507428 research-article2013
AOP471210.1177/1060028013507428Annals of PharmacotherapyBuckley et al
Research Report
Impact of a Clinical Pharmacy Admission Medication Reconciliation Program on Medication Errors in “High-Risk” Patients
Annals of Pharmacotherapy 47(12) 1599–1610 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1060028013507428 aop.sagepub.com
Mitchell S. Buckley, PharmD, FCCM, BCPS1, Lisa M. Harinstein, PharmD, BCPS2, Kimberly B. Clark, PharmD, BCPS3, Pamela L. Smithburger, PharmD, BCPS4,5, Doug J. Eckhardt, MS6, Earnest Alexander, PharmD, FCCM7, Sandeep Devabhakthuni, PharmD, BCPS8, Craig A. Westley, PharmD1, Butch David, RPh1, and Sandra L. Kane-Gill, PharmD, MSc, FCCM, FCCP4,5
Abstract Background: Medication errors are common upon hospital admission. Clinical pharmacist involvement in medication reconciliation is effective in identifying and rectifying medication errors. However, data is lacking on the economic impact, time requirements, and severity of errors resolved by clinical pharmacists. Objective: To determine the incidence of unintended admission medication discrepancies resolved by clinical pharmacists. Secondary objectives were to determine the type of discrepancies, potential severity, proximal cause, and economic impact of this clinical pharmacy program. Methods: This was a single-center, prospective, observational study conducted at a major teaching medical institution. Following institutional review board approval, data collection was conducted over a 4-week period (August 22, 2011, to September 16, 2011). Descriptive statistical methods were performed for all data analyses. Results: A total of 517 patients involving 5006 medications were included in this study. More than 25% (n = 132) of patients had at least 1 error associated with a medication ordered on hospital admission. Pharmacists resolved a total of 467 admission medication errors (3.5 ± 2.3 errors/patient). The most common type of medication error resolved was medication omission (79.6%). In regard to severity, 46% of medication errors were considered significant or serious. Overall, the mean total time was 44.4 ± 21.8 minutes per medication reconciliation. This clinical pharmacy program was estimated to carry a net present value of $5.7 million over 5 years. Conclusion: Clinical pharmacist involvement within a multidisciplinary health care team during the admission medication reconciliation process demonstrated a significant improvement in patient safety and an economic benefit. Keywords clinical pharmacy, medication safety, medication errors, medication reconciliation
Background The annual incidence of preventable adverse drug events (ADEs) resulting from medication errors in hospitalized patients is estimated at 400 000 events, which translates into a rate of approximately 1 medication error per patient per hospital-day.1 Several adverse clinical sequelae are associated with medication errors and ADEs. Hospital length of stay has been shown to increase up to an additional 4.6 days, whereas the mortality risk almost doubles.2 The economic impact is also significant, with estimated costs ranging from approximately $3500 to $4700 per preventable ADE, which amounts to more than $2.8 million annually.2,3 Most investigations into medication errors have determined that a significant portion of these misadventures
are preventable.4-7 Medication reconciliation is one of several strategies recommended to reduce preventable medication errors.8 1
Banner Good Samaritan Medical Center, Phoenix, AZ, USA Cleveland Clinic, Cleveland, OH, USA 3 Greenville Health System, Greenville, SC, USA 4 University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA 5 University Pittsburgh Medical Center, Pittsburgh, PA, USA 6 Banner Health, Phoenix, AZ, USA 7 Tampa General Hospital, Tampa, FL, USA 8 University of Maryland Medical Center, Baltimore, MD, USA 2
Corresponding Author: Mitchell S. Buckley, Department of Pharmacy, Banner Good Samaritan Medical Center, 1111 E McDowell Rd, Phoenix, AZ 85006, USA. Email: [email protected]
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The medication reconciliation process is described as verifying medication use, identifying discrepancies, and resolving any medication-related issues during all transitions of the hospital stay (admission, transfer of care, and discharge).9 Although medication errors have the potential to occur throughout the entire hospitalization, the admission process has been shown to be a particularly vulnerable area in terms of medication safety. At least 1 medication error relating to an insufficient admission drug history occurs in up to 67% of hospitalized patients, with approximately 39% of these errors considered moderate to severe in nature.10 Overall, 27% of hospital medication errors are a result of inaccurate or incomplete medication histories on admission.10 When looking specifically at the different types of medication errors, drug therapy omission and inaccurate dosing regimens are the most common types of errors observed.11 Implementation of an established medication reconciliation process may reduce medication errors and ADEs in hospitals by 46% and 20%, respectively.8 The Joint Commission established medication reconciliation as a National Patient Safety Goal in 2006 as a required means to improve patient safety.9 However, hospitals are presented with significant challenges in implementing and performing this process.11 Major obstacles in completing an accurate and timely medication history may include patient (cognitive and language barriers) and health care (dedicated personnel and technology) factors.11 Additionally, the interviewer’s drug therapy knowledge is a potential barrier to successful medication reconciliation.11 One strategy to overcome this barrier and improve the medication reconciliation process is to incorporate the pharmacist either as a collaborative member in a multidisciplinary team or as the primary health care provider responsible for performing this activity. Pharmacist-conducted patient drug histories have resulted in lower medication discrepancy rates when compared with histories taken by other health care professionals.12,13 Pharmacist involvement within the medication reconciliation process has also been shown to improve the effectiveness of identifying and rectifying these discrepancies.9-24 However, these studies were not comprehensive in measuring the impact of the pharmacist’s involvement on discrepancy rates, the types of discrepancies identified, and the potential severity of medication errors within the admission medication reconciliation process.9-24 We believe this evaluation to be unique in the assessment of clinical pharmacists’ impact on the admission medication reconciliation by incorporating discrepancy rates, error types, severity, and economic value in a high-risk patient population. The purpose of this study was to evaluate the incidence of unintended admission medication discrepancies resolved by pharmacist-conducted medication histories compared with other health care providers performing drug use histories and admission medication orders. The
type of discrepancies, potential ADE severity, proximal cause, and economic value were also evaluated.
Methods This was a single-center, prospective, observational study conducted at a major teaching medical institution (Banner Good Samaritan Medical Center, Phoenix, AZ; 668-bed quaternary care medical center), with an average daily admission rate of about 93.8 adult patients per day and >34 000 adult inpatient admissions annually. Individuals were included if admission medication reconciliation was performed by a pharmacist either at the request of the health care provider or after meeting the established criteria initiating pharmacist review. Patients 25% of all patients had at least 1 medication error associated with medications prescribed on hospital admission, whereas the published literature has shown 1.4% to 53.6% of patients to have had at least 1 error. Again, there is large variation between these numbers. One study with methods, sample size, and statistical analyses similar to ours showed a percentage of patients with at least 1 medication reconciliation error that was comparable to ours (35.9%).31 Agrawal and Wu9 showed a very low rate of medication reconciliation admission errors (1.4%). This finding may be explained by a sample size of >19 000 medication reconciliation events, and the use of an electronic system for medication reconciliation.9 One study did not find a significant association between the number of medications a patient was receiving and the rate of medication reconciliation errors found.11 However, other studies have found the number of medications to be an independent predictor. Compiling the findings from our study and prior studies emphasizes the importance of incorporating pharmacists into the whole
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medication reconciliation process to detect errors and make clinical interventions, not just document medication histories. The most common type of medication discrepancies involving the admission home medication list was omission orders followed by wrong frequency, wrong dosage, unnecessary medication, and wrong route. These findings are similar to that of other published studies in which omission errors occurred most often.10 If not detected, discrepancies at admission may persist throughout the patient’s entire hospitalization. Therefore, a comprehensive medication reconciliation process on admission as well as during all transitions of care and on discharge is needed to document the patient’s home medications but also to continuously evaluate optimal drug therapy throughout the continuum of care. This is vital because those admission medication discrepancies, which may have been insignificant or missed at admission, could become potentially serious ADEs by the time the patient is ready for discharge. To our knowledge, this is one of the first studies to evaluate the proximal causes contributing to the unintended medication discrepancies on hospital admission. Identification of proximal causes is a way to determine weaknesses in the medication reconciliation process where special attention should be focused to prevent future discrepancies. The majority of errors were a result of inaccurate or missing documentation followed by errors associated with a lack of clinician knowledge. Both the main proximal causes may be mitigated by having a pharmacy technician/ pharmacist team specifically trained at performing medication histories and reconciliation take part in the process. Pharmacists were able to resolve many of the errors. This reduction was most likely a result of the pharmacists’ more complete medication assessments and their clinical training regarding medications. Several studies have described the potential severity of medication discrepancies during the medication reconciliation process.11,14,16,18-22 Previously published reports have estimated clinically significant or serious medication errors to occur commonly. We found that 45.5% of our medication errors were classified as significant or serious in nature, which is comparable to the findings of other studies. Wong et al22 estimated that 29.5% of medication discrepancies identified during the discharge medication reconciliation process had the potential to cause possible/probable patient discomfort or clinical deterioration. Another study found that 38.6% of errors during admission medication reconciliation were considered potentially moderately harmful or severe.11 However, other studies have reported significant or serious errors to approach about 58% to 72%, which was higher than what was observed during this investigation.14,16,19 The true incidence of serious or fatal medication errors identified during medication reconciliation remains
unknown. Comparison among studies is difficult because of differences in the severity definitions, methods incorporated to evaluate these errors subjectively into an objective scale, patient population, and the stage of the medication reconciliation process (admission, discharge, both, etc) investigated. However, unlike previously published reports, we have reported the drug class and error types more commonly associated with serious medication errors. Our study included pharmacy technicians in the medication history process. After receiving the necessary training, the technician was responsible for performing the initial medication history, using multiple information sources to obtain the most accurate history possible. Previous studies have shown that technicians can accurately complete medication histories. van den Bemt et al32 looked at using pharmacy technicians to obtain medication histories in a preoperative screening clinic. A total of 93 medication histories were completed by the technician with no corrections needed after review by a pharmacist. Another study by Johnston et al33 directly compared medication histories obtained by technicians versus pharmacists in the emergency department setting and found no difference in the number or severity of discrepancies between the 2 histories. The pharmacy technicians involved in both these studies underwent extensive training prior to collecting histories. With the appropriate clinical training, it appears that technicians can reliably perform medication histories despite the fact that their familiarity and knowledge of drug therapy may not be as comprehensive as that of a pharmacist. Allowing pharmacy technicians to complete the medication history portion has several benefits. This change could alleviate or prevent a worsening of current pharmacist time constraints. In our study, the pharmacist spent on average 15.8 minutes in obtaining a medication history, with a mean of 30 medication histories completed per day. By having a technician complete this task, approximately 8 hours of additional pharmacist time per day are available to focus on other, more in-depth clinical activities. In addition to time, this shift in work could improve job satisfaction for both pharmacists and technicians. Finally, it allows pharmacists to put a greater emphasis on the reconciliation component of identifying discrepancies and errors. The cost driver for a pharmacist-led medication reconciliation service is the dedicated time for pharmacists’ participation. We determined that medication reconciliation conducted by a pharmacist was on average about 16 minutes per patient, which is less than the average reported in the literature, at 22 (range 12-46) minutes per patient.34 Our study also determined an additional 29 minutes per patient for the pharmacy technician evaluation, which would put this study on the higher end of the reported range, but from a cost perspective using technician time should provide a cost savings. Extrapolating the data to costs, reviewing 517
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Buckley et al patients in 4 weeks for this evaluation would require 34.5 hours of a pharmacist’s time per week. This would require that a minimum of 1.0 FTE for a pharmacist is available for this medication reconciliation service and 2.0 FTEs for a pharmacy technician for all patients. Potential additional costs beyond pharmacist time may include an increase in the prescriber’s time because of pharmacy contracting the provider to rectify all identified medication discrepancies in the prescriber’s time.34 Cost aversions include the prevention of medication errors and ADEs. Medication reconciliation has been shown to decrease ADEs by up to 43%, and this study identified that 45.6% of potential ADEs were averted.20,35 When a patient experiences an ADE in the hospital, there is an increase in the length of stay, hospital charges, and total costs for this patient when compared with those who do not experience an ADE.2 ADEs have also been shown to contribute to the loss of quality-adjusted life years (QALYs).34 One report found that up to 2.2 QALYs were gained per 1000 orders through the use of a pharmacist-led medication reconciliation process.34 Although there is an increased need for resources such as additional pharmacist time, the pharmacist-led medication reconciliation has overall net benefits because of the decrease in ADEs and increase in QALYs.34,36 Overall, our medication reconciliation program was estimated to save $1.3 million annually or $5.7 million over 5 years, and cost savings were upheld in the sensitivity analysis. Because a 50% variation in selected variables resulted in a positive net present value for this project, we found this clinical pharmacy program to be an attractive target for cost savings and quality improvement. It is also important that hospital staff understand the importance of medication reconciliation to increase acceptance and compliance with culture change. To increase the value providers place on the medication reconciliation process, the purpose, effectiveness, and cost benefits of medication reconciliation should be communicated to all health care providers involved in the process. This may need to be conveyed through various means of communication and education.37 Promotion by the leadership of the organization, department representatives, and “champions” for cultural change is needed across all health care institutions.37 The stakeholders need to support medication reconciliation endeavors as well as develop a process with specific and uniform tools that all health care practitioners involved with medication reconciliation can use.38 Electronic-based systems have also been shown to improve compliance rates by compelling the provider to document the medication reconciliation process.37 Our pilot study had a significant impact at our institution in justifying the essential role pharmacy technicians and pharmacists have in our medication reconciliation process. This demonstrated significant patient safety and an economic benefit. We continue to be involved with the
admission medication reconciliation process. Ideally, our goal would be to expand pharmacy involvement to all patient transitions of care (eg, intrafacility transfers and discharge).
Limitations Our study had several limitations. This single-center evaluation targeted high-risk patients as previously described, given the limited pharmacy resources we had to devote to the medication reconciliation process. Although we targeted patients based on our perception of those at risk of having drug therapy discrepancies, this was not a complete investigation for all patients admitted to our institution during the study period. Nonetheless, as in other institutions facing the challenges of optimizing pharmacy resource time, we implemented this strategy to balance pharmacist involvement in this process and to have the highest potential impact on ensuring appropriate continuation of medications on admission. Another possible limitation was that medication history interviews were performed by pharmacy technicians. Although familiarity with and knowledge of drug therapy in this population may not be as comprehensive as that of a pharmacist’s, technicians underwent extensive clinical training with the expectation that they would follow a written process. This process included established interview questions and interviews with the patient’s caretakers/ family members and outpatient pharmacy to ensure consistency as well as to increase the likelihood of identifying all active home medications. Also, the severity ranking was based on a review of the clinical scenario and involved medications. This subjective evaluation was reached by consensus, using methods similar to those in previously published reports. The proximal causes were subjective and determined by the clinical pharmacist performing the medication reconciliation process, which could have inaccurately estimated the true incidence of each cause. Finally, this evaluation focused on the admission reconciliation process. The full impact of pharmacy involvement during intrafacility transfer and discharge was not assessed.
Conclusion Medication discrepancies were common on hospital admission at our institution. Pharmacist involvement during the admission medication reconciliation process at our institution by targeting a high-risk patient population had a significant impact on reducing the number and severity of potential medication errors. The results of this study demonstrated the vital role of pharmacy technicians and pharmacists within the medication reconciliation process. Medication reconciliation programs at other institutions should incorporate a multidisciplinary approach to ensure safe and effective drug therapy throughout the continuum of care.
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Appendix Admission Medication Reconciliation History Form Pharmacy Name(s)/Location/Phone # (A) Primary:_____________________________________________ (B) Secondary:___________________________________________ (C) Alternate:____________________________________________ Medication (Name/Strength/Dose/Route/Frequency Date Filled
PATIENT NAME MRN
(1)
Patient Pt List Caregiver Rx Bottle Pharmacy MAR Unable to verify
Taking as prescribed NOT taking as prescribed NOT taking Patient Choice
Patient Pt List Caregiver Rx Bottle Pharmacy MAR Unable to verify
Taking as prescribed NOT taking as prescribed NOT taking Patient Choice
Patient Pt List Caregiver Rx Bottle Pharmacy MAR Unable to verify
Taking as prescribed NOT taking as prescribed NOT taking Patient Choice
Patient Pt List Caregiver Rx Bottle Pharmacy MAR Unable to verify
Taking as prescribed NOT taking as prescribed NOT taking Patient Choice
Patient Pt List Caregiver Rx Bottle Pharmacy MAR Unable to verify
Taking as prescribed NOT taking as prescribed NOT taking Patient Choice
Patient Pt List Caregiver Rx Bottle Pharmacy MAR Unable to verify
Taking as prescribed NOT taking as prescribed NOT taking Patient Choice
Patient Pt List Caregiver Rx Bottle Pharmacy MAR Unable to verify
Taking as prescribed NOT taking as prescribed NOT taking Patient Choice
Patient Pt List Caregiver Rx Bottle Pharmacy MAR Unable to verify
Taking as prescribed NOT taking as prescribed NOT taking Patient Choice
Patient Pt List Caregiver Rx Bottle Pharmacy MAR Unable to verify
Taking as prescribed NOT taking as prescribed NOT taking Patient Choice
Patient Pt List Caregiver Rx Bottle Pharmacy MAR Unable to verify
Taking as prescribed NOT taking as prescribed NOT taking Patient Choice
Comment: (2) Comment: (3) Comment: (4) Comment: (5) Comment: (6) Comment: (7) Comment: (8) Comment: (9) Comment: (10)
Source of Information
Patient Compliance
Comment:
A. B. C. D. E. F.
Is patient routinely taking OTC medication (including aspirin) Is patient routinely taking any vitamins/minerals/supplements or herbals? Is patient wearing any patches, using any eye/ear/nose drops/creams/ointments? Is patient using any medications to assist with breathing (i.e. inhalers of any kind)? Do you currently use any “sample” medications that your MD has provided you? Is patient using any INSULIN? (for diabetic patients only)
Yes Yes Yes Yes Yes Yes
No No No No No No
Patient Obstacles: Language Cognition Poor Historian Sight/Hearing Financial Non-compliance NONE PMH: HPI: Interviewer Name:__________________________________Date:__________________________________ Pharmacist Verifying Name:________________________________________________________________________
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Buckley et al Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
Authors’ Note This original research was presented as a poster at the 2012 American College of Clinical Pharmacy Annual Meeting on October 22, 2012.
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14. Climente-Martí M, García-Mañón ER, Artero-Mora A, Jiménez-Torres NV. Potential risk of medication discrepancies and reconciliation errors at admission and discharge from an inpatient medical service. Ann Pharmacother. 2010;44:1747-1754. doi:10.1345/aph.1P184. 15. Hayes BD, Donovan JL, Smith BS, Hartman CA. Pharmacistconducted medication reconciliation in an emergency department. Am J Health Syst Pharm. 2007;64: 1720-1723. 16. Vasileff HM, Whitten LE, Pink JA, Goldsworthy SJ, Angley MT. The effect on medication errors of pharmacists charting medication in an emergency department. Pharm World Sci. 2009;373-379. doi:10.1007/s11096-008-9271-y. 17. Unroe KT, Pfeiffenberger T, Rieglhaupt S, Jastrzembski J, Lokhnygina Y, Colon-Emeric C. Inpatient medication reconciliation at admission and discharge: a retrospective cohort study of age and other risk factors for medication discrepancies. Am J Geriatr Pharmacother. 2010;8:115-126. doi:10.1016/j.amjopharm.2010.04.002. 18. Vira T, Colquhoun M, Etchells E. Reconcilable differences: correcting medication errors at hospital admission and discharge. Qual Saf Health Care. 2006;15:122-126. 19. Nickerson A, MacKinnon NJ, Roberts N, Saulnier L. Drugtherapy problems, inconsistencies and omissions identified during a medication reconciliation and seamless care service. Healthc Q. 2005;8:65-72. 20. Schnipper JL, Hamann C, Ndumele CD, et al. Effect of an electronic medication reconciliation application and process redesign on potential adverse drug events: a cluster-randomized trial. Arch Intern Med. 2009;169:771-780. doi:10.1001/ archinternmed.2009.51. 21. Varkey P, Cunnningham J, O’Meara J, Bonacci R, Desai N, Sheeler R. Multidisciplinary approach to inpatient medication reconciliation in an academic setting. Am J Health Syst Pharm. 2007;64:850-854. 22. Wong JD, Bajcar JM, Wong GG, et al. Medication reconciliation at hospital discharge: evaluating discrepancies. Ann Pharmacother. 2008;42:1373-1379. doi:10.1345/aph.1L190. 23. Walker PC, Berstein SJ, Jones JN. Impact of a pharmacistfacilitated hospital discharge program: a quasi-experimental study. Arch Intern Med. 2009;169:2003-2010. doi:10.1001/ archinternmed.2009.398. 24. Comu P, Steurbaut S, Leysen T, et al. Effect of medication reconciliation at hospital admission on medication discrepancies during hospitalization and at discharge for geriatric patients. Ann Pharm. 2012;46:484-494. doi:10.1345/aph.1Q594. 25. Pedersen CA, Schneider PJ, Scheckelhoff DJ. ASHP national survey of pharmacy practice in hospital settings: monitoring and patient education-2012. Am J Health Syst Pharm. 2013;70:787-803. doi:10.2146/ajhp120777. 26. Classen DC, Pestotnik SL, Evans S, et al. Adverse drug events in hospitalized patients: excess length of stay, extra costs, and attributable mortality. JAMA. 1997;277:301-306. 27. Folli HL, Poole RI, Benitz WE, Russo JC. Medication error prevention by clinical pharmacists in two children’s hospitals. Pediatrics. 1987;79:718-722. 28. Duggal R, Budden MC. Assuring not-for-profit hospital competitiveness through proper accounting for the true cost of capital. J Bus Econ Res. 2010;8:1-6. 29. Reinhardt UE. The economics of for-profit and not-for-profit hospitals. Health Aff (Millwood). 2000;19:178-186.
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30. Mueller S, Sponsler KC, Kripalani S, Schnipper JL. Hospitalbased medication reconciliation practices: a systematic review. Arch Intern Med. 2012;172:1057-1069. doi:10.1001/ archinternmed.2012.2246. 31. Gleason KM, McDaniel MR, Feinglass J, et al. Results of the Medications at Transitions and Clinical Handoffs (MATCH) study: an analysis of medication reconciliation errors and risk factors at hospital admission. J Gen Intern Med. 2010;25: 441-447. doi:10.1007/s11606-010-1256-6. 32. van den Bemt PM, van den Broek S, van Nunen AK, Harbers JB, Lenderink AW. Medication reconciliation performed by pharmacy technicians at the time of preoperative screening. Ann Pharmacother. 2009;43:868-874. doi:10.1345/aph.1L579. 33. Johnston R, Saulnier L, Gould O. Best possible medication history in the emergency department: comparing pharmacy technicians and pharmacists. Can J Hosp Pharm. 2010;63: 359-365. 34. Karnon J, Campbell F, Czoski-Murray C. Model-based costeffectiveness analysis of interventions aimed at preventing
medication error at hospital admission (medicines reconciliation). J Eval Clin Pract. 2009;15:299-306. doi:10.1111/ j.1365-2753.2008.01000.x. 35. Boockvar KS, Blum S, Kugler A, et al. Effect of admission medication reconciliation on adverse drug events from admission medication changes. Arch Intern Med. 2011;171: 860-861. doi:10.1001/archinternmed.2011.163. 36. Bartick M, Baron D. Medication reconciliation at Cambridge Health Alliance: experiences of a 3-campus health system in Massachusetts. Am J Med Qual. 2006;21:304-306. 37. Evans AS, Lazar EJ, Tiase VL, et al. The role of housestaff in implementing medication reconciliation on admission at an academic medical center. Am J Med Qual. 2011;26:39-42. doi:10.1177/1062860610370712. 38. Bedard P, Trdif L, Ferland A, et al. A medication reconciliation form and its impact on the medical record in a paediatric hospital. J Eval Clin Pract. 2011;17:222-227. doi:10.1111/ j.1365-2753.2010.01424.x.
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AOP471210.1177/1060028013507428Annals of PharmacotherapyBuckley et al
Research Report
Impact of a Clinical Pharmacy Admission Medication Reconciliation Program on Medication Errors in “High-Risk” Patients
Annals of Pharmacotherapy 47(12) 1599–1610 © The Author(s) 2013 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1060028013507428 aop.sagepub.com
Mitchell S. Buckley, PharmD, FCCM, BCPS1, Lisa M. Harinstein, PharmD, BCPS2, Kimberly B. Clark, PharmD, BCPS3, Pamela L. Smithburger, PharmD, BCPS4,5, Doug J. Eckhardt, MS6, Earnest Alexander, PharmD, FCCM7, Sandeep Devabhakthuni, PharmD, BCPS8, Craig A. Westley, PharmD1, Butch David, RPh1, and Sandra L. Kane-Gill, PharmD, MSc, FCCM, FCCP4,5
Abstract Background: Medication errors are common upon hospital admission. Clinical pharmacist involvement in medication reconciliation is effective in identifying and rectifying medication errors. However, data is lacking on the economic impact, time requirements, and severity of errors resolved by clinical pharmacists. Objective: To determine the incidence of unintended admission medication discrepancies resolved by clinical pharmacists. Secondary objectives were to determine the type of discrepancies, potential severity, proximal cause, and economic impact of this clinical pharmacy program. Methods: This was a single-center, prospective, observational study conducted at a major teaching medical institution. Following institutional review board approval, data collection was conducted over a 4-week period (August 22, 2011, to September 16, 2011). Descriptive statistical methods were performed for all data analyses. Results: A total of 517 patients involving 5006 medications were included in this study. More than 25% (n = 132) of patients had at least 1 error associated with a medication ordered on hospital admission. Pharmacists resolved a total of 467 admission medication errors (3.5 ± 2.3 errors/patient). The most common type of medication error resolved was medication omission (79.6%). In regard to severity, 46% of medication errors were considered significant or serious. Overall, the mean total time was 44.4 ± 21.8 minutes per medication reconciliation. This clinical pharmacy program was estimated to carry a net present value of $5.7 million over 5 years. Conclusion: Clinical pharmacist involvement within a multidisciplinary health care team during the admission medication reconciliation process demonstrated a significant improvement in patient safety and an economic benefit. Keywords clinical pharmacy, medication safety, medication errors, medication reconciliation
Background The annual incidence of preventable adverse drug events (ADEs) resulting from medication errors in hospitalized patients is estimated at 400 000 events, which translates into a rate of approximately 1 medication error per patient per hospital-day.1 Several adverse clinical sequelae are associated with medication errors and ADEs. Hospital length of stay has been shown to increase up to an additional 4.6 days, whereas the mortality risk almost doubles.2 The economic impact is also significant, with estimated costs ranging from approximately $3500 to $4700 per preventable ADE, which amounts to more than $2.8 million annually.2,3 Most investigations into medication errors have determined that a significant portion of these misadventures
are preventable.4-7 Medication reconciliation is one of several strategies recommended to reduce preventable medication errors.8 1
Banner Good Samaritan Medical Center, Phoenix, AZ, USA Cleveland Clinic, Cleveland, OH, USA 3 Greenville Health System, Greenville, SC, USA 4 University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA 5 University Pittsburgh Medical Center, Pittsburgh, PA, USA 6 Banner Health, Phoenix, AZ, USA 7 Tampa General Hospital, Tampa, FL, USA 8 University of Maryland Medical Center, Baltimore, MD, USA 2
Corresponding Author: Mitchell S. Buckley, Department of Pharmacy, Banner Good Samaritan Medical Center, 1111 E McDowell Rd, Phoenix, AZ 85006, USA. Email: [email protected]
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The medication reconciliation process is described as verifying medication use, identifying discrepancies, and resolving any medication-related issues during all transitions of the hospital stay (admission, transfer of care, and discharge).9 Although medication errors have the potential to occur throughout the entire hospitalization, the admission process has been shown to be a particularly vulnerable area in terms of medication safety. At least 1 medication error relating to an insufficient admission drug history occurs in up to 67% of hospitalized patients, with approximately 39% of these errors considered moderate to severe in nature.10 Overall, 27% of hospital medication errors are a result of inaccurate or incomplete medication histories on admission.10 When looking specifically at the different types of medication errors, drug therapy omission and inaccurate dosing regimens are the most common types of errors observed.11 Implementation of an established medication reconciliation process may reduce medication errors and ADEs in hospitals by 46% and 20%, respectively.8 The Joint Commission established medication reconciliation as a National Patient Safety Goal in 2006 as a required means to improve patient safety.9 However, hospitals are presented with significant challenges in implementing and performing this process.11 Major obstacles in completing an accurate and timely medication history may include patient (cognitive and language barriers) and health care (dedicated personnel and technology) factors.11 Additionally, the interviewer’s drug therapy knowledge is a potential barrier to successful medication reconciliation.11 One strategy to overcome this barrier and improve the medication reconciliation process is to incorporate the pharmacist either as a collaborative member in a multidisciplinary team or as the primary health care provider responsible for performing this activity. Pharmacist-conducted patient drug histories have resulted in lower medication discrepancy rates when compared with histories taken by other health care professionals.12,13 Pharmacist involvement within the medication reconciliation process has also been shown to improve the effectiveness of identifying and rectifying these discrepancies.9-24 However, these studies were not comprehensive in measuring the impact of the pharmacist’s involvement on discrepancy rates, the types of discrepancies identified, and the potential severity of medication errors within the admission medication reconciliation process.9-24 We believe this evaluation to be unique in the assessment of clinical pharmacists’ impact on the admission medication reconciliation by incorporating discrepancy rates, error types, severity, and economic value in a high-risk patient population. The purpose of this study was to evaluate the incidence of unintended admission medication discrepancies resolved by pharmacist-conducted medication histories compared with other health care providers performing drug use histories and admission medication orders. The
type of discrepancies, potential ADE severity, proximal cause, and economic value were also evaluated.
Methods This was a single-center, prospective, observational study conducted at a major teaching medical institution (Banner Good Samaritan Medical Center, Phoenix, AZ; 668-bed quaternary care medical center), with an average daily admission rate of about 93.8 adult patients per day and >34 000 adult inpatient admissions annually. Individuals were included if admission medication reconciliation was performed by a pharmacist either at the request of the health care provider or after meeting the established criteria initiating pharmacist review. Patients 25% of all patients had at least 1 medication error associated with medications prescribed on hospital admission, whereas the published literature has shown 1.4% to 53.6% of patients to have had at least 1 error. Again, there is large variation between these numbers. One study with methods, sample size, and statistical analyses similar to ours showed a percentage of patients with at least 1 medication reconciliation error that was comparable to ours (35.9%).31 Agrawal and Wu9 showed a very low rate of medication reconciliation admission errors (1.4%). This finding may be explained by a sample size of >19 000 medication reconciliation events, and the use of an electronic system for medication reconciliation.9 One study did not find a significant association between the number of medications a patient was receiving and the rate of medication reconciliation errors found.11 However, other studies have found the number of medications to be an independent predictor. Compiling the findings from our study and prior studies emphasizes the importance of incorporating pharmacists into the whole
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medication reconciliation process to detect errors and make clinical interventions, not just document medication histories. The most common type of medication discrepancies involving the admission home medication list was omission orders followed by wrong frequency, wrong dosage, unnecessary medication, and wrong route. These findings are similar to that of other published studies in which omission errors occurred most often.10 If not detected, discrepancies at admission may persist throughout the patient’s entire hospitalization. Therefore, a comprehensive medication reconciliation process on admission as well as during all transitions of care and on discharge is needed to document the patient’s home medications but also to continuously evaluate optimal drug therapy throughout the continuum of care. This is vital because those admission medication discrepancies, which may have been insignificant or missed at admission, could become potentially serious ADEs by the time the patient is ready for discharge. To our knowledge, this is one of the first studies to evaluate the proximal causes contributing to the unintended medication discrepancies on hospital admission. Identification of proximal causes is a way to determine weaknesses in the medication reconciliation process where special attention should be focused to prevent future discrepancies. The majority of errors were a result of inaccurate or missing documentation followed by errors associated with a lack of clinician knowledge. Both the main proximal causes may be mitigated by having a pharmacy technician/ pharmacist team specifically trained at performing medication histories and reconciliation take part in the process. Pharmacists were able to resolve many of the errors. This reduction was most likely a result of the pharmacists’ more complete medication assessments and their clinical training regarding medications. Several studies have described the potential severity of medication discrepancies during the medication reconciliation process.11,14,16,18-22 Previously published reports have estimated clinically significant or serious medication errors to occur commonly. We found that 45.5% of our medication errors were classified as significant or serious in nature, which is comparable to the findings of other studies. Wong et al22 estimated that 29.5% of medication discrepancies identified during the discharge medication reconciliation process had the potential to cause possible/probable patient discomfort or clinical deterioration. Another study found that 38.6% of errors during admission medication reconciliation were considered potentially moderately harmful or severe.11 However, other studies have reported significant or serious errors to approach about 58% to 72%, which was higher than what was observed during this investigation.14,16,19 The true incidence of serious or fatal medication errors identified during medication reconciliation remains
unknown. Comparison among studies is difficult because of differences in the severity definitions, methods incorporated to evaluate these errors subjectively into an objective scale, patient population, and the stage of the medication reconciliation process (admission, discharge, both, etc) investigated. However, unlike previously published reports, we have reported the drug class and error types more commonly associated with serious medication errors. Our study included pharmacy technicians in the medication history process. After receiving the necessary training, the technician was responsible for performing the initial medication history, using multiple information sources to obtain the most accurate history possible. Previous studies have shown that technicians can accurately complete medication histories. van den Bemt et al32 looked at using pharmacy technicians to obtain medication histories in a preoperative screening clinic. A total of 93 medication histories were completed by the technician with no corrections needed after review by a pharmacist. Another study by Johnston et al33 directly compared medication histories obtained by technicians versus pharmacists in the emergency department setting and found no difference in the number or severity of discrepancies between the 2 histories. The pharmacy technicians involved in both these studies underwent extensive training prior to collecting histories. With the appropriate clinical training, it appears that technicians can reliably perform medication histories despite the fact that their familiarity and knowledge of drug therapy may not be as comprehensive as that of a pharmacist. Allowing pharmacy technicians to complete the medication history portion has several benefits. This change could alleviate or prevent a worsening of current pharmacist time constraints. In our study, the pharmacist spent on average 15.8 minutes in obtaining a medication history, with a mean of 30 medication histories completed per day. By having a technician complete this task, approximately 8 hours of additional pharmacist time per day are available to focus on other, more in-depth clinical activities. In addition to time, this shift in work could improve job satisfaction for both pharmacists and technicians. Finally, it allows pharmacists to put a greater emphasis on the reconciliation component of identifying discrepancies and errors. The cost driver for a pharmacist-led medication reconciliation service is the dedicated time for pharmacists’ participation. We determined that medication reconciliation conducted by a pharmacist was on average about 16 minutes per patient, which is less than the average reported in the literature, at 22 (range 12-46) minutes per patient.34 Our study also determined an additional 29 minutes per patient for the pharmacy technician evaluation, which would put this study on the higher end of the reported range, but from a cost perspective using technician time should provide a cost savings. Extrapolating the data to costs, reviewing 517
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Buckley et al patients in 4 weeks for this evaluation would require 34.5 hours of a pharmacist’s time per week. This would require that a minimum of 1.0 FTE for a pharmacist is available for this medication reconciliation service and 2.0 FTEs for a pharmacy technician for all patients. Potential additional costs beyond pharmacist time may include an increase in the prescriber’s time because of pharmacy contracting the provider to rectify all identified medication discrepancies in the prescriber’s time.34 Cost aversions include the prevention of medication errors and ADEs. Medication reconciliation has been shown to decrease ADEs by up to 43%, and this study identified that 45.6% of potential ADEs were averted.20,35 When a patient experiences an ADE in the hospital, there is an increase in the length of stay, hospital charges, and total costs for this patient when compared with those who do not experience an ADE.2 ADEs have also been shown to contribute to the loss of quality-adjusted life years (QALYs).34 One report found that up to 2.2 QALYs were gained per 1000 orders through the use of a pharmacist-led medication reconciliation process.34 Although there is an increased need for resources such as additional pharmacist time, the pharmacist-led medication reconciliation has overall net benefits because of the decrease in ADEs and increase in QALYs.34,36 Overall, our medication reconciliation program was estimated to save $1.3 million annually or $5.7 million over 5 years, and cost savings were upheld in the sensitivity analysis. Because a 50% variation in selected variables resulted in a positive net present value for this project, we found this clinical pharmacy program to be an attractive target for cost savings and quality improvement. It is also important that hospital staff understand the importance of medication reconciliation to increase acceptance and compliance with culture change. To increase the value providers place on the medication reconciliation process, the purpose, effectiveness, and cost benefits of medication reconciliation should be communicated to all health care providers involved in the process. This may need to be conveyed through various means of communication and education.37 Promotion by the leadership of the organization, department representatives, and “champions” for cultural change is needed across all health care institutions.37 The stakeholders need to support medication reconciliation endeavors as well as develop a process with specific and uniform tools that all health care practitioners involved with medication reconciliation can use.38 Electronic-based systems have also been shown to improve compliance rates by compelling the provider to document the medication reconciliation process.37 Our pilot study had a significant impact at our institution in justifying the essential role pharmacy technicians and pharmacists have in our medication reconciliation process. This demonstrated significant patient safety and an economic benefit. We continue to be involved with the
admission medication reconciliation process. Ideally, our goal would be to expand pharmacy involvement to all patient transitions of care (eg, intrafacility transfers and discharge).
Limitations Our study had several limitations. This single-center evaluation targeted high-risk patients as previously described, given the limited pharmacy resources we had to devote to the medication reconciliation process. Although we targeted patients based on our perception of those at risk of having drug therapy discrepancies, this was not a complete investigation for all patients admitted to our institution during the study period. Nonetheless, as in other institutions facing the challenges of optimizing pharmacy resource time, we implemented this strategy to balance pharmacist involvement in this process and to have the highest potential impact on ensuring appropriate continuation of medications on admission. Another possible limitation was that medication history interviews were performed by pharmacy technicians. Although familiarity with and knowledge of drug therapy in this population may not be as comprehensive as that of a pharmacist’s, technicians underwent extensive clinical training with the expectation that they would follow a written process. This process included established interview questions and interviews with the patient’s caretakers/ family members and outpatient pharmacy to ensure consistency as well as to increase the likelihood of identifying all active home medications. Also, the severity ranking was based on a review of the clinical scenario and involved medications. This subjective evaluation was reached by consensus, using methods similar to those in previously published reports. The proximal causes were subjective and determined by the clinical pharmacist performing the medication reconciliation process, which could have inaccurately estimated the true incidence of each cause. Finally, this evaluation focused on the admission reconciliation process. The full impact of pharmacy involvement during intrafacility transfer and discharge was not assessed.
Conclusion Medication discrepancies were common on hospital admission at our institution. Pharmacist involvement during the admission medication reconciliation process at our institution by targeting a high-risk patient population had a significant impact on reducing the number and severity of potential medication errors. The results of this study demonstrated the vital role of pharmacy technicians and pharmacists within the medication reconciliation process. Medication reconciliation programs at other institutions should incorporate a multidisciplinary approach to ensure safe and effective drug therapy throughout the continuum of care.
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Appendix Admission Medication Reconciliation History Form Pharmacy Name(s)/Location/Phone # (A) Primary:_____________________________________________ (B) Secondary:___________________________________________ (C) Alternate:____________________________________________ Medication (Name/Strength/Dose/Route/Frequency Date Filled
PATIENT NAME MRN
(1)
Patient Pt List Caregiver Rx Bottle Pharmacy MAR Unable to verify
Taking as prescribed NOT taking as prescribed NOT taking Patient Choice
Patient Pt List Caregiver Rx Bottle Pharmacy MAR Unable to verify
Taking as prescribed NOT taking as prescribed NOT taking Patient Choice
Patient Pt List Caregiver Rx Bottle Pharmacy MAR Unable to verify
Taking as prescribed NOT taking as prescribed NOT taking Patient Choice
Patient Pt List Caregiver Rx Bottle Pharmacy MAR Unable to verify
Taking as prescribed NOT taking as prescribed NOT taking Patient Choice
Patient Pt List Caregiver Rx Bottle Pharmacy MAR Unable to verify
Taking as prescribed NOT taking as prescribed NOT taking Patient Choice
Patient Pt List Caregiver Rx Bottle Pharmacy MAR Unable to verify
Taking as prescribed NOT taking as prescribed NOT taking Patient Choice
Patient Pt List Caregiver Rx Bottle Pharmacy MAR Unable to verify
Taking as prescribed NOT taking as prescribed NOT taking Patient Choice
Patient Pt List Caregiver Rx Bottle Pharmacy MAR Unable to verify
Taking as prescribed NOT taking as prescribed NOT taking Patient Choice
Patient Pt List Caregiver Rx Bottle Pharmacy MAR Unable to verify
Taking as prescribed NOT taking as prescribed NOT taking Patient Choice
Patient Pt List Caregiver Rx Bottle Pharmacy MAR Unable to verify
Taking as prescribed NOT taking as prescribed NOT taking Patient Choice
Comment: (2) Comment: (3) Comment: (4) Comment: (5) Comment: (6) Comment: (7) Comment: (8) Comment: (9) Comment: (10)
Source of Information
Patient Compliance
Comment:
A. B. C. D. E. F.
Is patient routinely taking OTC medication (including aspirin) Is patient routinely taking any vitamins/minerals/supplements or herbals? Is patient wearing any patches, using any eye/ear/nose drops/creams/ointments? Is patient using any medications to assist with breathing (i.e. inhalers of any kind)? Do you currently use any “sample” medications that your MD has provided you? Is patient using any INSULIN? (for diabetic patients only)
Yes Yes Yes Yes Yes Yes
No No No No No No
Patient Obstacles: Language Cognition Poor Historian Sight/Hearing Financial Non-compliance NONE PMH: HPI: Interviewer Name:__________________________________Date:__________________________________ Pharmacist Verifying Name:________________________________________________________________________
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Buckley et al Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
Authors’ Note This original research was presented as a poster at the 2012 American College of Clinical Pharmacy Annual Meeting on October 22, 2012.
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