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MEDICATION SAFETY AT TRANSITIONS OF CARE Elizabeth Isaac, PharmD, BCPS PGY-2 Medication Use Safety Resident UMass Memorial Medical Center.

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Presentation on theme: "MEDICATION SAFETY AT TRANSITIONS OF CARE Elizabeth Isaac, PharmD, BCPS PGY-2 Medication Use Safety Resident UMass Memorial Medical Center."— Presentation transcript:

1 MEDICATION SAFETY AT TRANSITIONS OF 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.

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

4 Patient Case  MB is 93 year old female who presented to the hospital on January 20 th 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)

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 Outpatient  Inpatient SNF/Rehabilitation  Inpatient   Outpatient Inpatient  SNF/Rehabilitation  Outpatient  Types of transitions 1

7 Outpatient areasEmergency Department Outpatient clinics or offices “observation” patients Source of informationPatient Previous inpatient records Potential risks for errors-Potential disjointed past medical history -Medications from various sources or prescribers -Multiple pharmacies -Incomplete documentation Types of transitions 1 Outpatient  Inpatient Outpatient areasEmergency Department Outpatient clinics or offices “observation” patients Source of information-Patient -Previous inpatient records -Pharmacies or outpatient records Examples-Emergency Department -Outpatient clinics or offices -“observation” patients

8 Types of transitions 1 SNF/Rehabilitation  Inpatient Source of informationFacility 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 Source of information-Facility paperwork -Patient -Recent discharge information

9 Types of transitions 1 Inpatient  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 Examples -ICU  step-down / floor -Floor  ICU / step-down -Step-down  floor

10 Types of transitions 1 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

11 Types of transitions 1 Inpatient  SNF/Rehabilitation 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 Examples- Similar to discharge to community

12 Types of transitions 1 SNF/Rehabilitation  Outpatient 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 Sources of information-Discharge paperwork from hospital -Discharge paperwork from rehab -Medication administration records -Previous medication reconciliations

13 Types of transitions 1 Outpatient  Example Ex: Primary care physician  cardiologist Potential risk for errors- Changes in medication use or diagnoses are not always reflected in either providers documentation Example - Primary care physician  cardiologist

14 Regulatory Standards 2  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

15 The advent of the hospitalist 3,4  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

16 Deficits in communication and information transfer between hospital-based and primary care physicians 5 PurposeTo 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 MethodsMeta-analysis InclusionCase studies and controlled studies involving information transfer at discharge Results1064 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 PHYSICIANS 5

18 Deficits in communication and information transfer between hospital-based and primary care physicians 5

19  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 Deficits in communication and information transfer between hospital-based and primary care physicians 5

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

21 Medication discrepancies during transitions of care: a comparison study 6 PurposeTo 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 MethodsSingle center, retrospective, chart review InclusionPatients from one of two outpatient offices Admitted between January and July 2009 ExclusionPatient records missing from primary care office Chart ReviewDemographic 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 Results251 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 study 6

23  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 healthcare 7  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 1000 beneficiaries increased from 4.7 to 5.8 from to

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

26 Medication discrepancies

27 Medication Reconciliation 8  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

28 Barriers to accurate medication reconciliation  Patient health literacy  Comorbidities  Polypharmacy  Multiple providers  Frequent transitions  Reconciler  Closed formulary  Pediatric dosing

29 High risk patients 3  Elderly  Patients with multiples medications and comorbidities  Patients with limited literacy skills  Patients who do not speak English  Pediatric patients

30 High Risk Medications 3  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 patients 8,9 AdultPediatrics 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 MethodsProspective, single center studyMeta-analysis InclusionPatients admitted to the 212 bed Canadian community hospital in July ,739 citations reviewed 10 studies included in analysis InterventionsStudy 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 Results60 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 discharge 8

33 Medication discrepancies at Transitions in Pediatrics: A Review of the Literature 9  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 Literature 9  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

35  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 Medication errors in adult and pediatric patients 8,9

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

38 Patient Case

39  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 works  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

41 When medication reconciliation works  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

42 When medication reconciliation works 11

43 Discharge Checklist 13

44 Pharmacist’s Role 14  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 role 14  Inpatient pharmacy  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 1. The Joint Commission. Transitions of care: the need for a more effective approach to continuing patient care. Hot Topics in Health Care. Jun 2012: The Joint Commission. National Patient Safety Goals. Hospital Accreditation Program. Jan 2014: 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. 2007;2: Society of Hospital Medicine. SMH Faq List Available at: https://www.hospitalmedicine.org/AM/Template.cfm?Section=FAQs&Template=/FAQ/FAQ ListAll.cfm. Accessed on 23 April https://www.hospitalmedicine.org/AM/Template.cfm?Section=FAQs&Template=/FAQ/FAQ ListAll.cfm 5. 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: Daughtridge GW, Archibald T, Conway PH. Quality improvement of care transitions and the trend of composite hospital care. JAMA. 2014;311:

50 References 8. Vira T, Colquhoun M, Etchells E. Reconcilable differences: correcting medication errors at hospital admission and discharge. Qual Saf Health Care. 2006;15: Huynh C etal. Medication discrepancies at transitions in pediatrics: a review of the literature. Pediatr Drugs. 2013;15: Kwan JL, Lo L, Sampson M, Shojania KG. Medication reconciliation during transitions of care as a patient safety strategy. Ann Intern Med. 2013;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 Coleman EA, Parry C, Chalmers S, Min S. The care transitions intervention. Arch Intern Med. 2006;166: Soong C et al. Development of a checklist of safe discharge practices for hospital patients. Journal of Hospital Medicine. 2013;8: Hume AL et al. Improving care transitions: current practice and future opportunities for pharmacists. Pharmacotherapy. 2012;32:e


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