Unintentional medication discrepancies are common and more often due to errors taking an accurate medication history than errors reconciling this history with patient orders. Focusing on accurate medication histories, on potential medication errors at discharge, and on identifying high-risk patients for more intensive interventions may improve medication safety during and after hospitalization.
A computerized medication reconciliation tool and process redesign were associated with a decrease in unintentional medication discrepancies with potential for patient harm. Software integration issues are likely important for successful implementation of computerized medication reconciliation tools.
Clinicians usually employ indirect measures of cognitive and physical function in order to assess medical decision-making capacity. We tested a reference group of well elderly (Mini-Mental State Exam [MMSE] score = 29.1 +/- 0.8, mean +/- SD), for their understanding of three increasingly complex, hypothetical treatment situations or "vignettes"--use of a hypnotic, need for thoracocentesis, and desire for CPR. From this, we have developed a more direct, Guttman-like assessment of decision-making capacity. Of 51 Veterans Affairs nursing home residents (MMSE score = 22.4 +/- 6.9), only 33.3% demonstrated intact decision-making capacity by this method, whereas 77% were felt by their primary physicians to be capable of giving consent for oral surgery; 37.3% had very impaired decision-making capacity; and 29.4% were intermediate in this ability. Judged against our more direct assessment of decision-making capacity, primary physicians' judgment of capacity for consent was 31% to 39% sensitive in identifying impaired decision-making and the MMSE was 53% to 63% sensitive. These measures were 100% and 82% to 83% specific in identifying intact decision-making capacity, respectively. We conclude that (1) more directly assessed decision-making capacity varies noticeably among elderly nursing home residents and correlates in only limited fashion with frequently used cognitive screening methods; and (2) cognitive screening tests underestimate the prevalence of impaired decision-making capacity in this population. For informed consent and advance directives, our study suggests that decision-making capacity should be directly, rather than indirectly, assessed.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.