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Patient Safety Tip
of the Week
November
2, 2021
Adverse
Drug Events After Hospitalization
Adverse
drug events (ADE’s) are both a major cause for emergency department visits and
hospitalizations but also a significant result of hospital discharge. 19-23% of
patients discharged from hospitals experienced an adverse event, the majority
being adverse drug events (Forster 2003, Forster 2004). Another study by Forster et al. (Forster 2005) found that, of adverse events occurring in patients
discharged home from the general medical service, 27% were preventable and 33%
were ameliorable.
So,
it’s no surprise that a focus on preventing adverse drug events after hospital
discharge is in order. Several recent studies have highlighted the magnitude
and seriousness of adverse drug events occurring after hospital discharge.
In
the recent PPSA (Pennsylvania Patient Safety Authority) analysis of medication
reconciliation failures that led to serious events (Harper 2021) 16.1% (15 of 93) instances involved
discharge. Events related to discharge often went unrecognized until the
patient returned to the emergency room (ER) or was readmitted. Orders often contributed
to the events. Dosage errors, omitted orders, and instructions that were
unclear or that differed from the discharge medication list contributed to
these types of events. The resulting medication error types were most often dose
omission and wrong dose. The report also suggests that medication errors at
discharge are also likely to be underreported and have the potential to be
life-threatening.
Gurwitz et al. (Gurwitz 2021) conducted a randomized clinical trial to determine
whether a multifaceted clinical pharmacist intervention improves medication
safety for patients who are discharged from the hospital and prescribed medications
within 1 or more of three high-priority, high-risk drug classes (anticoagulants,
diabetes agents, and opioids). Interventions included an in-home assessment by
a clinical pharmacist, evidence-based educational resources, communication with
the primary care team, and telephone follow-up. Participants in the control
group were provided educational materials via mail.
Those
results somewhat mirror the results of the MARQUIS trial (Schnipper 2018). This trial studied the impact of a
multifaceted medication reconciliation intervention at six US hospitals using the
MARQUIS medication reconciliation implementation toolkit. The intervention
included hiring or reallocating new staff to obtain medication histories,
performing both admission and discharge medication reconciliation, improving access
to preadmission medication sources, introducing policy, training staff on
obtaining medication histories and patient counselling, implementing a gold
standard medication reconciliation process including targeting of high-risk patients,
improving healthcare information technology and utilizing social marketing and
community engagement. The intervention was associated with a reduction in
total, but not potentially harmful, medication discrepancies. Results also
varied by site.
The
accompanying editorial (Etchells 2018) suggested that, rather than the
intervention being ineffective, it may simply have been difficult to implement.
It noted that there were some encouraging signals. Of the four sites that
implemented interventions, three did observe reductions in potentially harmful
discrepancies.
A
second study, MARQUIS2, was subsequently undertaken, utilizing a refined
toolkit and larger number of North American hospitals (Schnipper 2021). Both the number of system-level interventions
adopted per site and the proportion of patients receiving patient-level interventions
increased over time. During the intervention, patients experienced a steady decline
in their medication discrepancy rate from 2.85 discrepancies per patient to
0.98 discrepancies per patient. An interrupted time series analysis showed the
intervention was associated with a 5% relative decrease in discrepancies per month
over baseline temporal trends. MARQUIS2 included both system-level and
patient-level interventions. The system-level interventions alone were not associated
with decreased discrepancy rates. “In contrast, patient-level interventions, such
as receipt of a BPMH or admission or discharge medication reconciliation
performed by trained personnel, had a large effect” that grew over time. That
suggested to the authors there might be a synergistic effect of patient-level and
system-level interventions.
The
patient-level interventions included:
- Best possible medication history (BPMH)
in emergency department
- BPMH outside emergency department
- Admission medication reconciliation by
trained personnel
- Discharge medication reconciliation by
trained personnel
- Patient medication counselling at
discharge by trained personnel.\
- Other intensive interventions in
high-risk patients (eg, health coaching and
counselling with teach back)
The
editorial accompanying the MARQUIS2 study (Grimes 2021) notes the importance of patient engagement
and patient activation. Grimes notes that the MARQUIS2 results suggest either
that patient-level interventions may be more important than system-level interventions,
or that system-level interventions are necessary but not sufficient alone. Exploring
ways to promote patient involvement and activation in their own care should be
a focus of future research.
MARQUIS2 took place prior to the COVID-19 pandemic. One of
the few positive aspects of that pandemic has been the flourishing of telemedicine.
In our April 14, 2020 Patient Safety Tip of the Week “Patient
Safety Tidbits for the COVID-19 Pandemic” we
mentioned an interesting report from ISMP Canada (ISMP Canada 2020)
about medication reconciliation and discharge communication using telemedicine.
It described the process of medication reconciliation, including not only digital
identification of medications but also visual identification (via video or
sending photographs of the pills or containers via email). It went on to
describe how the same systems can be used to educate patients at or just after
hospital discharge (including ways to involve the patient’s PCP and community
pharmacy).
Medication
regimen reviews (MRR’s) have increasingly been performed using telemedicine. A
study on pharmacist‐conducted retrospective medication regimen reviews
(MRR’s) using telemedicine in nursing homes showed very encouraging results (Kane‐Gill 2021). Upon admission, pharmacists conducted
medication reconciliation and prospective MRR for residents and also used
telemedicine for communication with cognitively‐intact
residents. Post‐admission, pharmacists received clinical decision support
alerts to conduct targeted concurrent MRR’s and telemedicine. The intervention
group had a 92% lower incidence of alert‐specific
ADE’s than usual care.
A
recent Canadian study (McGillion 2021) assessed virtual care post-discharge after
surgery, using remote automated monitoring (RAM) to remotely obtain data on
patients’ biophysical variables. Virtual care and RAM did not significantly
increase days alive at home within 31 days of discharge from hospital after
surgery, the primary outcome variable. Interestingly, however, more
participants in the virtual care group than standard care group had a drug
error detected (29.7% vs. 5.5%) and a drug error corrected (22.6% vs. 1.3%). Drug
omission (patients not taking a drug they were supposed to take) was the most
common drug error detected (18.2% vs. 3.5%). Many such omissions were
patient-related (eg. intentional omission,
forgetfulness, mistake, or financial barriers). But doctors and nurses were
responsible in 18.5% of cases, such as failure to communicate clear
instructions on what drugs should and should not be taken at home, failure to
write a prescription for a new drug, and failure to provide an instruction to
discontinue a drug. Pharmacists were associated with 3.6% of the drug errors, always
related to a failure to provide the drug as prescribed. Virtual care with RAM also
resulted in substantial absolute reductions in pain at seven, 15 and 30 days.
We
think that greater use of telemedicine for medication reconciliation and
medication regimen review offers great opportunity to reduce adverse drug
events following hospital discharge.
A key
question is how to fund the resources necessary to do this well. Hospitals are
reluctant to spend money on interventions that might reduce their admissions
(excepting those that lead to readmission penalties or those that are part of a
global budget). Insurers responsible for all medical costs would benefit from
such a good system, as would entities like Accountable Care Organizations
(ACO’s). Alignment of incentives will ultimately be the key to successful
implementation of interventions to reduce adverse medication events after
hospital discharge.
Some
of our previous columns on medication reconciliation:
October
23, 2007 “Medication
Reconciliation Tools”
December
30, 2008 “Unintended Consequences: Is Medication
Reconciliation Next?”
May
13, 2008 “Medication Reconciliation: Topical and
Compounded Medications”
September
8, 2009 “Barriers to Medication Reconciliation”
August
2011 “The Amazon.com Approach to Medication
Reconciliation”
January
2012 “AHRQ’s New Medication Reconciliation Tool Kit”
September
2012 “Good News on Medication Reconciliation”
October
1, 2019 “Electronic
Medication Reconciliation: Glass Half Full or Half Empty?”
July
2020 “Not
Following Medication Changes after Hospitalization?”
References:
Forster AJ, Murff HJ,
Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events
affecting patients after discharge from the hospital. Ann Intern Med 2003; 138(3):
161-167
https://www.acpjournals.org/doi/10.7326/0003-4819-138-3-200302040-00007
Forster AJ, Clark HD, Menard A, et al.
Adverse events among medical patients after discharge from hospital. CMAJ 2004;
170(3): 345-349
https://www.cmaj.ca/content/170/3/345.long
Forster AJ, Murff
HJ, Peterson JF, Gandhi TK, Bates DW. Adverse drug events occurring following hospital
discharge. J Gen Intern Med 2005; 20(4): 317-323
https://link.springer.com/article/10.1111/j.1525-1497.2005.30390.x
Harper A, Kukielka
E, Jones R. Medication Reconciliation Process Failures: A Study of Serious
Events Reported by Pennsylvania Hospitals. Patient Safety Journal 2021; 3(1):
10-21
Gurwitz JH, Kapoor
A, Garber L, et al. Effect of a Multifaceted Clinical Pharmacist Intervention
on Medication Safety After Hospitalization in Persons Prescribed High-risk Medications:
A Randomized Clinical Trial. JAMA Intern Med 2021; Published online March 01,
2021
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2777050
Schnipper JL, Mixon
A, Stein J, et al. Effects of a multifaceted medication reconciliation quality
improvement intervention on patient safety: final results
of the MARQUIS study
BMJ Quality & Safety 2018; 27: 954-964
https://qualitysafety.bmj.com/content/27/12/954
Etchells E,
Fernandes O. Medication reconciliation: ineffective or hard to implement? BMJ
Quality & Safety 2018; 27: 947-949
https://qualitysafety.bmj.com/content/27/12/947
Schnipper JL, Reyes
Nieva H, Mallouk M, et al.
Effects of a refined evidence-based toolkit and mentored implementation on
medication reconciliation at 18 hospitals: results of the MARQUIS2 study. BMJ
Qual Saf 2021; Epub ahead
of print 29 April 2021
https://qualitysafety.bmj.com/content/early/2021/04/28/bmjqs-2020-012709
Grimes TC. Is it time for greater patient
involvement to enhance transitional medication safety? BMJ Quality & Safety
2021; Published Online First: 20 August 2021
https://qualitysafety.bmj.com/content/early/2021/08/19/bmjqs-2021-014116.citation-tools
ISMP Canada. Virtual Medication History
Interviews and Discharge Education. ISMP Canada Safety Bulletin 2020; 20(2):
April 7, 2020
Kane‐Gill SL, Wong A, Culley CM, et al.
Transforming the Medication Regimen Review Process Using Telemedicine to
Prevent Adverse Events. J Am Geriatr Soc 2021; 69(2):
530-538 First Published 24 November 2020
https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.16946
McGillion MH, Parlow J, Borges FK, et al. Post-discharge after surgery
Virtual Care with Remote Automated Monitoring-1 (PVC-RAM-1) technology versus
standard care: randomised controlled trial BMJ 2021; 374 :n2209
https://www.bmj.com/content/374/bmj.n2209
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