1. Medication Safety at transitions of care
Good morning. My name is Elizabeth Isaac and I am currently the medication use safety resident at Umass memorial medical center in Worcester Mass. Today I will be talking about medication safety at transitions of care. While my background and area of practice is primarily focused on the inpatient world I will attempt to bridge the gap between inpatient and outpatient, and the varying degrees of care between these areas as well as shed some light on the inpatient process and highlight some of the ways healthcare has changed and its impact on medication safety at these critical junctions in patient care.
Elizabeth Isaac, PharmD, BCPS
PGY-2 Medication Use Safety Resident
UMass Memorial Medical Center

2. Disclosures
I have no disclosures concerning possible financial or personal relationship with commercial entities.
So let’s begin.
First, I have no disclosers concerning possible financial or personal relationships with commercial entities.

3. Objectives Review the types of transitions of care
Understand the risk factors for medication discrepancies at transitions of care
Identify the types of patients and medications most at risk for having a medication discrepancy during transitions of care
Develop strategies to prevent medication errors while transitioning care
Transitions of care – This seems to be the most recent buzz-word in healthcare. During this presentation my hope is to look at the different types of transitions of care and look at the contributing factors to medication discrepancies at the transitions of care. We will also look at which patients are most at risk as well the medications most at risk.
As pharmacists most of what we will be talking about is related to the medication reconciliation process – although it is important to note that discrepancies occur with many other aspects of healthcare including missed diagnoses, labs, etc
Finally we will examine the strategies which can be used to prevent discrepancies from occurring during this critical time in the healthcare process.

4. Patient Case
MB is 93 year old female who presented to the hospital on January 20th with generalized weakness.
HPI: Pt was hospitalized in September 2013 for a pneumonia and recently completed a course of prednisone for COPD exacerbation.
PMH: CAD (3VD w/ bare metal stent, EF 60-65%), HTN, TIA, chronic rhinitis, dyslipidemia, GI bleed on clopidogrel, COPD, osteoarthritis, diverticulosis, pseudomonas pneumonia (on inhaled tobramycin)
We will first present a case. As we go through the presentation I would like everyone to start thinking about where this patient falls in the spectrum of care and what it is that puts this patient so at risk for having medication discrepancies.
MB is our 93 year old female who presented to the hospital on January 20th. Her complaint was generalized weakness. The patient was interviewed and a medication reconciliation form was filled out.

5. Patient Case: MB Allergies (from Pharmacy system)
Bactrim, doxycycline, nitrofurantoin, penicillins
A medication reconciliation was conducted based on an interview with the patient

6. Types of transitions1 Outpatient  Inpatient SNF/Rehabilitation
Let us first begin with the types of transitions of care. It seems relatively simple. A transfer in the level of care for a patient. In reality, there are a number of different types of transitions and in our world of healthcare, it is very likely that a patient will experience all of these types of transfers during their life.

7. Types of transitions1 Outpatient  Inpatient Examples
-Emergency Department
-Outpatient clinics or offices
-“observation” patients
Outpatient areas
Emergency Department
Outpatient clinics or offices
“observation” patients
Source of information
-Patient
-Previous inpatient records
-Pharmacies or outpatient records
Outpatient areas
Emergency Department
Outpatient clinics or offices
“observation” patients
Source of information
Patient
Previous inpatient records
Potential risks for errors
-Potential disjointed past medical history
-Medications from various sources or prescribers
-Multiple pharmacies
-Incomplete documentation
The transition for outpatient to inpatient
This particular transition can be tricky – patients are admitted from three different areas – clinics, EDs, or “observation
During this transition patient’s are primarily responsible for communicating information about themselves in regard to medications and past medical history. Some patients have been to the health system before or come from clinics associated with the health system and some of their past medical history or previous medications are a part of the medical record. These are not always up to date and much of the information can become lost

8. Types of transitions1 SNF/Rehabilitation  Inpatient
Source of information
-Facility paperwork
-Patient
-Recent discharge information
Source of information
Facility paperwork
Patient
Recent discharge information
Potential risks for error
-Temporary changes in medication history not always reflected in the record or paperwork
-Patient’s who do not return to the same hospital from which they came
This is similar to the transition from outpatient to inpatient although often times patients come with paperwork. These patients can often be in a very critical time period while they are recovering from an acute illness and interventions are still on hold or temporary. These can often be missed while patients transfer from one healthcare setting to another.

9. Types of transitions1 Inpatient  Examples ICU  step-down / floor
Floor  ICU / step-down
Step-down  floor
Examples
ICU  step-down / floor
Floor  ICU / step-down
Step-down  floor
Potential risks for error
Acuity of the patient
Prophylactic medications
Medications on hold
This can be from an acute care area to a step down or ICU floor and vice versa.
The acuity of the patient is a huge factor during this type of transition. As patients step up or down their level of care a medication reconciliation needs to be done – often times medications used for prophylaxis and core measures need to be started and are overlooked or medications which should not be continued during an acute illness or exacerbation need to be discontinued and again are overlooked when they can be continued

10. Types of transitions1 Inpatient  Outpatient Examples
Discharge to the community directly
From ICU, step-down, or floor
Sources of information
Discharge paperwork / summary
Patient discharge instructions
Potential risks for error
Lack of admitting privileges for PCPs
Prophylactic medications
Closed formularies
Sources of information
Discharge paperwork / summary
Patient discharge instructions
Any type of discharge from the hospital to the community directly
There are a number of factors which contribute to discrepancies during this type of transition
These include closed formularies, lack of admitting privileges for PCPs, PCPs lack of awareness of what their patients are admitted for, prophylactic medications for an inpatient admission unnecessary to continue,

11. Types of transitions1 Inpatient  SNF/Rehabilitation Examples
- Similar to discharge to community
Examples
- Similar to discharge to community
Potential risks for error
Additional step in the healthcare process
Closed formularies
Prophylactic medications
Notification to PCP
Care of patient from additional provider
Similar to the problems from inpatient to outpatient – this also presents another step where medical history can be lost or misinterpeted

12. Types of transitions1 SNF/Rehabilitation  Outpatient
Sources of information
Discharge paperwork from hospital
Discharge paperwork from rehab
Medication administration records
Previous medication reconciliations
Sources of information
Discharge paperwork from hospital
Discharge paperwork from rehab
Medication administration records
Previous medication reconciliations
Potential risk for errors
Disjointed care
Delay in PCP notification / information transfer
Medications which can now be continued
The transition between a nursing home or rehab center to home – this should be a relatively simple transfer of care but the patient may be receiving medications which they will not be on discharge. In addition, similarly to previous discharges, patients are often recovering from an acute illness and certain medications may still be on hold which could be missed.

13. Types of transitions1 Outpatient  Example
- Primary care physician  cardiologist
Example
Ex: Primary care physician  cardiologist
Potential risk for errors
- Changes in medication use or diagnoses are not always reflected in either providers documentation
This can be between providers, specifically between a primary care and consultants. Incomplete reconciliation or transfer of information between providers can present a problem at all levels of care. Often times, medications may be changed without another provider knowing and a patient may not have a complete medication list.

14. Regulatory Standards2
Joint Commission National Patient Safety Goal
To the best of one’s ability with the resources available
Record and pass along correct information about a patient’s medications. Find out what the patient is taking and compare them to new medications given by the LIP. Provide patient’s with the most up-to-date list of their medications that they are taking and educate them to take the most up-to-date list to every appointment
Type of medication reconciliation can vary by health care setting
Review the definition from joint commission
The Joint commission has mandated both medication reconciliation be completed with every transfer of care
They have also mandated patient discharge information be completed in 30 days

15. The advent of the hospitalist3,4
Increasing demands on outpatient providers have shifted the inpatient care of the patient to hospitalists
Currently estimated between 10,000 and 12,000 hospitalists are practicing in the United States
Expected to grow to 30,000 in the next decade according to the Society of Hospital Medicine
Add how hospitalists are trained – from SMH

16. Deficits in communication and information transfer between hospital-based and primary care physicians5
Purpose
To characterize the types of communication and information transfer between hospital-based and primary care physicians (PCPs)
Identify the deficits and determine the efficacy of interventions and clinical outcomes
Methods
Meta-analysis
Inclusion
Case studies and controlled studies involving information transfer at discharge
Results
1064 citations identified
55 observational studies (21 medical record audits, 23 physician surveys, 11 combined audit-surveys)
18 controlled intervention trials (3 randomized, 7 nonrandomized with concurrent control, 8 pre/post design)

17. Deficits in communication and information transfer between hospital-based and primary care physicians5

18. Deficits in communication and information transfer between hospital-based and primary care physicians5

19. Deficits in communication and information transfer between hospital-based and primary care physicians5
Conclusions
Transmission of information between disciplines at discharge varies and is often inefficient and incomplete
Discharge summaries should be based on a standardized format
Effect on clinical outcomes was hard to measure

20. The downside to the hospitalist
Primary care physicians are less involved in the care of the patient during hospitalization
Only taking care of the patient temporarily
Incomplete hospitalization records are often tied to medication discrepancies
Added burden to PCPs
Alert fatigue
Delay in test results or discharge paperwork
*Promoting effective transitions of care at hospital discharge – a review of key issues for hospitalists
SMH Faq List. Society of Hospital Medicine, Available at: Accessed on 23 April 2014.

21. Medication discrepancies during transitions of care: a comparison study6
Purpose
To determine if medication discrepancies exist between patients who are cared for in a hospital by primary care physicians (PCPs) with admitting privileges vs. those without
Methods
Single center, retrospective, chart review
Inclusion
Patients from one of two outpatient offices
Admitted between January and July 2009
Exclusion
Patient records missing from primary care office
Chart Review
Demographic information
Medication discrepancies at admission and discharge
Over the counter medications (except aspirin), herbals, vitamins, antibiotics, and short-term prescriptions (ie. Pain medications) were not evaluated
Medication accuracy of 85% was considered acceptable
Results
251 patient records evaluated
120 patients with physicians without admitting privileges vs.
131 patient with physicians with admitting privileges

22. Medication discrepancies during transitions of care: a comparison study6
Insert charts

23. Medication discrepancies during transitions of care: a comparison study6
Overall, a greater number of medication discrepancies were identified on patients cared for by physicians without admitting privileges
Most common discrepancy was the omission of a medication
Patients were more likely to follow up with their PCP if they had admitting privileges
Age, gender, healthcare coverage, and follow-up time did not have an effect on the discrepancy occurrences

24. Economic and financial influences of healthcare7
Affordable Care Act, Condition code 44 (2004)
Allows a hospital utilization review committee to change a patient’s status from inpatient to outpatient if the original admission is deemed unnecessary prior to discharge
Contributing to the utilization of “observation” status
Observation stays within 30 days of hospital discharge per beneficiaries increased from 4.7 to 5.8 from to
- Quality improvement of care transitions and the trend of composite hospital care

25. Disjointed Care Hospital-based vs. primary care physicians
Delay in information
“Observation” patients

26. Medication discrepancies
So what puts medications so at risk during this critical juncture in healthcare

27. Medication Reconciliation8
A three step process of verifying medication use, identifying variances, and rectifying medication errors at interfaces of care
Complete reconciliation should include a conversation with the patient and a review of pharmacy or patient records
Full definition of what a true med rec entails

28. Barriers to accurate medication reconciliation
Patient health literacy
Comorbidities
Polypharmacy
Multiple providers
Frequent transitions
Reconciler
Closed formulary
Pediatric dosing
Patient – not always clear what the patient is actually taking the list is often times incomplete or not up to date
eMAR – dependent on where the patient is followed as an outpatient, not always in the health-system. Not always up-to-date, often only for a consulting prescriber or specialist
Outpatient pharmacy – time consuming, prescribers do not have patience to go and get the medications
Who performs the med rec?
Prescriber – often not done in a timely manner
Medical student – not always appropriately trained on medications
Nurse – no time to interview patients, other patient care responsibilities
Pharmacist – not adequate staffing, do not have the time to interview patients
Student pharmacist
Pharmacy technician/intern

29. High risk patients3 Elderly
Patients with multiples medications and comorbidities
Patients with limited literacy skills
Patients who do not speak English
Pediatric patients

30. High Risk Medications3 Antithrombotics Insulin and other hypoglycemics
Opiates
Antiarrhythmics and other cardiovascular medications
Chemotherapy
Immunosuppressants
Antiseizure medications
Eye Medications
Inhalers
BEERs Criteria medications in patients over 65 years of age

31. Medication errors in adult and pediatric patients8,9
Pediatrics
Purpose
To examine the frequency and potential severity of unintended medication variances hospital admission and discharge
To review the potential impact of medication reconciliation
Review the occurrence rate of discrepancies in pediatric patients
Identify the rate and clinical significance of discrepancies
Look for specific interventions for pediatric reconciliation
Methods
Prospective, single center study
Meta-analysis
Inclusion
Patients admitted to the 212 bed Canadian community hospital in July 2002
1,739 citations reviewed
10 studies included in analysis
Interventions
Study pharmacist conducted a comprehensive medication history on admission for all randomized patients
Variances identified and discussed with patient’s team
Discharge medication lists compared with preadmission and hospital medication use
Results
60 patients chosen
6 medication reconciliation at admission to inpatient ward
4 other settings or transitions of care

32. Reconcilable differences: correcting medication errors at hospital admission and discharge8

33. Medication discrepancies at Transitions in Pediatrics: A Review of the Literature9
Discrepancies at admission
22 – 72.3% with an unintended discrepancy
In the ED
Pre- pharmacist implementation – 71%
Post- pharmacist implementation – 38.3%
At transfer
0.53 unintentional discrepancy per patient
At discharge
43% of patients and 15% of medications

34. Medication discrepancies at Transitions in Pediatrics: A Review of the Literature9
Clinical impact of discrepancies
Estimated that up to 6% could lead to severe discomfort or clinical deterioration
23% could have potential to cause, and 71% were unlikely
No specific discrepancies identified
In one of the reviews cited in the analysis

35. Medication errors in adult and pediatric patients8,9
Adult study conclusions
Impact of pharmacist reconciliation may have been falsely low
Economic analysis was favorable to pharmacy involvement
Pediatric study conclusions
Medication reconciliation tools used in the adult population may not be applicable to the pediatric population
Small, widely varied, studies are inconclusive of the clinical impact medication discrepancies have on pediatrics
Limitations to both studies

36. Medication discrepancies and their impact
Drug-drug interactions
Inappropriate medication use
Withdrawal from medications
Unintended consequences (seizures, thrombosis, tachycardia)
Over- or under- dose
Hospital readmission
Added health-care costs

37. Patient case
Let us revisit patient MB. As previously stated she was originally admitted to the hospital for generalized weakness. She came in through the emergency department and was seen by the admitting resident. A medication history was taken based on an interview with the patient and was transferred to the floor.
The next day, her care was taken over by a separate team. By chance, the patient’s daughter was with the patient when the team saw the patient that day and the daughter expressed concern over her mother’s medications. It was discovered that the the patient was not supposed to be on certain medications and they were discontinued

38. Patient Case
A new medication reconciliation was written and an order to discontinue the previous medication reconciliation was written. Unfortunately, the order to discontinue the previous med rec was missed and the patient continued to have isosorbide mononitrate active in her profile. She was discharged over the weekend, when the attending was not present, and isosorbide was continued based on both the initial med rec and her active medications in house.
During a phone call to the patient and her daughter a week later, the error was discovered and remediated

39. Patient Case A second medication reconciliation was conducted
Isosorbide and valsartan discontinued
Provider notes all indicated isosorbide and valsartan should be continued
Patient discharged on medications
Error later realized by daughter

40. When medication reconciliation works10-12
Several studies have looked at the impact of pharmacist or specialized nurse medication reconciliation and the impact on hospital readmission rates and economic outcomes
The 30 day readmission rate has been a major endpoint for most studies, but some have looked at 90 and 180 day readmissions
Medication reconciliation during transitions of care as a patient safety strategy

41. When medication reconciliation works10-12
Types of interventions
Implementation of a transition coach
Pharmacist reconciliation, counseling, and follow up
Overall, reduced readmission rates were seen with the high intensity interventions
Economically cost-neutral
Lower rates of preventable ADE’s
The Care transitions intervention

42. When medication reconciliation works11
Is implementation of the care transitions intervention associated with cost avoidance after hospital discharge?

43. Discharge Checklist13

44. Pharmacist’s Role14
Obtaining a comprehensive medication history using the three step process
Numerous studies have shown the benefit of involving a pharmacist across the continuum of care, especially in patients with multiple comorbidities and medications
Expanding role of the pharmacist is placing us in areas of health-care where we can take on a more active role in a patient’s medication management

45. Pharmacist’s role14 Inpatient pharmacy Community and Ambulatory care
Comprehensive medication reconciliation
Involved in discharge planning
Community and Ambulatory care
Use of MTM
Providing patients with up-to-date medication lists
Highlighting new medications for use
Long-term Care (LTCF)
Perform medication reconciliation within 5 days of readmittance to the LTCF
Monthly medication reconciliation to assure appropriate care

46. Assessment
MB is the 93 year old woman admitted for generalized weakness. A medication reconciliation is obtained by interviewing the patient. Later, discrepancies were identified when speaking with the patient’s daughter which were subsequently rectified. Which stage of the medication reconciliation process was missed which led to an error in the patient’s care?
a. Interview with the patient to obtain medication use
b. Review of pharmacy, outpatient, or hospital records for medication use
c. Identification of medication discrepancies
d. Rectifying medication discrepancies

47. Assessment
Which of the following is not a potential risk factor for medication discrepancies during transitions of care?
a. Elderly patients
b. Multiple comorbidities and polypharmacy
c. Patients on oral antibiotics
d. Multiple providers and disjointed care

48. Questions?

49. References
The Joint Commission. Transitions of care: the need for a more effective approach to continuing patient care. Hot Topics in Health Care. Jun 2012:1-8.
The Joint Commission. National Patient Safety Goals. Hospital Accreditation Program. Jan 2014:1-17.
Kripalani S, Jackson, AT, Schnipper JL, Coleman EA. Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. Journal of Hospital Medicine ;2:
Society of Hospital Medicine. SMH Faq List Available at: ListAll.cfm. Accessed on 23 April 2014.
Kripalani S, LeFavre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians. JAMA. 2007;297:
Trompeter JM, McMillan AN, Rager ML, Fox JR. Medication discrepancies during transitions of care: a comparison study. Journal of Healthcare Quality. 2014;00:1-7.
Daughtridge GW, Archibald T, Conway PH. Quality improvement of care transitions and the trend of composite hospital care. JAMA. 2014;311:

50. References
Vira T, Colquhoun M, Etchells E. Reconcilable differences: correcting medication errors at hospital admission and discharge. Qual Saf Health Care ;15:
Huynh C etal. Medication discrepancies at transitions in pediatrics: a review of the literature. Pediatr Drugs ;15:
Kwan JL, Lo L, Sampson M, Shojania KG. Medication reconciliation during transitions of care as a patient safety strategy. Ann Intern Med ;158:
Gardner R, Li Q, Baier RR, Butterfield K, Coleman EA, Gravenstein S. Is implementation of the care transitions intervention associated with cost avoidance after hospital discharge? J Gen Intern Med. E-published 2014.
Coleman EA, Parry C, Chalmers S, Min S. The care transitions intervention. Arch Intern Med ;166:
Soong C et al. Development of a checklist of safe discharge practices for hospital patients. Journal of Hospital Medicine. 2013;8:444-9.
Hume AL et al. Improving care transitions: current practice and future opportunities for pharmacists. Pharmacotherapy. 2012;32:e