What’s New in the Patient Safety World
September 2012
Good News on Medication Reconciliation
After a series of
articles with not-so-good conclusions regarding medication reconiciliation,
we’ve finally seen some good news. First, a recent large randomized clinical
trial (Kripalani
2012) showed that over 50% of
patients with cardiac conditions discharged from hospitals had one or more
clinically significant medication errors and that a health-literacy–sensitive,
pharmacist-delivered intervention did not reduce post-discharge medication
error rates. Then a recent systematic review of medication reconciliation
practices in hospitals (Mueller
2012) highlighted the relative paucity of high quality evidence supporting
best practices for medication reconciliation. They concluded that the best
evidence supports use of pharmacy staff in the medication reconciliation
process and targeting high-risk patients. But for most other approaches, there
is a relative paucity of evidence demonstrating desired outcomes.
But a new study from
Johns Hopkins (Feldman
2012) has more promising news using a nurse-pharmacist team to do
medication reconciliation. They found that a dedicated nurse interviewing the
patient and/or contacting the patient’s PCP or pharmacy or reviewing the EMR
was able to identify unintended discrepancies from the home medication list
compiled by the physician on admission in almost 50% of patients. The nurse
would then discuss those discrepancies with a consulting pharmacist and the
physician to come up with the best medication list. Such discrepancies were
slightly less common on discharge but those found on discharge had higher risk
of causing harm to the patient. They provided a cost analysis of the program
and concluded that it cost about $32 per patient or $114 to uncover one
potentially harmful discrepancy. Using a figure from the literature of $9300 to
manage each case with harmful events, they conclude that the program justifies
itself financially many times over.
An editorial
accompanying the Mueller review (Kaboli
2012) reinforces that targeted interventions are probably most
cost-effective. They advocate for
targeting highest-risk patients for medication reconciliation but note the need
to balance this against the need to provide safe medication practices for all
patients.
There is more to
medication reconciliation that just identifying what medications the patient is
taking at home. One field we commonly see missing on medication reconciliation
forms is “time last dose taken”. While that may be less relevant for drugs like
daily statins, it is very relevant for drugs like insulin, anticoagulants, or
cardiovascular medications that affect blood pressure or heart rate. Add to
that the nuances of various hospital pharmacy dispensing systems that relate
time of the order to time a medication may be given. For example, some
hospitals might dispense/administer their “once daily” medications every
morning at 8:00 AM. In such cases, a patient admitted at 8:30 AM may not get
his/her dose of that medication until 8:00 AM the following morning. In the old
days a physician would handwrite orders and given them to a nurse who would
often ask “do you want the patient to get a dose today?”. Nowdays, with CPOE
that step is often lost and there may be no warning on the CPOE system that
such medications won’t be given until the next morning.
References:
Feldman LS, Costa LL, Feroli ER, et al. Nurse-pharmacist collaboration on medication reconciliation prevents potential harm. J Hosp Med 2012; 7(5): 396-401
http://onlinelibrary.wiley.com/doi/10.1002/jhm.1929/abstract
Mueller SK, Sponsler KC, Kripalani S, Schnipper JL. Hospital-Based Medication Reconciliation PracticesA Systematic Review. Arch Intern Med. 2012; 172(14): 1057-1069
http://archinte.jamanetwork.com/article.aspx?articleid=1203516
Kaboli PJ, Fernandes O. Medication ReconciliationComment on “Hospital-Based Medication Reconciliation Practices”. Arch Intern Med. 2012; 172(14): 1069-1070
http://archinte.jamanetwork.com/article.aspx?articleid=1203520
Kripalani S, Roumie CL, Dalal AK, et al. Effect of a Pharmacist Intervention on Clinically Important Medication Errors After Hospital Discharge: A Randomized Trial
Ann Intern Med 2012; 157(1): 1-10
http://annals.org/article.aspx?articleid=1206684
http://www.patientsafetysolutions.com/