Presentation on theme: "Medication Safety at transitions of care"— Presentation transcript:
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, BCPSPGY-2 Medication Use Safety ResidentUMass Memorial Medical Center
2 DisclosuresI 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 careIdentify the types of patients and medications most at risk for having a medication discrepancy during transitions of careDevelop strategies to prevent medication errors while transitioning careTransitions 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, etcFinally we will examine the strategies which can be used to prevent discrepancies from occurring during this critical time in the healthcare process.
4 Patient CaseMB 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, penicillinsA 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” patientsOutpatient areasEmergency DepartmentOutpatient clinics or offices“observation” patientsSource of information-Patient-Previous inpatient records-Pharmacies or outpatient recordsOutpatient areasEmergency DepartmentOutpatient clinics or offices“observation” patientsSource of informationPatientPrevious inpatient recordsPotential risks for errors-Potential disjointed past medical history-Medications from various sources or prescribers-Multiple pharmacies-Incomplete documentationThe transition for outpatient to inpatientThis particular transition can be tricky – patients are admitted from three different areas – clinics, EDs, or “observationDuring 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 informationSource of informationFacility paperworkPatientRecent discharge informationPotential 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 cameThis 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-downStep-down floorExamplesICU step-down / floorFloor ICU / step-downStep-down floorPotential risks for errorAcuity of the patientProphylactic medicationsMedications on holdThis 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 directlyFrom ICU, step-down, or floorSources of informationDischarge paperwork / summaryPatient discharge instructionsPotential risks for errorLack of admitting privileges for PCPsProphylactic medicationsClosed formulariesSources of informationDischarge paperwork / summaryPatient discharge instructionsAny type of discharge from the hospital to the community directlyThere are a number of factors which contribute to discrepancies during this type of transitionThese 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 communityExamples- Similar to discharge to communityPotential risks for errorAdditional step in the healthcare processClosed formulariesProphylactic medicationsNotification to PCPCare of patient from additional providerSimilar 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 informationDischarge paperwork from hospitalDischarge paperwork from rehabMedication administration recordsPrevious medication reconciliationsSources of informationDischarge paperwork from hospitalDischarge paperwork from rehabMedication administration recordsPrevious medication reconciliationsPotential risk for errorsDisjointed careDelay in PCP notification / information transferMedications which can now be continuedThe 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 cardiologistExampleEx: Primary care physician cardiologistPotential risk for errors- Changes in medication use or diagnoses are not always reflected in either providers documentationThis 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 Standards2Joint Commission National Patient Safety GoalTo the best of one’s ability with the resources availableRecord 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 appointmentType of medication reconciliation can vary by health care settingReview the definition from joint commissionThe Joint commission has mandated both medication reconciliation be completed with every transfer of careThey 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 hospitalistsCurrently estimated between 10,000 and 12,000 hospitalists are practicing in the United StatesExpected to grow to 30,000 in the next decade according to the Society of Hospital MedicineAdd how hospitalists are trained – from SMH
16 Deficits in communication and information transfer between hospital-based and primary care physicians5PurposeTo 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 outcomesMethodsMeta-analysisInclusionCase studies and controlled studies involving information transfer at dischargeResults1064 citations identified55 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 physicians5ConclusionsTransmission of information between disciplines at discharge varies and is often inefficient and incompleteDischarge summaries should be based on a standardized formatEffect 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 hospitalizationOnly taking care of the patient temporarilyIncomplete hospitalization records are often tied to medication discrepanciesAdded burden to PCPsAlert fatigueDelay in test results or discharge paperwork*Promoting effective transitions of care at hospital discharge – a review of key issues for hospitalistsSMH Faq List. Society of Hospital Medicine, Available at: https://www.hospitalmedicine.org/AM/Template.cfm?Section=FAQs&Template=/FAQ/FAQListAll.cfm. Accessed on 23 April 2014.
21 Medication discrepancies during transitions of care: a comparison study6 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 withoutMethodsSingle center, retrospective, chart reviewInclusionPatients from one of two outpatient officesAdmitted between January and July 2009ExclusionPatient records missing from primary care officeChart ReviewDemographic informationMedication discrepancies at admission and dischargeOver the counter medications (except aspirin), herbals, vitamins, antibiotics, and short-term prescriptions (ie. Pain medications) were not evaluatedMedication accuracy of 85% was considered acceptableResults251 patient records evaluated120 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 privilegesMost common discrepancy was the omission of a medicationPatients were more likely to follow up with their PCP if they had admitting privilegesAge, 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 dischargeContributing to the utilization of “observation” statusObservation 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 careComplete reconciliation should include a conversation with the patient and a review of pharmacy or patient recordsFull definition of what a true med rec entails
28 Barriers to accurate medication reconciliation Patient health literacyComorbiditiesPolypharmacyMultiple providersFrequent transitionsReconcilerClosed formularyPediatric dosingPatient – not always clear what the patient is actually taking the list is often times incomplete or not up to dateeMAR – 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 specialistOutpatient pharmacy – time consuming, prescribers do not have patience to go and get the medicationsWho performs the med rec?Prescriber – often not done in a timely mannerMedical student – not always appropriately trained on medicationsNurse – no time to interview patients, other patient care responsibilitiesPharmacist – not adequate staffing, do not have the time to interview patientsStudent pharmacistPharmacy technician/intern
29 High risk patients3 Elderly Patients with multiples medications and comorbiditiesPatients with limited literacy skillsPatients who do not speak EnglishPediatric patients
30 High Risk Medications3 Antithrombotics Insulin and other hypoglycemics OpiatesAntiarrhythmics and other cardiovascular medicationsChemotherapyImmunosuppressantsAntiseizure medicationsEye MedicationsInhalersBEERs Criteria medications in patients over 65 years of age
31 Medication errors in adult and pediatric patients8,9 PediatricsPurposeTo examine the frequency and potential severity of unintended medication variances hospital admission and dischargeTo review the potential impact of medication reconciliationReview the occurrence rate of discrepancies in pediatric patientsIdentify the rate and clinical significance of discrepanciesLook for specific interventions for pediatric reconciliationMethodsProspective, single center studyMeta-analysisInclusionPatients admitted to the 212 bed Canadian community hospital in July 20021,739 citations reviewed10 studies included in analysisInterventionsStudy pharmacist conducted a comprehensive medication history on admission for all randomized patientsVariances identified and discussed with patient’s teamDischarge medication lists compared with preadmission and hospital medication useResults60 patients chosen6 medication reconciliation at admission to inpatient ward4 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 admission22 – 72.3% with an unintended discrepancyIn the EDPre- pharmacist implementation – 71%Post- pharmacist implementation – 38.3%At transfer0.53 unintentional discrepancy per patientAt discharge43% of patients and 15% of medications
34 Medication discrepancies at Transitions in Pediatrics: A Review of the Literature9 Clinical impact of discrepanciesEstimated that up to 6% could lead to severe discomfort or clinical deterioration23% could have potential to cause, and 71% were unlikelyNo specific discrepancies identifiedIn one of the reviews cited in the analysis
35 Medication errors in adult and pediatric patients8,9 Adult study conclusionsImpact of pharmacist reconciliation may have been falsely lowEconomic analysis was favorable to pharmacy involvementPediatric study conclusionsMedication reconciliation tools used in the adult population may not be applicable to the pediatric populationSmall, widely varied, studies are inconclusive of the clinical impact medication discrepancies have on pediatricsLimitations to both studies
36 Medication discrepancies and their impact Drug-drug interactionsInappropriate medication useWithdrawal from medicationsUnintended consequences (seizures, thrombosis, tachycardia)Over- or under- doseHospital readmissionAdded health-care costs
37 Patient caseLet 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 CaseA 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 discontinuedProvider notes all indicated isosorbide and valsartan should be continuedPatient discharged on medicationsError 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 outcomesThe 30 day readmission rate has been a major endpoint for most studies, but some have looked at 90 and 180 day readmissionsMedication reconciliation during transitions of care as a patient safety strategy
41 When medication reconciliation works10-12 Types of interventionsImplementation of a transition coachPharmacist reconciliation, counseling, and follow upOverall, reduced readmission rates were seen with the high intensity interventionsEconomically cost-neutralLower rates of preventable ADE’sThe Care transitions intervention
42 When medication reconciliation works11 Is implementation of the care transitions intervention associated with cost avoidance after hospital discharge?
44 Pharmacist’s Role14Obtaining a comprehensive medication history using the three step processNumerous studies have shown the benefit of involving a pharmacist across the continuum of care, especially in patients with multiple comorbidities and medicationsExpanding 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 reconciliationInvolved in discharge planningCommunity and Ambulatory careUse of MTMProviding patients with up-to-date medication listsHighlighting new medications for useLong-term Care (LTCF)Perform medication reconciliation within 5 days of readmittance to the LTCFMonthly medication reconciliation to assure appropriate care
46 AssessmentMB 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 useb. Review of pharmacy, outpatient, or hospital records for medication usec. Identification of medication discrepanciesd. Rectifying medication discrepancies
47 AssessmentWhich of the following is not a potential risk factor for medication discrepancies during transitions of care?a. Elderly patientsb. Multiple comorbidities and polypharmacyc. Patients on oral antibioticsd. Multiple providers and disjointed care
49 ReferencesThe 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: https://www.hospitalmedicine.org/AM/Template.cfm?Section=FAQs&Template=/FAQ/FAQ 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 ReferencesVira 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