Pharmacy student-assisted medication reconciliation: Number and types of medication discrepancies identified by pharmacy students

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Abstract

Background:

Medication reconciliation aims to prevent unintentional medication discrepancies that can result in patient harm at transitions of care. Pharmacist-led medication reconciliation has clear benefits, however workforce limitations can be a barrier to providing this service. Pharmacy students are a potential workforce solution.

Objective:

To evaluate the number and type of medication discrepancies identified by pharmacy students.

Methods:

Fourth year pharmacy students completed best possible medication histories and identified discrepancies with prescribed medications for patients admitted to hospital. A retrospective audit was conducted to determine the number and type of medication discrepancies identified by pharmacy students, types of patients and medicines involved in discrepancies.

Results:

There were 294 patients included in the study. Overall, 72% (n=212/294) had medication discrepancies, the most common type being drug omission. A total of 645 discrepancies were identified, which was a median of three per patient. Patients with discrepancies were older than patients without discrepancies with a median (IQR) age of 74 (65-84) vs 68 (53-77) years (p=0.001). They also took more medicines with a median (IQR) number of 9 (6-3) vs 7 (2-10) medicines per patient (p<0.001). The most common types of medicines involved were those related to the alimentary tract and cardiovascular system.

Conclusions:

Pharmacy students identified medication discrepancies in over 70% of hospital inpatients, categorised primarily as drug omission. Pharmacy students can provide a beneficial service to the hospital and contribute to improved patient safety by assisting pharmacists with medication reconciliation.

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Most cited references 23

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Unintended medication discrepancies at the time of hospital admission.

S. Knowles, David Juurlink, Steven Shadowitz … (2005)

Prior studies suggest that unintended medication discrepancies that represent errors are common at the time of hospital admission. These errors are particularly worthy of attention because they are not likely to be detected by computerized physician order entry systems. We prospectively studied patients reporting the use of at least 4 regular prescription medications who were admitted to general internal medicine clinical teaching units. The primary outcome was unintended discrepancies (errors) between the physicians' admission medication orders and a comprehensive medication history obtained through interview. We also evaluated the potential seriousness of these discrepancies. All discrepancies were reviewed with the medical team to determine if they were intentional or unintentional. All unintended discrepancies were rated for their potential to cause patient harm. After screening 523 admissions, 151 patients were enrolled based on the inclusion criteria. Eighty-one patients (53.6%; 95% confidence interval, 45.7%-61.6%) had at least 1 unintended discrepancy. The most common error (46.4%) was omission of a regularly used medication. Most (61.4%) of the discrepancies were judged to have no potential to cause serious harm. However, 38.6% of the discrepancies had the potential to cause moderate to severe discomfort or clinical deterioration. Medication errors at the time of hospital admission are common, and some have the potential to cause harm. Better methods of ensuring an accurate medication history at the time of hospital admission are needed.

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Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review.

Vincent C Tam, Sandra R Knowles, Patricia L Cornish … (2005)

Over a quarter of hospital prescribing errors are attributable to incomplete medication histories being obtained at the time of admission. We undertook a systematic review of studies describing the frequency, type and clinical importance of medication history errors at hospital admission. We searched MEDLINE, EMBASE and CINAHL for articles published from 1966 through April 2005 and bibliographies of papers subsequently retrieved from the search. We reviewed all published studies with quantitative results that compared prescription medication histories obtained by physicians at the time of hospital admission with comprehensive medication histories. Three reviewers independently abstracted data on methodologic features and results. We identified 22 studies involving a total of 3755 patients (range 33-1053, median 104). Errors in prescription medication histories occurred in up to 67% of cases: 10%- 61% had at least 1 omission error (deletion of a drug used before admission), and 13%- 22% had at least 1 commission error (addition of a drug not used before admission); 60%- 67% had at least 1 omission or commission error. Only 5 studies (n = 545 patients) explicitly distinguished between unintentional discrepancies and intentional therapeutic changes through discussions with ordering physicians. These studies found that 27%- 54% of patients had at least 1 medication history error and that 19%- 75% of the discrepancies were unintentional. In 6 of the studies (n = 588 patients), the investigators estimated that 11%-59% of the medication history errors were clinically important. Medication history errors at the time of hospital admission are common and potentially clinically important. Improved physician training, accessible community pharmacy databases and closer teamwork between patients, physicians and pharmacists could reduce the frequency of these errors.

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Hospital-based medication reconciliation practices: a systematic review.

Stephanie K Mueller, Kelly Cunningham Sponsler, Sunil Kripalani … (2012)

Medication discrepancies at care transitions are common and lead to patient harm. Medication reconciliation is a strategy to reduce this risk. To summarize available evidence on medication reconciliation interventions in the hospital setting and to identify the most effective practices. MEDLINE (1966 through February 2012) and a manual search of article bibliographies. Twenty-six controlled studies. Data were extracted on study design, setting, participants, inclusion/exclusion criteria, intervention components, timing, comparison group, outcome measures, and results. Studies were grouped by type of medication reconciliation intervention-pharmacist related, information technology (IT), or other-and were assigned quality ratings using US Preventive Services Task Force criteria. Fifteen of 26 studies reported pharmacist-related interventions, 6 evaluated IT interventions, and 5 studied other interventions. Six studies were classified as good quality. The comparison group for all the studies was usual care; no studies compared different types of interventions. Studies consistently demonstrated a reduction in medication discrepancies (17 of 17 studies), potential adverse drug events (5 of 6 studies), and adverse drug events (2 of 2 studies) but showed an inconsistent reduction in postdischarge health care utilization (improvement in 2 of 8 studies). Key aspects of successful interventions included intensive pharmacy staff involvement and targeting the intervention to a high-risk patient population. Rigorously designed studies comparing different inpatient medication reconciliation practices and their effects on clinical outcomes are scarce. Available evidence supports medication reconciliation interventions that heavily use pharmacy staff and focus on patients at high risk for adverse events. Higher-quality studies are needed to determine the most effective approaches to inpatient medication reconciliation.

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Author and article information

Contributors

Louise Deep:

ORCID: https://orcid.org/0000-0002-8522-1704

Carl R. Schneider:

ORCID: https://orcid.org/0000-0002-2921-5609

Rebekah Moles:

ORCID: https://orcid.org/0000-0002-4043-6728

Asad E. Patanwala:

ORCID: https://orcid.org/0000-0003-3999-4703

Linda L. Do:

ORCID: https://orcid.org/0000-0002-0202-2487

Rosemary Burke:

ORCID: https://orcid.org/0000-0002-5396-8977

Jonathan Penm:

ORCID: https://orcid.org/0000-0001-9606-7135

Journal

Journal ID (nlm-ta): Pharm Pract (Granada)

Journal ID (iso-abbrev): Pharm Pract (Granada)

Title: Pharmacy Practice

Publisher: Centro de Investigaciones y Publicaciones Farmaceuticas

ISSN (Print): 1885-642X

ISSN (Electronic): 1886-3655

Publication date (Print): Jul-Sep 2021

Publication date (Electronic): 15 September 2021

Volume: 19

Issue: 3

Electronic Location Identifier: 2471

Affiliations

Department of Pharmacy, Royal Prince Alfred Hospital , Camperdown, NSW (Australia). Louise.deep@ 123456health.nsw.gov.au

School of Pharmacy, Faculty of Medicine and Health, University of Sydney . Sydney, NSW (Australia). Carl.schneider@ 123456sydney.edu.au

School of Pharmacy, Faculty of Medicine and Health, University of Sydney . Sydney, NSW (Australia). Rebekah.moles@ 123456sydney.edu.au

School of Pharmacy, Faculty of Medicine and Health, University of Sydney . Sydney, NSW (Australia). Asad.patanwala@ 123456sydney.edu.au

School of Pharmacy, Faculty of Medicine and Health, University of Sydney . Sydney, NSW (Australia). Linda.do@ 123456sydney.edu.au

Sydney Local Health District , Sydney, NSW (Australia). Rosemary.burke@ 123456health.nsw.gov.au

School of Pharmacy, Faculty of Medicine and Health, University of Sydney . Sydney, NSW (Australia). Jonathan.penm@ 123456sydney.edu.au

Author notes

Conceptualization: LD, CRS, RM, AEP, LLD, RB, JP. Data curation: LD, AEP, JP. Formal analysis: LD, JP. Investigation: LD. Methodology: LD, CRS, RM, AEP, LLD, RB, JP. Supervision: CRS, RM, AEP, JP. Writing – original draft: LD. Writing – review & editing: LD, CRS, RM, AEP, LLD, RB, JP.

Author information

Louise Deep https://orcid.org/0000-0002-8522-1704

Carl R. Schneider https://orcid.org/0000-0002-2921-5609

Rebekah Moles https://orcid.org/0000-0002-4043-6728

Asad E. Patanwala https://orcid.org/0000-0003-3999-4703

Linda L. Do https://orcid.org/0000-0002-0202-2487

Rosemary Burke https://orcid.org/0000-0002-5396-8977

Jonathan Penm https://orcid.org/0000-0001-9606-7135

Article

Publisher ID: pharmpract-19-2471

DOI: 10.18549/PharmPract.2021.3.2471

PMC ID: 8456341

PubMed ID: 34621455

SO-VID: d7a7d66a-3949-4d31-9bba-45f6462164c5

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY-NC-ND 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

History

Date received : 24 June 2021

Date accepted : 12 September 2021

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Pharmacy student-assisted medication reconciliation: Number and types of medication discrepancies identified by pharmacy students

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Abstract

Background:

Objective:

Methods:

Results:

Conclusions:

Related collections

SciELO Spain

Most cited references 23

Unintended medication discrepancies at the time of hospital admission.

Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review.

Hospital-based medication reconciliation practices: a systematic review.

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Contributors

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Cited by 2

Most referenced authors 160