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 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 Patients for Patient Safety

2020 ◽  
pp. 67-79
Author(s):  
Susan Sheridan ◽  
Heather Sherman ◽  
Allison Kooijman ◽  
Evangelina Vazquez ◽  
Katrine Kirk ◽  
...  
Keyword(s):  
Patient Safety ◽  
Civil Society ◽  
Improve Patient Safety ◽  
Building Blocks ◽  
Developed Countries ◽  
World Health ◽  
Member States ◽  
World Health Assembly ◽  
Reduction Strategies ◽  
Global Action

AbstractUnsafe care results in over 2 million deaths per year and is considered one of the world’s leading causes of death. In 2019, the 72nd World Health Assembly issued a call to action, The Global Action on Patient Safety, that called for Member States to democratize healthcare by engaging with the very users of the healthcare system—patients, families, and community members—along with other partners—in the “co-production” of safer healthcare.The WHO’s Patients for Patient Safety (PFPS) Programme, guided by the London Declaration, addresses this global concern by advancing co-production efforts that demonstrate the powerful and important role that civil society, patients, families, and communities play in building harm reduction strategies that result in safer care in developing and developed countries. The real-world examples from the PFPS Programme and Member States illustrate how civil society as well as patients, families, and communities who have experienced harm from unsafe care have harnessed their wisdom and courageously partnered with passionate and forward-thinking leaders in healthcare including clinicians, researchers, policy makers, medical educators, and quality improvement experts to co-produce sustainable patient safety initiatives. Although each example is different in scope, structure, and purpose and engage different stakeholders at different levels, each highlights the necessary building blocks to transform our healthcare systems into learning environments through co-production of patient safety initiatives, and each responds to the call made in the London Declaration, the WHO PFPS Programme, and the World Health Assembly to place patients, families, communities, and civil society at the center of efforts to improve patient safety.

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 Does electronic medication reconciliation at hospital discharge decrease prescription medication errors?

2015 ◽  
Vol 28 (6) ◽  
pp. 564-573 ◽  
Author(s):  
Geneve M. Allison ◽  
Bernard Weigel ◽  
Christina Holcroft
Keyword(s):  
Patient Safety ◽  
Hospital Discharge ◽  
Medication Errors ◽  
Medication Reconciliation ◽  
Improve Patient Safety ◽  
Safety Issue ◽  
Inpatient Service ◽  
Intravenous Antibiotic ◽  
Content Type ◽  
The Impact

Purpose – Medication errors are an important patient safety issue. Electronic medication reconciliation is a system designed to correct medication discrepancies at transitions in healthcare. The purpose of this paper is to measure types and prevalence of intravenous antibiotic errors at hospital discharge before and after the addition of an electronic discharge medication reconciliation tool (EDMRT). Design/methodology/approach – A retrospective study was conducted at a tertiary hospital where house officers order discharge medications. In total, 100 pre-EDMRT and 100 post-EDMRT subjects were randomly recruited from the study center’s clinical Outpatient Parenteral Antimicrobial Therapy (OPAT) program. Using infectious disease consultant recommendations as gold standard, each antibiotic listed in these consultant notes was compared to the hospital discharge orders to ascertain the primary outcome: presence of an intravenous antibiotic error in the discharge orders. The primary covariate of interest was pre- vs post-EDMRT group. After generating the crude prevalence of antibiotic errors, logistic regression accounted for potential confounding: discharge day (weekend vs weekday), average years of practice by prescribing physician, inpatient service (medicine vs surgery) and number of discharge mediations per patient. Findings – Prevalence of medication errors decreased from 30 percent (30/100) among pre-EDMRT subjects to 15 percent (15/100) errors among post-EDMRT subjects. Dosage errors were the most common type of medication error. The adjusted odds ratio of discharge with intravenous antibiotic error in the post-EDMRT era was 0.39 (0.18, 0.87) compared to the pre-EDMRT era. In the adjusted model, the total number of discharge medications was associated with increased OR of discharge error. Originality/value – To the authors’ knowledge, no other study has examined the impact of reconciliation on types and prevalence of medication errors at hospital discharge. The focus on intravenous antibiotics as a class of high-stakes medications with serious risks to patient safety during error events highlights the clinical importance of the findings. Electronic medication reconciliation may be an important tool in efforts to improve patient safety.

scholarly journals Value of pharmacy services upon admission to an orthopedic surgery unit

2021 ◽  
Vol 14 (1) ◽  
Author(s):  
Ahmad El Ouweini ◽  
Lamis R. Karaoui ◽  
Nibal Chamoun ◽  
Chahine Assi ◽  
Kaissar Yammine ◽  
...  
Keyword(s):  
Orthopedic Surgery ◽  
Medication Reconciliation ◽  
Tertiary Care ◽  
Medication History ◽  
Surgical Department ◽  
Clinically Significant ◽  
Antihyperlipidemic Agents ◽  
Surgery Department ◽  
The Impact ◽  
Reconciliation Process

Abstract Background In Lebanon, the role of the pharmacist remains underestimated in the medication reconciliation process, especially in surgical departments. This study aims to assess the impact of pharmacist-conducted medication reconciliation performed within 48 h of hospital admission to the orthopedic surgical department. Methods This was a prospective single-arm study conducted in a tertiary-care teaching hospital in Lebanon between October 2019 and April 2020. Participants were adult inpatients hospitalized for orthopedic surgeries with ≥ 1 outpatient medications. Properly trained pharmacy resident obtained the Best Possible Medication History (BPMH) and led the reconciliation process. The primary endpoint was the number of reconciliation errors (REs) identified. Descriptive statistics were used to report participants’ responses and relevant findings. Linear regression was performed with the number of REs as a continuous dependent variable using backward method. Results were assumed to be significant when p was < 0.05. Results The study included 100 patients with a mean age of 73.8 years, admitted for elective (54%) or emergency (46%) surgeries. Half of the study population had ≥ 5 home medications. The mean time for taking BPMH was around 8 min. A total of 110 REs were identified in 74 patient cases. The most common discrepancies consisted of medication omission (89.1%) and the most common medications involved were antihyperlipidemic agents. Twenty-four REs were judged as clinically significant, and four as serious. The most common interventions included the addition of a medication (71.9%). Most of the relayed interventions (84.5%) were accepted. The number of home medications was the only variable significantly associated with the number of REs (β 0.492; p < 0.001). Conclusion Pharmacy-led medication reconciliation upon admission to orthopedic surgery department can reduce reconciliation errors and improve medication safety. Trial registration Retrospectively registered in the Lebanon Clinical Trials Registry (LBCTR2020124680).

scholarly journals Pharmacy student-assisted medication reconciliation: Number and types of medication discrepancies identified by pharmacy students

2021 ◽  
Vol 19 (3) ◽  
pp. 2471
Author(s):  
Louise Deep ◽  
Carl R. Schneider ◽  
Rebekah Moles ◽  
Asad E. Patanwala ◽  
Linda L. Do ◽  
...  
Keyword(s):  
Patient Safety ◽  
Medication Reconciliation ◽  
Alimentary Tract ◽  
Common Type ◽  
Pharmacy Students ◽  
Transitions Of Care ◽  
Patient Harm ◽  
Medication Discrepancies ◽  
Retrospective Audit ◽  
Hospital Inpatients

Background: Medication reconciliation aims to prevent unintentional medication discrepancies that can result in patient harm at transitions of care. Pharmacist-led medication reconciliation has clear benefits, however workforce limitations can be a barrier to providing this service. Pharmacy students are a potential workforce solution. Objective: To evaluate the number and type of medication discrepancies identified by pharmacy students. Methods: Fourth year pharmacy students completed best possible medication histories and identified discrepancies with prescribed medications for patients admitted to hospital. A retrospective audit was conducted to determine the number and type of medication discrepancies identified by pharmacy students, types of patients and medicines involved in discrepancies. Results: There were 294 patients included in the study. Overall, 72% (n=212/294) had medication discrepancies, the most common type being drug omission. A total of 645 discrepancies were identified, which was a median of three per patient. Patients with discrepancies were older than patients without discrepancies with a median (IQR) age of 74 (65-84) vs 68 (53-77) years (p=0.001). They also took more medicines with a median (IQR) number of 9 (6-3) vs 7 (2-10) medicines per patient (p<0.001). The most common types of medicines involved were those related to the alimentary tract and cardiovascular system. Conclusions: Pharmacy students identified medication discrepancies in over 70% of hospital inpatients, categorised primarily as drug omission. Pharmacy students can provide a beneficial service to the hospital and contribute to improved patient safety by assisting pharmacists with medication reconciliation.

scholarly journals Assessing the knowledge, perception and practices of physicians and pharmacists towards medication reconciliation in Kuwait governmental hospitals: a cross-sectional study

BMJ Open ◽  
2019 ◽  
Vol 9 (6) ◽  
pp. e027395
Author(s):  
Jacinthe Lemay ◽  
Tania Bayoud ◽  
Hajer Husain ◽  
Prem Sharma
Keyword(s):  
Patient Safety ◽  
Medication Reconciliation ◽  
Improve Patient Safety ◽  
Cross Sectional Study ◽  
Successful Implementation ◽  
Sectional Study ◽  
Hospital Policy ◽  
Cross Sectional ◽  
Attitudes And Practices ◽  
Self Administered Questionnaire

ObjectivesTo assess the knowledge, perception and practices towards medication reconciliation (MedRec) and its related institutional policies among physicians and pharmacists in governmental hospitals in Kuwait and identifying potential obstacles that prevent the successful implementation of MedRec.DesignA descriptive, cross-sectional study.SettingSix governmental hospitals across Kuwait in January–May 2017.Participants351 physicians and 214 pharmacists.Brief interventionA self-administered questionnaire distributed to the participants.Main outcome measuresKnowledge, perception, attitudes and practices of hospital physicians and pharmacists towards MedRec, and major barriers to implementing a MedRec process in their institution/department.ResultsOf the 739 questionnaires distributed, 565 were completed (351 physicians and 214 pharmacists), giving a response rate of 76.5%. Results showed that most participants were familiar with the term MedRec (n=419; 75.2%) with significantly more pharmacists compared with physicians (n=171; 81.8% vs n=248; 71.3%; p=0.005). Most participants (n=432; 80.0%) reported perceiving MedRec as a valuable process for patient safety. However, significantly more physicians compared with pharmacists were aware of a MedRec policy in their institution (n=195; 55.9% vs n=78; 37.9%; p<0.001) and routinely asked patients about their current list of medication on arrival (n=339; 96.6% vs n=129; 61.1%; p<0.001) and provided an updated list on discharge (n=281; 80.1% vs n=107; 52.0%; p<0.001). These results are supported by the findings that participants perceived physicians as providers, mainly responsible for various steps of MedRec.ConclusionsOverall, this study showed low awareness among physicians and pharmacists of hospital policy despite MedRec being perceived as valuable. Physicians were the providers most responsible and involved in MedRec, who may be driven by the policy putting them at core of the process. The current findings could pave the way for the expansion of the existing MedRec policies and processes in Kuwait to include pharmacists and improve patient safety.

scholarly journals Beyond the corrective action hierarchy: A systems approach to organizational change

2020 ◽  
Vol 32 (7) ◽  
pp. 438-444 ◽  
Author(s):  
Laura J Wood ◽  
Douglas A Wiegmann
Keyword(s):  
Patient Safety ◽  
Systems Approach ◽  
Improve Patient Safety ◽  
Systems Change ◽  
Corrective Action ◽  
Patient Harm ◽  
Corrective Actions ◽  
Definition Of ◽  
Transformative Approach ◽  
Improve Patient

Abstract Background Many patient safety organizations recommend the use of the action hierarchy (AH) to identify strong corrective actions following an investigative analysis of patient harm events. Strong corrective actions, such as forcing functions and equipment standardization, improve patient safety by either preventing the occurrence of active failures (i.e. errors or violations) or reducing their consequences if they do occur. Problem We propose that the emphasis on implementing strong fixes that incrementally improve safety one event at a time is necessary, yet insufficient, for improving safety. This singular focus has detracted from the pursuit of major changes that transform systems safety by targeting the latent conditions which consistently underlie active failures. To date, however, there are no standardized models or methods that enable patient safety professionals to assess, develop and implement systems changes to improve patient safety. Approach We propose a multifaceted definition of ‘systems change’. Based on this definition, various types and levels of systems change are described. A rubric for determining the extent to which a specific corrective action reflects a ‘systems change’ is provided. This rubric incorporates four fundamental dimensions of systems change: scope, breadth, depth and degree. Scores along these dimensions can then be used to classify corrective actions within our proposed systems change hierarchy (SCH). Conclusion Additional research is needed to validate the proposed rubric and SCH. However, when used in conjunction with the AH, the SCH perspective will serve to foster a more holistic and transformative approach to patient safety.

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