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Medication reconciliation practice at transitions of care: a new challenge or opportunity for the clinical pharmacist?

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European Statement

Clinical Pharmacy Services

Author(s)

Elisabetta Volpi, Giuseppa Lo Surdo, Sara Tonazzini, Stefania Alduini, Maurizio Mangione, Umberto Paradossi, Monica Baroni, Sergio Berti, Stefania Biagini

Why was it done?

Several data suggest that pharmacists and physician collaboration, direct pharmacist interaction with patients or caregivers through medication reconciliation and discharge counselling decreases the number of adverse drug events (ADEs) and plays an overall positive role in transitional care. Our aim is to demonstrate the constant necessity of pharmacist led medication reconciliation in order to maintain a high standard of care and safe medication use.

What was done?

Medication reconciliation at hospital discharge is essential for the prevention of medication discrepancies and patient harm. Hospital pharmacists are recognised as one of main healthcare providers that can support the physicians in this activity.
Since 2016, the medication reconciliation process has been performed by physicians and clinical pharmacists before home discharge from the Heart Hospital, Fondazione Toscana G.Monsaterio in Italy.

How was it done?

We analysed the medication reconciliation activity performed in our hospital over time and we observed that the number of unintentional discrepancies was always around 20%.
A shared pre-discharge prescription review programme has been activated with all doctors, so when the final lists of drug prescriptions are ready, the pharmacist examines them and suggests improvements or corrections to the doctor before the discharge letter is delivered to patients. Among the unintentional discrepancy observed, the most frequent were omissions of chronic therapy, lack of information about suspension for low molecular weight heparin or antibiotics.

What has been achieved?

A strong collaboration between physicians and clinical pharmacists has been achieved as we shared the results of this improvement. The same activity has been required and extended to the paediatric ward where the demand of simple, clear and complete information is even more crucial given the particular inter-individual variability and fragility of this population.

What next?

We would like to improve the prescription review programme also at admission in order to minimise drug omissions and at transition between different wards or different hospitals with the aim of improving communication between health care settings.

Pharmacist prescriber embedded within medical team improves patient care by timely and accurate discharge medication prescribing

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European Statement

Clinical Pharmacy Services

Author(s)

Fiona Watson, Amanda Plummer, Aqleema Akhter

Why was it done?

For discharge medication to be dispensed a medicines list plus discharge letter, often referred to as a To-Take-Out (TTO) is required. The letter section communicates information for safe patient transfer and provides context for the pharmacist clinical verification. With increasing demands on junior doctors, the production of TTOs is often delayed until after all urgent clinical duties are completed, so dispensing commences late in the working day. in addition, junior doctors’ prescribing errors cause delay while queries are resolved. The late completion of TTOs slows patient flow across the whole system. It was accepted that a different strategy, using a PP to prioritise prescribing, needed exploration.

What was done?

A prescribing pharmacist (PP) was embedded within a specialist medical team, to perform prescribing activities in a timely manner, with a focus on discharge prescriptions. The PP was additional to the standard ward pharmacy establishment, allowing prescribing to be the focus of the role.

How was it done?

A PP was embedded within the Respiratory team and another within Gastroenterology with the primary aim of producing TTOs as early as possible. There was a requirement for the PP to learn how to write the discharge letter, via training with junior doctors. The PP prioritised any prescribing to facilitate discharge, but also attended the consultant ward round undertaking medicines optimisation for each patient. Rather than the junior doctor returning later to prescribe, the PP made any necessary medication changes during the ward round, facilitating the timely receipt of appropriate therapy.

What has been achieved?

Both pilots reduced the time from medically fit for discharge to the TTO written by approximately 3 hours. There was a reduction in prescribing error rate of 37% to 1% in Respiratory and 9.5% to 0.7% in the Gastroenterology project.

What next?

The “Embedded Prescribing Pharmacist” role is now permanent within the two pilot specialities, with plans for further extension under consideration. The role demonstrates the “Right first time” concept and a modernised model of hospital pharmacist practice.

AN AUDIT OF DISCHARGE PRESCRIPTIONS FOR SURGICAL AND MEDICAL PATIENTS WITH A QUALITY IMPROVEMENT INITIATIVE (submitted in 2019)

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European Statement

Patient Safety and Quality Assurance

Author(s)

Eva Heffernan, Deirdre Smith , Avril Tierney, Louise McDonnell

Why was it done?

Transitions of care such as hospital discharge present an opportunity for medication error. Lapses in communication at this interface are common. For the next healthcare provider (HCP) to issue the correct medication safely and in a timely manner, the discharge prescription needs to bridge this communication gap. Prescribing errors are the most frequent subtype of medication errors and can be repeated systematically for prolonged periods. Detection of medication error using tools such as audit, learning from these errors and planning corrective action is essential to building safer healthcare systems.
This study adapted the Health Information and Quality Authority (HIQA) national standard for patient discharge summaries to create a benchmark for discharge prescriptions in SVPH. A QI initiative targeting prescribers was developed. This was designed as a bundle intervention and was called the Discharge Prescription Education Bundle (DPEB).

What was done?

The aim of this project was to evaluate the current level of discrepancies on discharge prescriptions for surgical and medical patients and to ascertain if a quality improvement (QI) initiative can impact on the severity of medication error at the point of discharge.

How was it done?

Uncontrolled consecutive baseline and re-audit of discharge prescriptions on a 26-bed mixed medical and surgical ward. The baseline audit assessed 70 patients’ discharge prescriptions. Deviations from the standard were termed discrepancies. Discrepancies were divided based on capacity to cause error (NCC-MERP Category A) and error occurred (NCC-MERP Category B-I). Discrepancies where an error occurred (NCC-MERP Category B-I) were reported using the in-house medication incident reporting (MIR) system and dually assessed by an independent panel and the project lead for potential to cause harm. The QI initiative was implemented and its impact assessed with a re-audit of 70 patients’ discharge prescriptions.

What has been achieved?

The overall number of discrepancies reduced from 156 in the baseline to 59 in the re-audit (p<0.05). Overall compliance with the audit standards improved from 17.1% to 54.3% (p <0.05). In the baseline audit 22.8% (n=16) of patients had a discrepancy where an error occurred; this reduced to 2.65% (n=2) in the re-audit (p<0.05). The severity of errors reduced in the re-audit.

What next?

The QI initiative used was proactive not reactive. Use of the discharge education bundle was not restricted to pharmacy opening hours.
This initiative was very low cost to implement. Following on from the successful results of this project one component of DPEB called the discharge prescription visual prompt is now preprinted on all SVPH discharge prescriptions as a reminder to prescribers.

IMPROVING PATIENT FLOW: NOVEL APPROACH TO COMPLETING DISCHARGE SUMMARIES BY PHARMACIST PRESCRIBERS

European Statement

Clinical Pharmacy Services

Author(s)

Louisa Kasprowicz, Elizabeth Wright, Tejal Vaghela, Mohan Thaoa

Why was it done?

The time taken from decision to discharge to discharge summary written on average was 2.5 hours prior to the new service as the clinicians completed the ward rounds before starting on completing the discharge summaries. Prior to implementation of this service the prescribing error rate was 24% and the accuracy of information (medicines started, discontinued and altered during admission) transferred to general practitioners (GPs) was 44%.

What was done?

The novel approach to completing full discharge summaries by independent pharmacist prescribers (PP) was implemented in a busy admissions unit at a large district general hospital in the east of England. PP writing discharge summaries are recommended in the ECIP, Carter and hospital transformation plans.1 2 We introduced the completion of a full discharge summary by PP instead of a medication-only list currently carried out by other NHS Trusts. The aim was to reduce prescribing errors, improve patient flow through AAU and to reduce pressure on the emergency department.

How was it done?

A pharmacist prescribing a discharge service from 9am to 3pm was proposed for patients who have been admitted for < 48 hours. The medical team bleeped the PP when a patient was being discharged to alert the PP. The primary aim of the service was to increase the number of discharge summaries completed before 3pm, reduce the prescribing error rate and to improve the accuracy of information transferred to GPs. The time of 3pm was chosen to allow the clinicians to complete urgent jobs after the ward round.

What has been achieved?

The data showed that after the implementation of the pharmacist prescribing service, 34% of discharge summaries were completed by PP compared to 0% prior to implementation. This released junior doctors time from completed discharge summaries to concentrate on urgent clinical duties. This also meant discharge summaries were received by the pharmacy in a timelier manner and patients were ready for discharge earlier in the day. The prescribing error rate was reduced to 0.9% and the accuracy of information to GPs was increased to 98% on discharges summaries completed by PP compared to junior doctors’ discharge.

What next?

This new service has made a positive impact on the discharge flow from AAU. Patients are receiving their discharge medications earlier so improving patient flow and patient experience through the department. The service has received positive feedback from patients, the lead consultant, doctors and nursing staff. It is hoped in the future this service could be extended until 5pm and rolled out to other areas in the hospital.

PROTOCOL FOR MEDICATION RECONCILIATION AT DISCHARGE

European Statement

Patient Safety and Quality Assurance

Author(s)

Álvaro Caballero Romero, Enrique Galindo Sacristán, Fernando Malpica Chica , Enriqueta González González, Ana María Manzano Bonilla, Marcos Camacho Romera

Why was it done?

Medication errors (ME) are often identified in transitions of patients at admission to and discharge from the hospital. Medication reconciliation at discharge is an effective process to decrease the morbidity, mortality and healthcare expenses.

What was done?

A protocol for a medication reconcialiation project was designed by hospital and primary health care pharmacists.

How was it done?

The protocol has the following steps. To identify all the patients from the hospital at discharge daily. To select the polimedicated (5 or more prescribed medicament) and elderly (over 65 years old) patients. To review the discharge report in the clinical history patient in order to compare whether doctor prescriptions of medicaments (medicine, dose, posology, duration) correspond to the prescriptions included in the report at discharge. To identify discrepancies between both the discharge report and doctor prescriptions of medicaments. The discrepancies were clasified in justified and unjustified. The unjustified discrepancies were categorised as omissions, unnecesary addition, wrong medications, wrong drug frequency/dose, duplicities, pharmacological interacctions and inappropiated medicine regarding to the current clinical practice guidelines. The discrepancies are classified as high and low priority. Finally, both types of discrepancias are reported by sending emails to the specific physicians for each patient along the primary health care system. Some specific cases are discussed on phone calls by doctors and the pharmacists in order to achieve the best clinical goal for the patient.

What has been achieved?

The project was evaluated from June 2016 to May 2017. Total of discharges: 2788. Included patients: 863. Patients with discrepancies: 309 (35%). Detected discrepancies: 470. Rate discrepancies/patient: 1.52. Omissions: 122 of 470. (25.96%). Unnecesary addition: 60 of 470 (12.76%). Wrong medicine: 3 (0.63%). Wrong frequency/dose: 167 (35.53%). Duplicities: 92 (19.57%). Pharmacological interactions: 13 (2.65%). Inappropiated medicine: 13 (2.77%). Reported emails: 309/309 (100%).

What next?

Polimedicated and over 65 years old patients play an extremely important role in the current health care systems. The ME are frequent and may be particullary severe in this type of patients. To develope a protocol for medication reconciliation at discharge in order to identify potencial prescriptions problems is an oppotunity for the multidisciplinar care team to improve the patient care and decrease the expenses associated to primary health care.

DISCHARGE MANAGEMENT: SAFER DISCHARGES AND IMPROVED INFORMATION TRANSFER METRICS

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European Statement

Clinical Pharmacy Services

Author(s)

Marie-Claire Jago-Byrne, Sinead McCool, Caroline Reidy, Stephen Byrne

Why was it done?

Published research had demonstrated that 50% of discharge prescriptions were non-reconciled(1). A recent study demonstrated that 43% of patients experienced post-discharge medication errors(2). The prevalence of polypharmacy (>5 medications) has increased over the 15 years to 2012, from 17.8% to 60.4% in people 65 years and older in Ireland(3).

What was done?

The aim of this project was to improve medication safety at the point of hospital discharge by using targeted medication reconciliation and producing a computer-generated prescription. This new model for discharge prescribing was introduced for patients who met both of the following criteria in two acute hospitals:
• Prescribed 9 or more medications, at the time of admission.
• Aged 70 years and over

How was it done?

The new model for discharge prescribing used collaborative medication reconciliation and the e-Discharge software to improve the quality of discharge prescriptions. The model was introduced in both hospitals and received support from community and hospital colleagues. Clinical pharmacists became the project champions and worked closely with medics during the change process. Key safety aspects were:
• Clinical double check for this high-risk process- the pharmacist and the doctor sign the prescription.
• Increased legibility
• Explanation for all prescription changes to community colleagues.
Phase 2: The software was further tested on 200 patients in a bench top exercise

What has been achieved?

Phase 1: The overall compliance with the national discharge prescription standards increased from 50.4% to 96.9% with the new model for discharge prescribing. The biggest change in compliance was observed in the three communication categories, which explain to community healthcare providers the rationale behind the medication changes made during the hospital stay. A user acceptability survey of HCP involved in the project demonstrated that all those involved had benefited from improved workflows in hospital and community settings, and more appropriate and efficient use of resources. All users requested expansion of this service.
Phase 2: This review allowed for the improvement of the e-Discharge Software using anonymised patient cases to test issues identified in Phase 1.

What next?

In Phase 3 the model will be introduced to a third hospital to evaluate transferability of the concept alongside current practice outlined above

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