Background
The first Multi-center Medication Reconciliation Quality Improvement Study (MARQUIS1) demonstrated that implementation of a medication reconciliation best practices toolkit decreased total unintentional medication discrepancies in five hospitals. We sought to implement the MARQUIS toolkit in more diverse hospitals, incorporating lessons learned from MARQUIS1.
Methods
MARQUIS2 is a pragmatic, mentored implementation QI study which collected clinical and implementation outcomes. Sites implemented a revised toolkit, which included interventions from these domains: 1) best possible medication history (BPMH)-taking; 2) discharge medication reconciliation and patient/caregiver counseling; 3) identifying and defining clinician roles and responsibilities; 4) risk stratification; 5) health information technology improvements; 6) improved access to medication sources; 7) identification and correction of real-time discrepancies; and, 8) stakeholder engagement. Eight hospitalists mentored the sites via one site visit and monthly phone calls over the 18-month intervention period. Each site’s local QI team assessed opportunities to improve, implemented at least one of the 17 toolkit components, and accessed a variety of resources (e.g. implementation manual, webinars, and workshops). Outcomes to be assessed will include unintentional medication discrepancies per patient.
Discussion
A mentored multi-center medication reconciliation QI initiative using a best practices toolkit was successfully implemented across 18 medical centers. The 18 participating sites varied in size, teaching status, location, and electronic health record (EHR) platform.
We introduce barriers to implementation and lessons learned from MARQUIS1, such as the importance of utilizing dedicated, trained medication history takers, simple EHR solutions, clarifying roles and responsibilities, and the input of patients and families when improving medication reconciliation.
Pharmacy transitions-of-care services at the time of hospital discharge are helpful in reducing medication errors. Validated risk tools are commonly used by pharmacists to identify patients at greatest benefit of these services. However, current tools lack assessment of medication-related risk factors and predict hospital readmissions rather than medication errors. To address this, a novel medication-focused risk tool (UCSD-Rx risk score) was created to help classify patients at a higher risk for medication errors. This study was split into 2 phases aimed to internally validate the risk score. Phase I of the study compared the predictability of 30-day unplanned readmissions between the UCSD-Rx risk score and a well-validated risk tool, the LACE+ index. To further specify our risk score for pharmacist use, phase II of the study analyzed the predictability of the risk score to medication errors at discharge. Phase I demonstrated similar classification performance of 30-day unplanned readmissions between the UCSD-Rx risk score (C-statistic, 0.66; 95% confidence interval [CI], 0.64-0.68; P < .0001) and the LACE+ index (C-statistic, 0.69; 95%CI, 0.67-0.71; P < .0001). In phase II, logistic regression showed an increasing UCSD-Rx risk score was predictive of individuals who would experience a medication error at discharge (odds ratio, 1.068; 95%CI, 1.005-1.136; P = .035). Results of this study demonstrate that the UCSD-Rx risk score is a promising tool targeted for pharmacist use to identify patients that may benefit most from transitions-of-care services prior to discharge.
Background: Unfractionated heparin (UFH) infusions are commonly managed with nurse-driven nomograms titrated to activated partial thromboplastin time (aPTT). In some patients, anti-Xa values may be more appropriate measures of anticoagulation. At the present institution, an update to the nurse-driven aPTT nomogram requires pharmacist notification and clinical assessment for critically supratherapeutic aPTT results. Objective: The purpose of this study was to evaluate the efficacy and safety of the nomogram update. Methods: A single-center, retrospective, pre-post analysis was conducted in patients treated with UFH who experienced a critical aPTT during the 6 months preceding and following the nomogram update. Patients with erroneous critical aPTT results were excluded. The primary endpoint was the time in therapeutic range (Rosendaal method) from the first critical aPTT until UFH discontinuation. Secondary endpoints included the proportion of patients transitioned to anti-Xa monitoring and the incidence of Bleeding Academic Research Consortium (BARC) 2, 3, 5 bleeding. Data were analyzed by the χ2 test. The study was institutional review board approved. Results: Of 277 UFH infusions, 142 belonged to the pre-implementation group and 135 to the post-implementation group. Baseline aPTTs were similar between the 2 groups. Time in therapeutic range was 58.1% versus 62.4% of between groups ( P = .467). UFH was transitioned to pharmacist-driven anti-Xa monitoring in 16.2% versus 40.3% of patients ( P < .001). BARC 2, 3, 5 bleeding occurred in 23.2% versus 13.4% of patients ( P < .001). Conclusions: Application of these data suggest improved safety and efficacy outcomes with directed pharmacist management of UFH in patients with critically elevated aPTTs.
Background: Current literature suggests that patients with psychiatric disorders are at an increased risk for inpatient readmission. This study evaluated the impact of pharmacist-driven discharge medication reconcilliation (DMR) on readmission rates of patients discharged with one or more psychotropic medications. Methods: This study was a retrospective review of patients receiving a pharmacist-driven DMR. The primary outcome was to compare the prevalence of 30-day readmission rates among patients who had a pharmacist DMR between patients who had at least one psychotropic medication upon discharge versus those without psychotropic medications. Secondary objectives were to (1) compare the number of medication discrepancies and pharmacist interventions prior to discharge and (2) compare prevalence of medical comorbidities between patients who had at least one psychotropic medication upon discharge versus those without psychotropic medications. Results: A total of 151 subjects were included who had a DMR and either at least one psychotropic medication at discharge (n = 69) or no psychotropic medications at discharge (n = 82). The 30-day readmission rates were similar between both groups ( P = .609). The mean number of discrepancies ( P < .001) and number of pharmacist interventions ( P = .005) were significantly greater in patients who had at least one psychotropic medication upon discharge compared to those without psychotropic medication. Conclusions: The prevalence of 30-day readmissions was similar between the two groups; however, patients discharged with at least one psychotropic medication had a greater number of discrepancies requiring significantly more discharge interventions during a pharmacist DMR.
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