Transcript Medication Safety at Transitions of Care

MEDICATION SAFETY
AT TRANSITIONS OF CARE
Elizabeth Isaac, PharmD, BCPS
PGY-2 Medication Use Safety Resident
UMass Memorial Medical Center
Disclosures
I have no disclosures concerning possible financial or
personal relationship with commercial entities.
Objectives
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Review the types of transitions of care
Understand the risk factors for medication
discrepancies at transitions of care
Identify the types of patients and medications most
at risk for having a medication discrepancy during
transitions of care
Develop strategies to prevent medication errors
while transitioning care
Patient Case
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MB is 93 year old female who presented to the hospital
on January 20th with generalized weakness.
HPI: Pt was hospitalized in September 2013 for a
pneumonia and recently completed a course of
prednisone for COPD exacerbation.
PMH: CAD (3VD w/ bare metal stent, EF 60-65%),
HTN, TIA, chronic rhinitis, dyslipidemia, GI bleed on
clopidogrel, COPD, osteoarthritis, diverticulosis,
pseudomonas pneumonia (on inhaled tobramycin)
Patient Case: MB
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Allergies (from Pharmacy system)
 Bactrim,
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doxycycline, nitrofurantoin, penicillins
A medication reconciliation was conducted based on
an interview with the patient
Types of
1
transitions
Outpatient

Inpatient
SNF/Rehabilitation

Inpatient
Inpatient

Inpatient
Inpatient

Outpatient
Inpatient

SNF/Rehabilitation
SNF/Rehabilitation

Outpatient
Outpatient

Outpatient
Types of
1
transitions
Outpatient
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Inpatient
Outpatient areas
Examples
-EmergencyDepartment
Emergency
Department
Outpatient clinics
-Outpatient
clinicsororoffices
offices
“observation” patients
-“observation”
patients
Source of information
-Patient
-Previous inpatient records
Patient
-Pharmacies or outpatient records
Previous inpatient records
Source of information
Potential risks for errors
-Potential disjointed past medical history
-Medications from various sources or
prescribers
-Multiple pharmacies
-Incomplete documentation
Types of
1
transitions
SNF/Rehabilitation
Source of information

Inpatient
-Facilitypaperwork
Facility
paperwork
Patient
-Patient
Recent discharge
-Recent
dischargeinformation
information
Potential risks for error -Temporary changes in medication
history not always reflected in the
record or paperwork
-Patient’s who do not return to the same
hospital from which they came
Types of
1
transitions
Inpatient
Examples
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Inpatient
- ICU  step-down / floor
- Floor  ICU / step-down
- Step-down  floor
Potential risks for error - Acuity of the patient
- Prophylactic medications
- Medications on hold
Types of
1
transitions
Examples
- Discharge to the community directly
- From ICU, step-down, or floor
Inpatient
Sources of information
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Outpatient
- Discharge paperwork / summary
- Patient discharge instructions
Potential risks for error - Lack of admitting privileges for
PCPs
- Prophylactic medications
- Closed formularies
Types of
1
transitions
Examples
- Similar to discharge to community
Potential risks for error - Additional step in the healthcare
process
- Closed formularies
- Prophylactic medications
- Notification to PCP
- Care of patient from additional
provider
Inpatient

SNF/Rehabilitation
Types of
1
transitions
Sources of information
-
Potential risk for errors
- Disjointed care
- Delay in PCP notification /
information transfer
- Medications which can now be
continued
SNF/Rehabilitation
Discharge paperwork from hospital
Discharge paperwork from rehab
Medication administration records
Previous medication reconciliations

Outpatient
Types of
1
transitions
Example
- Primary
Ex:
Primary
care
care
physician
physician

cardiologist
Potential risk for errors
- Changes in medication use or
diagnoses are not always reflected in
either providers documentation
Outpatient
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Outpatient
Regulatory
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Standards
Joint Commission National Patient Safety Goal 03.06.01
To the best of one’s ability with the resources available
Record and pass along correct information about a patient’s
medications. Find out what the patient is taking and compare
them to new medications given by the LIP. Provide patient’s
with the most up-to-date list of their medications that they are
taking and educate them to take the most up-to-date list to
every appointment
Type of medication reconciliation can vary by health care
setting
The advent of the
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3,4
hospitalist
Increasing demands on outpatient providers have
shifted the inpatient care of the patient to
hospitalists
Currently estimated between 10,000 and 12,000
hospitalists are practicing in the United States
Expected to grow to 30,000 in the next decade
according to the Society of Hospital Medicine
Deficits in communication and information transfer between
hospital-based and primary care physicians5
Purpose
To characterize the types of communication and information
transfer between hospital-based and primary care physicians
(PCPs)
Identify the deficits and determine the efficacy of interventions
and clinical outcomes
Methods
Meta-analysis
Inclusion
Case studies and controlled studies involving information
transfer at discharge
Results
1064 citations identified
55 observational studies (21 medical record audits, 23
physician surveys, 11 combined audit-surveys)
18 controlled intervention trials (3 randomized, 7
nonrandomized with concurrent control, 8 pre/post design)
DEFICITS IN COMMUNICATION AND INFORMATION TRANSFER
BETWEEN HOSPITAL-BASED AND PRIMARY CARE PHYSICIANS5
Deficits in communication and information transfer between
hospital-based and primary care physicians5
Deficits in communication and information transfer between
hospital-based and primary care physicians5
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Conclusions
 Transmission
of information between disciplines at
discharge varies and is often inefficient and incomplete
 Discharge summaries should be based on a
standardized format
 Effect on clinical outcomes was hard to measure
The downside to the hospitalist
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Primary care physicians are less involved in the care
of the patient during hospitalization
Only taking care of the patient temporarily
Incomplete hospitalization records are often tied to
medication discrepancies
Added burden to PCPs
 Alert
fatigue
 Delay in test results or discharge paperwork
Medication discrepancies during
transitions of care: a comparison study6
Purpose
To determine if medication discrepancies exist between patients who
are cared for in a hospital by primary care physicians (PCPs) with
admitting privileges vs. those without
Methods
Single center, retrospective, chart review
Inclusion
Patients from one of two outpatient offices
Admitted between January and July 2009
Exclusion
Patient records missing from primary care office
Chart Review
Demographic information
Medication discrepancies at admission and discharge
Over the counter medications (except aspirin), herbals, vitamins,
antibiotics, and short-term prescriptions (ie. Pain medications) were
not evaluated
Medication accuracy of 85% was considered acceptable
Results
251 patient records evaluated
120 patients with physicians without admitting privileges vs.
131 patient with physicians with admitting privileges
Medication discrepancies during
transitions of care: a comparison study6
Medication discrepancies during
transitions of care: a comparison study6
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Overall, a greater number of medication discrepancies were
identified on patients cared for by physicians without admitting
privileges
Most common discrepancy was the omission of a medication
Patients were more likely to follow up with their PCP if they
had admitting privileges
Age, gender, healthcare coverage, and follow-up time did not
have an effect on the discrepancy occurrences
Economic and financial influences of
healthcare7
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Affordable Care Act, Condition code 44 (2004)
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Allows a hospital utilization review committee to change a
patient’s status from inpatient to outpatient if the original
admission is deemed unnecessary prior to discharge
Contributing to the utilization of “observation” status
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Observation stays within 30 days of hospital discharge per
1000 beneficiaries increased from 4.7 to 5.8 from 20092010 to 2012-2013
Disjointed Care
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Hospital-based vs. primary care physicians
Delay in information
“Observation” patients
Medication discrepancies
Medication
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Reconciliation
A three step process of verifying medication use,
identifying variances, and rectifying medication
errors at interfaces of care
Complete reconciliation should include a
conversation with the patient and a review of
pharmacy or patient records
Barriers to accurate medication
reconciliation
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Patient health literacy
Comorbidities
Polypharmacy
Multiple providers
Frequent transitions
Reconciler
Closed formulary
Pediatric dosing
High risk
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patients
Elderly
Patients with multiples medications and
comorbidities
Patients with limited literacy skills
Patients who do not speak English
Pediatric patients
High Risk
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Medications
Antithrombotics
Insulin and other hypoglycemics
Opiates
Antiarrhythmics and other cardiovascular medications
Chemotherapy
Immunosuppressants
Antiseizure medications
Eye Medications
Inhalers
BEERs Criteria medications in patients over 65 years of age
Medication errors in adult and pediatric patients8,9
Purpose
Adult
Pediatrics
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Review the occurrence rate of discrepancies
in pediatric patients
- Identify the rate and clinical significance
of discrepancies
- Look for specific interventions for
pediatric reconciliation
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To examine the frequency and potential
severity of unintended medication
variances hospital admission and
discharge
To review the potential impact of
medication reconciliation
Methods
Prospective, single center study
Meta-analysis
Inclusion
Patients admitted to the 212 bed Canadian
community hospital in July 2002
1,739 citations reviewed
10 studies included in analysis
Interventions
Study pharmacist conducted a comprehensive
medication history on admission for all
randomized patients
Variances identified and discussed with
patient’s team
Discharge medication lists compared with
preadmission and hospital medication use
Results
60 patients chosen
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6 medication reconciliation at admission
to inpatient ward
4 other settings or transitions of care
Reconcilable differences: correcting medication
errors at hospital admission and discharge8
Medication discrepancies at Transitions in
Pediatrics: A Review of the Literature9
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Discrepancies at admission
 22
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– 72.3% with an unintended discrepancy
In the ED
 Pre-
pharmacist implementation – 71%
 Post- pharmacist implementation – 38.3%
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At transfer
 0.53
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unintentional discrepancy per patient
At discharge
 43%
of patients and 15% of medications
Medication discrepancies at Transitions in
Pediatrics: A Review of the Literature9
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Clinical impact of discrepancies
 Estimated
that up to 6% could lead to severe
discomfort or clinical deterioration
 23% could have potential to cause, and 71% were
unlikely
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No specific discrepancies identified
Medication errors in adult and pediatric patients8,9
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Adult study conclusions
Impact of pharmacist reconciliation may have been falsely
low
 Economic analysis was favorable to pharmacy involvement
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Pediatric study conclusions
Medication reconciliation tools used in the adult population
may not be applicable to the pediatric population
 Small, widely varied, studies are inconclusive of the clinical
impact medication discrepancies have on pediatrics
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Limitations to both studies
Medication discrepancies and their
impact
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Drug-drug interactions
Inappropriate medication use
Withdrawal from medications
Unintended consequences (seizures, thrombosis,
tachycardia)
Over- or under- dose
Hospital readmission
Added health-care costs
Patient case
Patient Case
Patient Case
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A second medication reconciliation was conducted
Isosorbide and valsartan discontinued
Provider notes all indicated isosorbide and
valsartan should be continued
Patient discharged on medications
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Error later realized by daughter
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When medication reconciliation works10-12
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Several studies have looked at the impact of
pharmacist or specialized nurse medication
reconciliation and the impact on hospital
readmission rates and economic outcomes
The 30 day readmission rate has been a major
endpoint for most studies, but some have looked at
90 and 180 day readmissions
When medication reconciliation works10-12
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Types of interventions
 Implementation
of a transition coach
 Pharmacist reconciliation, counseling, and follow up
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Overall, reduced readmission rates were seen with
the high intensity interventions
Economically cost-neutral
Lower rates of preventable ADE’s
When medication reconciliation works11
Discharge
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Checklist
Pharmacist’s
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Role
Obtaining a comprehensive medication history using the
three step process
Numerous studies have shown the benefit of involving a
pharmacist across the continuum of care, especially in
patients with multiple comorbidities and medications
Expanding role of the pharmacist is placing us in areas
of health-care where we can take on a more active role
in a patient’s medication management
Pharmacist’s
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role
Inpatient pharmacy
Comprehensive medication reconciliation
 Involved in discharge planning
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Community and Ambulatory care
Use of MTM
 Providing patients with up-to-date medication lists
 Highlighting new medications for use
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Long-term Care (LTCF)
Perform medication reconciliation within 5 days of
readmittance to the LTCF
 Monthly medication reconciliation to assure appropriate
care
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Assessment
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MB is the 93 year old woman admitted for generalized weakness. A
medication reconciliation is obtained by interviewing the patient. Later,
discrepancies were identified when speaking with the patient’s daughter
which were subsequently rectified. Which stage of the medication
reconciliation process was missed which led to an error in the patient’s care?
a.
Interview with the patient to obtain medication use
b.
Review of pharmacy, outpatient, or hospital records for
medication use
c.
Identification of medication discrepancies
d.
Rectifying medication discrepancies
Assessment
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Which of the following is not a potential risk factor
for medication discrepancies during transitions of
care?
a. Elderly patients
b. Multiple comorbidities and polypharmacy
c. Patients on oral antibiotics
d. Multiple providers and disjointed care
Questions?
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3.
4.
5.
6.
7.
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The Joint Commission. National Patient Safety Goals. Hospital Accreditation Program. Jan
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Kripalani S, LeFavre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in
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Daughtridge GW, Archibald T, Conway PH. Quality improvement of care transitions and
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Vira T, Colquhoun M, Etchells E. Reconcilable differences: correcting medication errors at
hospital admission and discharge. Qual Saf Health Care. 2006;15:122-26.
Huynh C etal. Medication discrepancies at transitions in pediatrics: a review of the
literature. Pediatr Drugs. 2013;15:201-15.
Kwan JL, Lo L, Sampson M, Shojania KG. Medication reconciliation during transitions of care
as a patient safety strategy. Ann Intern Med. 2013;158:397-403.
Gardner R, Li Q, Baier RR, Butterfield K, Coleman EA, Gravenstein S. Is implementation of
the care transitions intervention associated with cost avoidance after hospital discharge? J
Gen Intern Med. E-published 2014.
Coleman EA, Parry C, Chalmers S, Min S. The care transitions intervention. Arch Intern Med.
2006;166:1822-28.
Soong C et al. Development of a checklist of safe discharge practices for hospital patients.
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Hume AL et al. Improving care transitions: current practice and future opportunities for
pharmacists. Pharmacotherapy. 2012;32:e326-37.