  
W. Agbor Bawa ◽  
N. Rianon ◽  
B. Melton ◽  
J. Chen ◽  
R. Rasu
Keyword(s):  
Patient Safety ◽  
Medication Reconciliation ◽  
Improve Patient Safety ◽  
Improve Patient

scholarly journals A Lean Approach to Evaluating Prescribing Errors in Medication Reconciliation

2021 ◽  
Author(s):  
Yudha Putra ◽  
Maryati Mohd. Yusof
Keyword(s):  
Patient Safety ◽  
Medication Reconciliation ◽  
Qualitative Case Study ◽  
System Function ◽  
Prescribing Errors ◽  
Rigid System ◽  
Staff Shortage ◽  
Continuous Evaluation ◽  
High Workload

We evaluated medication reconciliation processes of a qualitative case study at a 1000-bed public hospital. Lean tools were applied to identify factors contributing to prescribing errors and propose process improvement. Errors were attributed to the prescriber’s skills, high workload, staff shortage, poor user attitude and rigid system function. Continuous evaluation of medication reconciliation efficiency is imperative to identify and mitigate errors and increase patient safety.

scholarly journals CLINICAL PHARMACIST-LED PROGRAM ON MEDICATION RECONCILIATION AND PATIENT COUNSELING IN THE DEPARTMENT OF GASTROENTEROLOGY

2019 ◽  
pp. 6-10
Author(s):  
U. KRUTHIKA ◽  
M. SUDHASREE ◽  
J. MOUNIKA ◽  
N. TANDAVA KRISHNA ◽  
M. DIVYA ◽  
...  
Keyword(s):  
Patient Safety ◽  
Sample Size ◽  
Clinical Pharmacist ◽  
Medication Reconciliation ◽  
Patient Counseling ◽  
Interventional Study ◽  
Total Prevalence ◽  
Study Population ◽  
Male Patients

Objective: To study the effects of medication reconciliation and patient counseling on the overall health benefits of the patients in the department of gastroenterology. Methods: This study is a prospective interventional study, was conducted in a 500 bedded MNR Hospital. The sample size taken was 150 patients and the study population comprised of patients aged 18-80 y, admitted in the hospital during the study period of six months. Results: Out of 150 patients, there were 98 (65.33%) male patients and 52 (34.67%) female patients. Patients between 18 and 30 y of age were 29(19.33%), between the age of 30 and 50 y were 71 (47.33%) and above 50 were 50(33.33%). Pancreatitis was most prevalent with 21% of total prevalence, followed by CLD and cholelithiasis with 17%, then IBD 16%, PUD and Gastritis 5%, GERD 4% and other diseases 15%. Conclusion: The basic role of the pharmacist, is to help in minimizing the errors and to perform medication reconciliation. In patient counseling, pharmacists provide information about the disease, and the medications to increase patient safety and the changes in the behavior for the better outcome.

scholarly journals Best Paper Selection

2019 ◽  
Vol 28 (01) ◽  
pp. 081-082
Keyword(s):  
Patient Safety ◽  
Decision Support ◽  
Medication Reconciliation ◽  
Hospital Setting ◽  
Clinical Decision ◽  
Population Based ◽  
Design Methods ◽  
User Centered Design ◽  
Contextual Design ◽  
Care Partners

Couture B, Lilley E, Chang F, DeBord Smith A, Cleveland J, Ergai A, Katsulis Z, Benneyan J, Gershanik E, Bates DW, Collins SA. Applying user-centered design methods to the development of an mHealth application for use in the hospital setting by patients and care partners. Appl Clin Inform 2018 Apr;9(2):302-12 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5943079/ Miller A, Koola JD, Matheny ME, Ducom JH, Slagle JM, Groessl EJ, Minter FF, Garvin JH, Weinger MB, Ho SB. Application of contextual design methods to inform targeted clinical decision support interventions in sub-specialty care environments. Int J Med Inform 2018 Sep;117:55-65 https://www.sciencedirect.com/science/article/pii/S138650561830580X?via%3Dihub Tamblyn R, Winslade N, Lee TC, Motulsky A, Meguerditchian A, Bustillo M, Elsayed S, Buckeridge DL, Couture I, Qian CJ, Moraga T, Huang A. Improving patient safety and efficiency of medication reconciliation through the development and adoption of a computerassisted tool with automated electronic integration of population-based community drug data: the RightRx project. J Am Med Inform Assoc 2018 May 1;25(5):482-95 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6018649/ Tscholl DW, Handschin L, Neubauer P, Weiss M, Seifert B, Spahn DR, Noethiger CB. Using an animated patient avatar to improve perception of vital sign information by anaesthesia professionals. Br J Anaesth 2018 Sep;121(3):662-71 https://bjanaesthesia.org/article/S0007-0912(18)30332-5/fulltext

Medication Reconciliation and Patient Safety in Trauma: Applicability of Existing Strategies

2020 ◽  
Vol 246 ◽  
pp. 482-489 ◽  
Author(s):  
Jonathan H. DeAntonio ◽  
Stefan W. Leichtle ◽  
Sarah Hobgood ◽  
Laura Boomer ◽  
Michel Aboutanos ◽  
...  
Keyword(s):  
Patient Safety ◽  
Medication Reconciliation

Medication Reconciliation – Theorie und Praxis

2014 ◽  
Vol 71 (6) ◽  
pp. 335-342
Author(s):  
Katharina Franzen ◽  
Rebekka Lenssen ◽  
Ulrich Jaehde ◽  
Albrecht Eisert
Keyword(s):  
Patient Safety ◽  
Medication Reconciliation ◽  
Wird Eine ◽  
Theorie Und Praxis ◽  
Praktische Umsetzung

Im Rahmen des WHO Projektes „High5s Action on Patient Safety“ wird „Medication Reconciliation“ an derzeit elf deutschen Kliniken implementiert. Ziel des High5s-Projektes ist es, innerhalb von fünf Jahren in fünf Ländern, fünf schwerwiegende Patientensicherheitsprobleme messbar, signifikant und anhaltend zu senken. Hierzu zählt unter anderem die Sicherstellung der richtigen Medikation bei Übergängen im Behandlungsprozess (Medication Reconciliation). Medication Reconciliation ist der systematische Abgleich der bestehenden Medikation eines Patienten mit der stationären Verordnung. Durch die nationale Koordinierungsstelle wurde hierfür eine standardisierte Handlungsempfehlung übersetzt und adaptiert. Hier wird sowohl die Implementierung als auch das Vorgehen im Medication Reconciliation Prozess strukturiert dargestellt. Der Medication Reconciliation Prozess gliedert sich in drei Teile. Zunächst wird eine bestmögliche Arzneimittelanamnese erfasst, anschließend erstellt der Arzt anhand dieser seine Aufnahmeverordnung und es erfolgt im letzten Schritt ein Abgleich der bestmöglichen Arzneimittelanamnese mit der Aufnahmeverordnung. Hierbei aufgetretene Diskrepanzen werden mit dem behandelten Arzt besprochen und geklärt. Der Erfassung der bestmöglichen Arzneimittelanamnese kommt hierbei eine besondere Rolle zu, da diese den Patienten während des gesamten Krankenhausaufenthaltes begleitet und an jeder Schnittstelle erneut zu Rate gezogen wird. Die praktische Umsetzung von Medication Reconciliation bedarf meist einer umfangreichen Umstellung der aktuellen Verordnungsbögen bzw. Verordnungssoftware und stellt somit für viele Kliniken eine große Herausforderung dar. Dennoch war es in den Niederlanden möglich, die Zahl an unbeabsichtigten Diskrepanzen um bis zu 90 % zu senken. Auch eine deutsche Klinik erzielt mit einer Reduktion der Diskrepanzen um ca. 77 % erste positive Ergebnisse. Des Weiteren wird der Nutzen von Medication Reconciliation für die Sicherheit des Patienten derzeit anhand klinisch-relevanter Endpunkte in einer weiteren Studie evaluiert.

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