Medication Reconciliation Accuracy and Patient Understanding of Intended Medication Changes on Hospital Discharge

Abstract

BACKGROUND: Adverse drug events after hospital discharge are common and often serious. These events may result from provider errors or patient misunderstanding. OBJECTIVE: To determine the prevalence of medication reconciliation errors and patient misunderstanding of discharge medications. DESIGN: Prospective cohort study SUBJECTS: Patients over 64 years of age admitted with heart failure, acute coronary syndrome or pneumonia and discharged to home. MAIN MEASURES:We assessed medication reconciliation accuracy by comparing admission to discharge medication lists and reviewing charts to resolve discrepancies. Medication reconciliation changes that did not appear intentional were classified as suspected provider errors. We assessed patient understanding of intended medication changes through post-discharge interviews. Understanding was scored as full, partial or absent. We tested the association of relevance of the medication to the primary diagnosis with medication accuracy and with patient understanding, accounting for patient demographics, medical team and primary diagnosis. KEY RESULTS: A total of 377 patients were enrolled in the study. A total of 565/2534 (22.3 %) of admission medications were redosed or stopped at discharge. Of these, 137 (24.2 %) were classified as suspected provider errors. Excluding suspected errors, patients had no understanding of 142/205 (69.3 %) of redosed medications, 182/223 (81.6 %) of stopped medications, and 493 (62.0 %) of new medications. Altogether, 307 patients (81.4 %) either experienced a provider error, or had no understanding of at least one intended medication change. Providers were significantly more likely to make an error on a medication unrelated to the primary diagnosis than on a medication related to the primary diagnosis (odds ratio (OR) 4.56, 95 % confidence interval (CI) 2.65, 7.85, p<0.001). Patients were also significantly more likely to misunderstand medication changes unrelated to the primary diagnosis (OR 2.45, 95 % CI 1.68, 3.55), p<0.001). CONCLUSIONS: Medication reconciliation and patient understanding are inadequate in older patients postdischarge. Errors and misunderstandings are particularly common in medications unrelated to the primary diagnosis. Efforts to improve medication reconciliation and patient understanding should not be diseasespecific, but should be focused on the whole patient.

Care Transition Experiences of Older Veterans and Their Caregivers: Table 1:

“…Many of these medical errors and adverse events are potentially preventable by improving communication between hospital staff, patients, and caregivers. Studies indicate that patients are routinely discharged with test results pending; unresolved plans for follow-up tests, appointments, or both; vague discharge orders; and insufficient contact with their physicians ( Ziaeian, Araujo, Van Ness, & Horwitz, 2012). This lack of communication and coordination results in patients being uninformed or misinformed about their illnesses or medications, lacking follow-up resources, and being not fully prepared to manage their own health ( Lum, Studenski, Degenholtz, & Hardy, 2012).…”

Using HCAHPS data to model correlates of medication understanding at hospital discharge

“…21 Other studies have found that patients' perceptions of understanding their discharge instructions, including medications, do not indicate actual understanding in the older adult population. 22,23 Ziaeian et al 22 found that by interviewing patients aged 64 and over and asking them to name their medications, misunderstanding about medication changes, such as dose changes, new medications, and stopping medications, occurred as often as 88.7% of the time. Despite patients' perceptions of understanding each of their medications well, as observed in the present study, these perceptions may not accurately reflect patients' understanding.…”

Medication-Related Factors Affecting Discharge to Home

“…23) Pharmacists can be helpful as a resource for medication reconciliation. 24,25) The process also provides an opportunity for clinicians to ensure that patients understand which medications they are consuming, how to consume them, and why they are consuming them. [26][27][28][29][30] From this study, the importance of care for cognitive function and excretion in home care is clarified.…”