The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
Shah AS, Hollingsworth EK, Shotwell MS, et al. J Am Geriatr Soc. 2022;70:1180-1189.
Medication reconciliations, including conducting a best possible medication history (BPMH), may occur multiple times during a hospital stay, especially at admission and discharge. By conducting BPMH analysis of 372 hospitalized older adults taking at least 5 medications at admission, researchers found that nearly 90% had at least one discrepancy. Lower age, total prehospital medication count, and admission from a non-home setting were statistically associated with more discrepancies.
Volpi E, Giannelli A, Toccafondi G, et al. J Patient Saf. 2021;17:e143-e148.
Medication errors are a common and significant causes of patient harm. This retrospective study examined regional prescription registry (RPR) data at a single Italian hospital at 4 comparison points, pre-admission, admission, hospitalization, and post-discharge. Researchers identified 4,363 discrepancies among 14,573 prescriptions originating from 298 patients with a mean age of 71.2 years. Approximately one third of the discrepancies (1,310) were classified as unintentional and the majority (62.1%) of those were found when comparing the prescriptions during the transition from hospital discharge and the 9-month follow up. The study points to the need for enhanced communication between hospitalists and primary care providers at the hospital-home interface.
Daliri S, Bouhnouf M, van de Meerendonk HWPC, et al. Res Social Adm Pharm. 2020;17:677-684.
This study explored the impact of longitudinal medication reconciliation performed at transitions (admission, discharge, five-days post-discharge). Medication changes implemented due to longitudinal reconciliation prevented harm in 82% of patients. Potentially serious errors were frequently identified at hospital discharge and commonly involved antithrombotic medications.
Medication errors present challenges to patient safety worldwide. Vulnerabilities in the medication-use process are exacerbated by the need to navigate comorbidities in older patients and the general complexity of care. This review examines prescribing concerns and highlights three areas of focus to improve safety: engagement with patients and families as partners in decision making, care coordination, and application of system approaches to support medication safety.
Pellegrin K, Lozano A, Miyamura J, et al. BMJ Qual Saf. 2019;28:103-110.
Older adults frequently encounter medication-related harm, which may result in preventable hospitalizations. In six Hawaiian hospitals, hospital pharmacists identified older patients at risk of medication problems and assigned them to a community pharmacist who coordinated their medications across prescribers for 1 year after discharge. This post-hoc analysis of the intervention found that most medication-related harm occurred in the community (70%) rather than the hospital and that the intervention successfully reduced community-acquired harm.
Pevnick JM, Nguyen C, Jackevicius CA, et al. BMJ Qual Saf. 2018;27:512-520.
Among hospitalized patients, adverse drug events (ADEs) are a common and serious source of patient harm. Medication reconciliation at the time of hospital admission reduces preventable ADEs and is a National Patient Safety Goal. In this three-arm, nonblinded, randomized controlled trial, researchers compared pharmacist or pharmacy technician–performed medication reconciliation before admission orders were placed to usual care among patients with at least 10 medications. Pharmacist and technician reconciliation led to similarly large decreases in minor and life-threatening medication order errors. Although pharmacist-led reconciliation reduces in-hospital ADEs in research settings, real-world implementation has been more challenging. Previous WebM&M commentaries highlight the dangers of inadequate medication reconciliation in inpatient and outpatient settings.
Medication reconciliation was initially established as a National Patient Safety Goal in 2005. This systematic review included 19 studies that supported the positive impact of pharmacy-led medication reconciliation on decreasing discrepancies during hospital admission and discharge.
L'Hommedieu T, DeCoske M, Lababidi RE, et al. Am J Health Syst Pharm. 2015;72:1266-8.
Miscommunication during transitions of care can contribute to medication errors. This commentary describes an initiative to involve pharmacy students in care transitions services. Although the authors found that scheduling and training the students for the program was a challenge, 30-day readmission rates were lower for patients who received transitions of care services with pharmacy students versus those who did not.
Griesbach S, Lustig A, Malsin L, et al. J Manag Care Spec Pharm. 2016;21:330-336.
This study of a quality improvement initiative found that automated screening of prescribing data uncovered many potential adverse drug events. Prescribers were notified about these safety concerns, and almost 80% of these potential adverse drug events were resolved through prescription changes. The extent of patient harm which occurred or was averted was not reported. This work suggests that real-time data from electronic prescribing could be harnessed to improve patient safety, as others have suggested.
Ensing HT, Koster ES, Stuijt CCM, et al. Int J Clin Pharm. 2015;37:430-4.
Patients are susceptible to various problems following hospital discharge, including medication errors. This commentary suggests that improving the transfer of patient medication history, performing home visits to follow up with patients, and collaboration between primary care and community pharmacy can help reduce adverse drug events after patients are discharged from the hospital.
Schillig J, Kaatz S, Hudson M, et al. J Hosp Med. 2011;6:322-8.
Patients receiving warfarin therapy are at high risk for adverse events. Interventions to improve warfarin safety have focused on trigger tools, communication protocols, and the use of visual medication schedules. This study implemented a pharmacist-directed anticoagulation service to capture inpatients on warfarin and provide them with dosing, monitoring, and coordination of transition from the inpatient to outpatient setting. This cluster randomized trial demonstrated safer transitions in 73% more patients and a 32% reduction in the composite safety end point, which was driven by fewer patients experiencing an INR ≥ 5 (i.e., supratherapeutic levels that increase the risk of bleeding). This study adds further support to the role of pharmacists in driving medication safety, specifically for warfarin in both the inpatient and community settings. A past AHRQ WebM&M commentary discussed a case of a near miss due to a warfarin drug interaction that led to a supratherapeutic level following hospital discharge.
Lee JY, Leblanc K, Fernandes OA, et al. Ann Pharmacother. 2010;44:1887-95.
This study found that 62% of patients transferred between units during a hospitalization had at least one unintentional medication discrepancy. The most common discrepancy was medication omission, independent of which system was used (e.g., paper versus computerized).
Boockvar KS, Livote EE, Goldstein N, et al. Qual Saf Health Care. 2010;19:e16.
Addressing handoffs in patient care is a continued challenge, particularly around medication safety. Medication reconciliation was seen as a preventive strategy to handle such concerns, though the lack of proven strategies led The Joint Commission to soften its previous National Patient Safety Goal. A commonly held belief is that electronic health records (EHRs) provide solutions to communicating health information. This study compared medication reconciliation events for patient handoffs within a computerized VA system to a paper-based system outside the VA. Interestingly, there was no significant difference between medication discrepancies and adverse drug events (ADEs) in the highly computerized system. The authors suggest that their findings support a need for specialized tools to facilitate medication review at times of transfer. A past AHRQ WebM&M commentary discussed medication reconciliation after an avoidable error.
Gleason KM, McDaniel MR, Feinglass J, et al. J Gen Intern Med. 2010;25.
Discrepancies in patients' medications at the time of hospital admission are common. Performed at an academic medical center, this cohort study used a pharmacist-led medication reconciliation process to determine a "gold standard" medication list for newly admitted patients, identify discrepancies between patients' medication lists and the medications ordered by admitting physicians, and investigate risk factors for preventable medication errors. More than one-third of patients had at least one discrepancy, with elderly patients and patients with more complex medication regimens being at higher risk—factors also documented in prior research. Patients who presented their own medication list or pill bottles were at reduced risk. The medication reconciliation process used in this study is available as an online toolkit.
Grimes T, Delaney T, Duggan C, et al. Ir J Med Sci. 2008;177:93-7.
Medication reconciliation conducted by clinical pharmacists found that nearly one in nine patients discharged from an inpatient cardiology service had at least one discrepancy in their medication documentation. The most frequent error was inadvertent omission of a medication.
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