Medication reconciliation: a practical tool to reduce the risk of medication errors

doi:10.1016/j.jcrc.2003.10.001

Journal of Critical Care

Volume 18, Issue 4, December 2003, Pages 201-205

https://doi.org/10.1016/j.jcrc.2003.10.001 Get rights and content

Abstract

Preventable adverse drug events are associated with one out of five injuries or deaths. Estimates reveal that 46% of medication errors occur on admission or discharge from a clinical unit/hospital when patient orders are written. This study was performed to reduce medication errors in patient’s discharge orders through a reconciliation process in an adult surgical intensive care unit (ICU). A discharge survey was implemented as part of the medication reconciliation process. The admitting nurse initiated the survey within 24 hours of ICU admission and the charge nurse completed the survey on discharge. Baseline data were obtained through a random sampling of 10% of discharges in first 2 weeks of the study (July 2001-May 2002). Medical and anesthesia records were reviewed, allergies and home medications verified with patient/family and findings compared with orders at time of ICU discharge. Baseline data revealed that 31 of 33 (94%) patients had orders changed. By week 24, nearly all medication errors in discharge orders were eliminated. In conclusion, use of the discharge survey in this medication reconciliation process resulted in a dramatic drop in medications errors for patients discharged from an ICU. The survey is now a part of our electronic medical record and used in 4 adult ICUs and 2 medicine floors.

Section snippets

Objectives

The specific aim of this study was to reduce medication errors in discharge orders by implementing a medication reconciliation process for all patients discharged from the surgical ICU in an academic medical center. We accomplished this by using the improvement model developed by Langley and Nolan.8

Data sources and settings

Data were collected by using a medication reconciliation tool called a discharge survey. The patient’s medical and anesthesia records were reviewed and the patient and family members queried regarding medication history. The setting was an adult surgical ICU at an academic medical center.

Study design methods

Medication reconciliation was developed and implemented in a 14-bed surgical ICU that receives 1,300 admissions annually, on average 25 per week, in an academic medical center. To achieve the study aim, a multispecialty team consisting of the director of patient safety (also an ICU attending), a pharmacist, a nurse administrator, a nurse from the participating ICU, a representative from Information Systems, and administration formed a work team to develop and implement a medication

Data collection methods

The primary outcome variable was the percent of randomly audited medical records per week that contained a medication error in the discharge orders, defined as such if the physician changed the orders as a result of the information obtained through the medication reconciliation processes. Two research nurses audited approximately 10% of discharges (10 to 15 random patients) per week. The nurses conducted this audit 2 weeks prior and for 19 weeks after making the discharge survey part of routine

Results

During the first 2 weeks, we obtained baseline data regarding medication errors, and found that 31 of 33 (94%) patients had their orders changed. As a result, the discharge survey became part of the routine ICU discharge process. Figure 1 displays the rates of medication errors per week that were identified by auditing approximately 10 randomly selected patients per week. Through the use of the discharge survey, we nearly eliminated medication errors in discharge orders (10 of the 25 [on

Conclusion

The use of medication reconciliation was associated with a dramatic reduction in medication errors in patients transferring from an ICU at an academic medical center. The medication reconciliation tool is now automated and part of our electronic medical record and used on all discharges. Nurse and physician perceptions support the data that using this tool is associated with significant improvements in patient safety. The process of medication reconciliation is based on the safety principle of

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ICU survivors often have complex care needs and can experience insufficient medication reconciliation and polypharmacy. It is unknown which ICU survivors are at risk of new sedative use posthospitalization.
For sedative-naive, older adult ICU survivors, how common is receipt of new and persistent sedative prescriptions, and what factors are associated with receipt?
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el objetivo de este estudio fue determinar si la transición del alta de la unidad de cuidados intensivos a la planta de hospitalización conlleva un alto riesgo de errores de conciliación. Se definió como objetivo principal del estudio describir y cuantificar las discrepancias y los errores de conciliación. Los objetivos secundarios incluyeron clasificar los errores de conciliaciòn por tipo, grupo terapéutico de los medicamentos implicados y la gravedad potencial.
se llevó a cabo un estudio observacional retrospectivo de los pacientes dados de alta de la unidad de cuidados intensivos a la planta de hospitalización. Antes de que un paciente fuese dado de alta desde la unidad de cuidados intensivos, sus últimas prescripciones fueron comparadas con el listado de medicación propuesto en la planta de hospitalización. Las discrepancias entre ambos listados fueron clasificadas como discrepancias justificadas o errores de conciliación. Los errores de conciliación fueron clasificados por tipo de error, por gravedad potencial y por grupo terapéutico.
fueron conciliados 452 pacientes. Se encontró al menos una discrepancia en un 34,29% (155/452), y presentaba al menos un error de conciliación 18,14% (82/452). Los errores de conciliación más frecuentes fueron diferente dosis o vía de administración (31,79% [48/151]) y errores de omisión (31,79% [48/151]). Un 19,20% (29/151) involucraba a medicamentos de alto riesgo.
el alta desde la unidad de cuidados intensivos a la planta de hospitalización convencional es una transición asistencial que presenta alto riesgo de errores de conciliación. Los errores de conciliación ocurren con frecuencia, en ocasiones involucran a medicamentos de alto riesgo, su potencial gravedad puede requerir una monitorización adicional o producir daño temporal, y en algunos casos, más de un error de conciliación puede tener lugar. La conciliación de medicamentos por un farmacéutico puede reducir los errores de conciliación.
The aim of this study was to determine whether the transition of care from the intensive care unit to the ward would pose a high risk for reconciliation errors. The primary outcome of this study was to describe and quantify the discrepancies and reconciliation errors. Secondary outcomes included classification of the reconciliation errors by type of medication error, therapeutic group of the drugs involved and grade of potential severity.
We conducted a retrospective observational study of reconciliated adult patients discharged from the Intensive Care Unit to the ward. Before a patient was discharged from the intensive care unit, their last intensive care unit’s prescriptions were compared with their proposed medication list in the ward. The discrepancies between these were classified as justified discrepancies or reconciliation errors. Reconciliation errors were classified by type of error, potential severity, and therapeutic group.
We found that 452 patients were reconciliated. At least one discrepancy was detected in 34.29% (155/452), and 18.14% (82/452) had at least one reconciliation errors. The most found error types were a different dose or administration route (31.79% [48/151]) and omission errors (31.79% [48/151]). High alert medication was involved in 19.20% of reconciliation errors (29/151).
Our study shows that intensive care unit to non-intensive care unit transitions are high-risk processes for reconciliation error. They frequently occur and occasionally involve high alert medication, and their severity could require additional monitoring or cause temporary harm. Medication reconciliation can reduce reconciliation errors.
Medication reconciliation for patients after their discharge from intensive care unit to the hospital ward
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The aim of this study was to determine whether the transition of care from the intensive care unit to the ward would pose a high risk for reconciliation errors. The primary outcome of this study was to describe and quantify the discrepancies and reconciliation errors. Secondary outcomes included classification of the reconciliation errors by type of medication error, therapeutic group of the drugs involved and grade of potential severity.
We conducted a retrospective observational study of reconciliated adult patients discharged from the Intensive Care Unit to the ward. Before a patient was discharged from the intensive care unit, their last intensive care unit's prescriptions were compared with their proposed medication list in the ward. The discrepancies between these were classified as justified discrepancies or reconciliation errors. Reconciliation errors were classified by type of error, potential severity, and therapeutic group.
We found that 452 patients were reconciliated. At least one discrepancy was detected in 34.29% (155/452), and 18.14% (82/452) had at least one reconciliation errors. The most found error types were a different dose or administration route (31.79% (48/151)) and omission errors (31.79% (48/151)). High alert medication was involved in 19.20% of reconciliation errors (29/151).
Our study shows that intensive care unit to non-intensive care unit transitions are high-risk processes for reconciliation error. They frequently occur and occasionally involve high alert medication, and their severity could require additional monitoring or cause temporary harm. Medication reconciliation can reduce reconciliation errors.
El objetivo de este estudio fue determinar si la transición del alta de la unidad de cuidados intensivos a la planta de hospitalización conlleva un alto riesgo de errores de conciliación. Se definió como objetivo principal del estudio describir y cuantificar las discrepancias y los errores de conciliación. Los objetivos secundarios incluyeron clasificar los errores de conciliación por tipo, grupo terapéutico de los medicamentos implicados y la gravedad potencial.
Se llevó a cabo un estudio observacional retrospectivo de los pacientes dados de alta de la unidad de cuidados intensivos a la planta de hospitalización. Antes de que un paciente fuese dado de alta desde la unidad de cuidados intensivos, sus últimas prescripciones fueron comparadas con el listado de medicación propuesto en la planta de hospitalización. Las discrepancias entre ambos listados fueron clasificadas como discrepancias justificadas o errores de conciliación. Los errores de conciliación fueron clasificados por tipo de error, por gravedad potencial y por grupo terapéutico.
Fueron conciliados 452 pacientes. Se encontró al menos una discrepancia en un 34,29% (155/452), y presentaba al menos un error de conciliación un 18,14% (82/452). Los errores de conciliación más frecuentes fueron diferente dosis o vía de administración (31,79% (48/151)) y errores de omisión (31,79% (48/151)). Un 19,20% (29/151) involucraba a medicamentos de alto riesgo.
El alta desde la unidad de cuidados intensivos a la planta de hospitalización convencional es una transición asistencial que presenta alto riesgo de errores de conciliación. Los errores de conciliación ocurren con frecuencia, en ocasiones involucran a medicamentos de alto riesgo, su potencial gravedad puede requerir una monitorización adicional o producir daño temporal, y en algunos casos, más de un error de conciliación puede tener lugar. La conciliación de medicamentos por un farmacéutico puede reducir los errores de conciliación.
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Citation Excerpt :
These conditions are associated with increased morbidity, length of hospital stay, and costs, and their impact on patient safety is profound.4 Numerous studies have identified medication reconciliation by clinical pharmacists as a practical tool to reduce the risk of medication errors and costs incurred during hospitalization.5–15 Interventions by pharmacists include detecting medication discrepancies and identifying possible drug-drug interactions, drug-disease interactions, errors in the route of administration, or duplication of medications.16
Minimizing unintended medication errors after admission is a common goal for clinical pharmacists and hospitalists.
We assessed the clinical and economic impact of a medication reconciliation service in a model of designated ward pharmacists working in a hospitalist-managed acute medical unit as part of a multidisciplinary team.
In this retrospective observational study, we compared pharmacist intervention records before and after the implementation of a medication reconciliation service by designated pharmacists. The frequency and type of intervention were assessed and their clinical impact was estimated according to the length of hospital stay and 30-day readmission rate. A cost analysis was performed using the average hourly salary of a pharmacist, cost of interventions (time spent on interventions), and cost avoidance (avoided costs generated by interventions).
After the implementation of the medication reconciliation service, the frequency of pharmacist interventions increased from 3.9% to 22.1% (p < 0.001). Intervention types were also more diverse than those before the implementation. The most common interventions included identifying medication discrepancies between pre-admission and hospitalization (22.7%) and potentially inappropriate medication use in the elderly (13.1%). The median length of hospital stay decreased from 9.6 to 8.9 days (p = 0.024); the 30-day readmission rate declined significantly from 7.8% to 4.8% (p = 0.046). Over two-thirds of interventions accepted by hospitalists were considered clinically significant or greater in severity. The cost difference between avoided cost and cost of interventions was 9838.58 USD in total or 1967.72 USD per month.
The implementation of a designated pharmacist-led medication reconciliation service had a positive clinical and economic impact in our hospitalist unit.
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Quality cornerMedication reconciliation: a practical tool to reduce the risk of medication errors

Abstract

Section snippets

Objectives

Data sources and settings

Study design methods

Data collection methods

Results

Conclusion

Am J Cardiol

To Err is HumanBuilding A Safer Health System

Human errormodels and management

Brit Med J

The link between safety attitudes and observed performance in flight operations

We are all saferNTSB-inspired improvements in transportation safety

The nature of adverse events in hospitalized patientsresults of the Harvard Medical Practice Study II

N Engl J Med

The costs of adverse drug events in hospitalized patients

JAMA

Translating research into practiceReducing errors in healthcare

Quality corner
Medication reconciliation: a practical tool to reduce the risk of medication errors