Analysis of an electronic medication reconciliation and information at discharge programme for frail elderly patients

Abstract

Background During care transitions, discrepancies and medication errors often occur, putting patients at risk, especially older patients with polypharmacy. Objective To assess the results of a medication reconciliation and information programme for discharge of geriatric patients conducted through hospital information systems. Setting A 1300-bed university hospital in Madrid, Spain. Method A prospective observational study. Geriatricians selected candidates for medication reconciliation at discharge, and sent an electronic inter-consultation request to the pharmacy department. Pharmacists reviewed the medication list, comparing it with electronic prescriptions, medication previously prescribed by primary care physicians and other medical records, and resolved any discrepancies. An individualized and tailored drug information at discharge sheet was sent to geriatricians and made available to primary care physicians. Main outcome measure The number and type of discrepancies, the number, type and severity of errors, and the main pharmacological groups involved. Results Medication reconciliation was performed for 118 patients with a mean age of 87 years (SD 5.9), involving a total of 2054 medications, or 17.4 per patient. Discrepancies were found in 723 (35 %) drugs, 105 of which were considered medication errors (15 %); 66 patients (56 %) had at least one error. This gave 0.9 reconciliation errors per patient reviewed and 1.6 per patient with errors. Of the 105 errors, 14 (13 %) were considered serious. The most frequent errors were incomplete prescriptions (40 %) and omissions (35 %). Conclusion An electronic medication reconciliation programme helps pharmacists detect serious medication errors in frail elderly patients and provides complete and up-to-date written information to prevent additional errors at home.

Facilitating holistic continuity of care for older patients: Home care nurses’ experiences using checklists

“…Patients' transfers from one healthcare setting to another have proven to be a critical point where a range of problems may occur (Tingle, 2016). Examples of such challenges include limited clinical information flow, insufficient updated documentation (Melby, Brattheim, & Hellesø, 2015;Nelson & Carington, 2011) and medication-related errors (Agud et al, 2016;Tong, Choo, Ooi, & Newnham, 2015). With high rates of chronic conditions and often complex medical treatment, older patients often receive care from many healthcare providers and move frequently within different healthcare settings.…”

Medication discrepancies across multiple care transitions: A retrospective longitudinal cohort study in Italy

“…Medication reconciliation is a formal process that involves matching the medicines that the patient should be prescribed with those that are actually prescribed and involves adequately reporting any therapy change [ 3 , 11 ]. Medication reconciliation has been identified in the literature as an important tool for preventing pharmacological discrepancies and the World Health Organization, in the “ Action on Patient Safety” , considers medication reconciliation to be one of the five top strategies for ensuring patient safety [ 12 ].…”

“…The problem of medication discrepancies that occur during the entire care pathway from hospital admission to a local care setting discharge (namely, all types of settings dedicated to formal care other than hospitals) has received little attention in the medical literature. Indeed, there are studies in the literature on single points of transitions of care: most analyze discrepancies upon hospital admission or discharge [ 3 , 4 , 14 – 18 ], and little is known about the prevalence of medication discrepancies upon admission or discharge from local care settings, such as the home and rehabilitation facilities [ 1 , 19 ]. According to the literature unintended medication discrepancies occurred in 25%-70% of hospital admissions and in 33%-96% of hospital discharges [ 4 , 6 , 20 – 22 ] and up to 71% of patients admitted to local care settings [ 1 , 19 ].…”

The PHARMS (Patient Held Active Record of Medication Status) feasibility study: a research proposal

“…Medication error during transitional care is an important patient safety issue and establishing effective medication reconciliation strategies is currently an international priority [ 11 – 13 ]. Benefit has been demonstrated with use of electronic systems of medication reconciliation during transitional care [ 19 , 21 , 22 , 35 ]. Prior research has highlighted firstly the importance of integration of medication information between primary and secondary care [ 35 ] and secondly the need for multidisciplinary and patient involvement [ 35 , 36 ].…”

“…Benefit has been demonstrated with use of electronic systems of medication reconciliation during transitional care [ 19 , 21 , 22 , 35 ]. Prior research has highlighted firstly the importance of integration of medication information between primary and secondary care [ 35 ] and secondly the need for multidisciplinary and patient involvement [ 35 , 36 ]. To date there is no consensus regarding the most effective method [ 18 ] and the patient held electronic medication record represents a novel method of electronic medication reconciliation.…”