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Chaos Waiting for Bad Luck?
Medication Reconciliation
Should Be Mandatory
Roni Cohen, B.Sc., Inbal Yifrach-Damari, M.Sc.*
Dr. Meir Frankel, Prof. Mayer Brezis
Hadassah-Hebrew University Hospital, Jerusalem, Israel
* Clinical Pharmacist, Pharmacy Division
Supported by a joint non-restricted educational grant established by Pfizer,
Hadassah Medical Organization and the Hebrew University School of Pharmacy
Pharm-D student, School of Pharmacy, Hebrew University
With Help From Joint Commission International
Medication Errors
 Medication errors are the fourth leading cause of death or
major permanent loss of function in hospital patients.
 The majority of problems with patient safety occur during the
transition from one care setting to another.
 Ambulatory-hospital lack of communication is responsible for
50% of medical errors.
 To improve patient safety, the Joint Commission on
Accreditation of Healthcare Organizations now recommends a
procedure designed to minimize errors.
What is Medication Reconciliation?
Obtaining a complete and accurate list of each
patient’s medications.
Documenting EVERY change:
Before the patient moves on, the physician must
decide about each drug:
CONTINUE
DISCONTINUE
This way, no drug is forgotten!
Drugs include: ‘over-the-counter’ medications, topical medications,
eye drops, vitamins, herbal medications and ‘occasional’ medications.
Methods for current project
 Over 100 adult patients admitted to the ER, on at least
5 regular drugs, underwent medication reconciliation.
 Review of medications with patient, family, primary
physician and/or database of HMOs (sick funds).
 After 24-48 hours, we checked the list of medications
prescribed to the patient by the ward staff.
 Our list was then compared with the list in the ward.
 If any discrepancy was observed
or an error was suspected, the
staff was approached to clarify
the reason for the change.
Overall Errors
In 97% of our patients, an error / intervention was found
on admission, during hospitalization or at discharge.
On average: 7 mistakes / interventions per patient
Pharmacological interventions
in 85%
Med-Rec interventions
in 87%
On average: ≈ 3 mistakes / interventions per patient from any kind
Medication Errors on Hospitalization
At least one error was found in 73% of the patients
Enalapril and ramipril
were both prescribed
in the ward.
11%
5%
11%
Antiepileptic drug, taken at
home, was not continued in the
ward.
5%
19%
19%
65%
65%
Captopril was prescribed to a
patient only once a day
(instead of 3 times a day).
Unexplained discrepancies in medication
Unexplained
in medication
Doublediscrepancies
treatment / contraindications
Double treatment / contraindications
Hydralazine erroneously
prescribed from
outdated medical
record.
Wrong dosage /frequency /route
Wrong put
dosage
/frequency
/routepharmacy
Medication
on hold
- not in Hadassah
Medication put on hold - not in Hadassah pharmacy
Medication Errors at Discharge
At least one error was found in 65% of the patients
“Pain killers as needed”
11%
6%
Combination of nortriptyline
11%
& citalopram
17% 6%
Propafenone
prescribed once a day
(instead of 3 times a day).
17%
10%
56%
56%
Levothyroxine
(eltroxin) omitted from
discharge letter.
10%
Alendronate
omitted from discharge letter.
Unexplained medication discrepancies
Medications on hold during hospitalization - not included in discharge letter
medication
discrepancies
WrongUnexplained
dosage /frequency
/route
Medications on hold during hospitalization - not included in discharge letter
Double treatment / contraindications
Wrong dosage /frequency /route
Unclear instructions on discharge letter
Double treatment / contraindications
Severity of Medication Errors
Severity of Medication Errors
On Hospitalization
At Discharge
Minor
22.5%
27%
Significant
61.5%
63%
Serious
15%
9%
Life Threatening
1%
1%
Telephone Interviews
At least one error / problem was found in 23% of the patients!
● Nearly all patients had visited primary care
physician after discharge.
● 25% of patients were not aware of a
change in medication.
● On occasion, an error noted during
admission was continued after discharge.
Clinical Pharmacist Service
In 85% of patients:
• Apply correct indications and
contra-indications (≈18%).
• Adapt dosage to kidney or
liver function (≈15%).
• Drug-Drug Interaction (≈37%).
• Correct administration:
discharge, over 50% of
patients were not taking
medications correctly.
After
Polypharmacy
Discussion
• Avoidable mistakes in medications are very common.
About 1% can be life threatening.
• Drug lists, in the community and in hospitals, are not
updated and often fail to reflect the medications that
the patient actually takes.
• A correct medical history can identify errors and can
sometimes even shed new light on the cause of
hospitalization.
• Critical changes in medications made during
hospitalization are often not implemented after
discharge.
On Medication-Reconciliation Elsewhere
Survey of 100 patients at the Mayo Clinic: Inpatient Medication
Reconciliation in an Academic Setting American Journal of HealthSystem Pharmacy 2007
Number of medication discrepancies decreased from 3 per patient
in phase 1 to 1.8 per patient in phase 2 (p = 0.003)
Survey of 180 patients at Brigham and Women’s Hospital, in
Boston: Classifying and Predicting Errors of Inpatient Medication
Reconciliation. J Gen Intern Med 2008.
Average of 1.5 error per patient with potential for harm.
Solutions included development of special software for adapting
prescription to the patient’s provider preferred medications outside
hospital.
Solutions to Reduce Errors
• Devise a computerized table for medication reconciliation for
each patient at each transfer of care provider.
Medication
Aspirin
Furosemide
Continue
Discontinue
Why?

hypokalemia

 At the individual level: have patient bring his/her bag of drugs
and carefully review them with him/her.
 Improve IT for transfer of information between Hadassah and
outside providers on admission and on discharge.
 Monitor quality for continuity of care by measuring quality of
handovers within Hadassah wards and with outside.
 A clinical pharmacist is very useful, as shown in literature:
↓errors and improvement in outcomes.
Conclusion
Medication Reconciliation
Should Be Mandatory!
Special thanks to Ms. Lois Gordon for graphics assistance.