Reducing medication errors at transitions of care is everyone's business

Abstract

Medication errors are a common and significant problem, particularly when patients transition between healthcare providers. Discrepancies are especially prevalent on hospital admission and discharge. People with complex medication regimens, older people, those with mental health problems, people who are poor or have low literacy, and Aboriginal and Torres Strait Islander and migrant populations are particularly at risk of medication discrepancies. A patient-centred approach is a necessary shift towards reducing medication discrepancies and errors. The patient is the one 'constant' as they progress through GP and ancillary primary care services, hospital services, and specialist outpatient and private clinics. Patients and their carers need to be involved as active participants in this process. Maintaining an accurate, comprehensive and up-to-date medicines list that follows the patient, reduces serious medication error. Pivotal to this record is a medicines reconciliation review at error-prone transition points. Multiple health professionals involved in a patient's journey through healthcare services need to embrace accountability for medicines-related outcomes. Emerging technologies for communication between primary care and specialist or secondary services will facilitate this, but importantly, there needs to be commitment from each health professional to undertake this approach. medicines GPs think they are taking at home, medicines listed in GP referral letters, medicines people obtain from pharmacies, the medicines recorded when they are admitted to hospital, and when they leave hospital, and the medicines detailed in their official discharge summary. These discrepancies often relate to medicine omissions. 6-8 In mental health community care, medication discrepancies cause particular problems. Psychiatrists often remain involved in prescribing and reviewing psychotropic medicines, while GPs are expected to manage medicines related to other conditions. Patients may take a number of medicines in complex regimens so there is a high potential for drug interactions, particularly given the substantial comorbidity and mortality rates in this population. 9,10 Recent research on clozapine has shown that discrepancies with concomitant medications can have potentially fatal outcomes (see Box). 11,12 Indigenous or migrant people, and those who are socially disadvantaged or have low literacy, experience health outcomes that reflect their difficulties when navigating the healthcare system. 13-16 Culturally appropriate delivery of health services is crucial to effective engagement and uptake, and this may be challenging to do well.

Understanding Philippines Nurses' Competency in the Delivery of Healthcare Services

“…It is alleged caused by nurses, who are fatigued, tired, or stressed that led to incapability of providing quality care that they are essential to offer and are at an excessive risk of making mistakes leading to damage, or even worse, patient mortality. Consequently, medication inconsistencies and mistakes occurring from deficiency of care synchronization for healthcare is a great challenge [13]. Moreover, another study uses public data of 1990-2014 National Practitioner Data Bank and identifies the highest fraction of malpractice that indicates implicating nurses were diagnosis-related (41.46%) and treatmentrelated (30.79%) [14].…”

The Case Against

“…There are significant gaps in the quality of care provided to patients at transitions, from clinician to clinician and between settings in Australia — this is not disputed or new, and issues associated with medication are major contributors to the gaps in care at times of transition . This includes transition at hospital admission and at discharge.…”

“…There continues to be a high level of medication errors at transition into hospital and at discharge. There is evidence that more errors arise at hospital admission than at other times and, in many instances, errors relating to medications are not identified during hospitalisation and then flow through to discharge . In fact, the World Health Organization (WHO) third global patient safety challenge (Medication Without Harm) was launched in 2017 with the goal of reducing severe, avoidable medication‐related harm by 50% globally in the next 5 years .…”

“…The challenge has defined three flagship areas for improvement: polypharmacy, high‐risk situations and transitions of care. There are some fundamental principles for improving transitions of care, including obtaining a proper preadmission medication list, avoiding reconciliation errors, reviewing medication and planning patient and provider follow‐up …”

Inpatient Medication Errors and Pharmacist Intervention at Ministry of Health Public Hospital, Riyadh, Saudi Arabia

“…11 Pharmacists' interventions were clinically estimated. 12 Worldwide, several investigations have been conducted related to the pharmacist's intervention and prevention of MEs, [13][14][15][16][17][18][19][20][21] whereas similar studies conducted locally in KSA are scarce. 22 To the best of our knowledge, there are no studies conducted locally or in Gulf or in Middle Eastern countries regarding the pharmacist's role in preventing MEs in inpatient setting.…”