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.
High Performance Medicines Management – HPMMF
Pdf
European Statement
Introductory Statements and Governance
Author(s)
Lars-Åke Söderlund, Marie Olsson Nerfeldt , Birgitta Elfsson
A TARGETED STRATEGY AND TRAINING PROGRAM TO IMPROVE THE MEDICATION RECONCILIATION PROCESS
European Statement
Clinical Pharmacy Services
Why was it done?
Medication reconciliation at admission was implemented in our hospital in 2011 and since then we could hardly meet the expectations of clinicians (completion of a Best Possible Medication History (BPMH) for 70% of patients in less than 24 hours). We also observed that the high patient volume decreased the quality of our BPMH completion process.
What was done?
We developed a strategy and an organisational thinking to remove human and technology barriers in performing medication reconciliation (MR). We designed a program to improve the overall quality of MR and increase the added value of MR for clinicians, nurses and pharmacists.
How was it done?
Our approach included four steps:
(1) “customer approach”; by conducting semi-structured interviews with students, clinicians and nurses to get their feedback, needs, expectations about medication reconciliation,
(2) literature review with Pubmed® and Embase®and benchmarking of other similar practices in France and Canada
(3) set a task force including pharmacists and students to define a strategy and metrics
(4) design solutions and assess them.
What has been achieved?
First, we defined and chose to target “High risk” admission inpatients only. Second, a training program based on two e-learning modules was implemented to develop skills of pharmacy students and residents. This program explores the “why” of conducting MR based on real life examples. It also defines the “what” (what is MR) and the “how” (i.e the different steps to run a MR and how to appropriately interact with the patient).
What next?
At each student rotation, the efficacy of the training program will be evaluated by comparing the concordance of BPMHs performed separately by a student and a pharmacist. A survey will be conducted to evaluate the level of learners’ satisfaction.