Applying quality improvement methods to address gaps in medicines reconciliation at transfers of care from an acute UK hospital

Abstract

ObjectivesReliable reconciliation of medicines at admission and discharge from hospital is key to reducing unintentional prescribing discrepancies at transitions of healthcare. We introduced a team approach to the reconciliation process at an acute hospital with the aim of improving the provision of information and documentation of reliable medication lists to enable clear, timely communications on discharge.SettingAn acute 400-bedded teaching hospital in London, UK.ParticipantsThe effects of change were measured in a simple random sample of 10 adult patients a week on the acute admissions unit over 18 months.InterventionsQuality improvement methods were used throughout. Interventions included education and training of staff involved at ward level and in the pharmacy department, introduction of medication documentation templates for electronic prescribing and for communicating information on medicines in discharge summaries co-designed with patient representatives.ResultsStatistical process control analysis showed reliable documentation (complete, verified and intentional changes clarified) of current medication on 49.2% of patients' discharge summaries. This appears to have improved (to 85.2%) according to a poststudy audit the year after the project end. Pharmacist involvement in discharge reconciliation increased significantly, and improvements in the numbers of medicines prescribed in error, or omitted from the discharge prescription, are demonstrated. Variation in weekly measures is seen throughout but particularly at periods of changeover of new doctors and introduction of new systems.ConclusionsNew processes led to a sustained increase in reconciled medications and, thereby, an improvement in the number of patients discharged from hospital with unintentional discrepancies (errors or omissions) on their discharge prescription. The initiatives were pharmacist-led but involved close working and shared understanding about roles and responsibilities between doctors, nurses, therapists, patients and their carers.

Improvement on prescribing appropriateness after implementing an interdisciplinary pharmacotherapy quality programme in a long-term care hospital

“…Lack of information on outpatient medication lists, incomplete anamnesis or complexity of medication regimens might contribute to drug omissions at admission, suggesting the need for pharmacotherapy quality programmes during care transitions, as some other authors have recognised 30. In contrast with other published studies,17–21 the majority of detected reconciliation errors were judged to be of clinical importance and a higher percentage of them involved high-alert medications.…”

Pharmacist–Physician Collaboration to Improve the Accuracy of Medication Information in Electronic Medical Discharge Summaries: Effectiveness and Sustainability

“…Models involving the addition of clinical pharmacists into patient care teams have improved the completeness and accuracy of discharge information and decreased medication errors [18,23,33]. However, it should be acknowledged that this requires a close working relationship and shared understanding regarding the roles and responsibilities of members of the healthcare team [34].…”

Deprescribing medicines in the acute setting to reduce the risk of falls

“…It is imperative, however, to acknowledge that a condition for medication review is reliable medicines reconciliation at admission and discharge from hospital. 15 Any review process typically begins with confirmation of a patient's current medication; if inaccurate, decisions may be made based on the wrong information. 16 Therefore, prescribing and deprescribing is safe only in the context of a full understanding of the patient's drug history.…”