Prescribing discrepancies likely to cause adverse drug events after patient transfer

Boockvar, Kenneth S.; Liu, Sophia; Goldstein, Nathan E.; Nebeker, Jonathan R.; Siu, Albert L.; Fried, Terri R.

doi:10.1136/qshc.2007.025957

Cited by 90 publications

(84 citation statements)

References 25 publications

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“…1 These errors can increase the risk of adverse drug events (ADEs) during hospitalization or following discharge. [2][3][4] Hospitals attempt to avert medication errors and ADEs by implementing medication reconciliation, the process by which a clinician compiles an accurate list of all medications that an individual is currently taking [5][6][7] and uses that list to provide correct medications anywhere within the health care system. 8 Hospital-based medication reconciliation is to be completed upon admission, transfer, and at discharge.…”

Section: Introductionmentioning

confidence: 99%

Effect of Patient- and Medication-Related Factors on Inpatient Medication Reconciliation Errors

et al. 2012

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BACKGROUND:Little research has examined the incidence, clinical relevance, and predictors of medication reconciliation errors at hospital admission and discharge. OBJECTIVE: To identify patient-and medication-related factors that contribute to pre-admission medication list (PAML) errors and admission order errors, and to test whether such errors persist in the discharge medication list. DESIGN, PARTICIPANTS: We conducted a crosssectional analysis of 423 adults with acute coronary syndromes or acute decompensated heart failure admitted to two academic hospitals who received pharmacistassisted medication reconciliation during the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) Study. MAIN MEASURES:Pharmacists assessed the number of total and clinically relevant errors in the PAML and admission and discharge medication orders. We used negative binomial regression and report incidence rate ratios (IRR) of predictors of reconciliation errors. KEY RESULTS: On admission, 174 of 413 patients (42%) had ≥1 PAML error, and 73 (18%) had ≥1 clinically relevant PAML error. At discharge, 158 of 405 patients (39%) had ≥1 discharge medication error, and 126 (31%) had ≥1 clinically relevant discharge medication error. Clinically relevant PAML errors were associated with older age (IRR=1.46; 95% CI, 1.00-2.12) and number of pre-admission medications (IRR=1.17; 95% CI, 1.10-1.25), and were less likely when a recent medication list was present in the electronic medical record (EMR) (IRR=0.54; 95% CI, 0.30-0.96). Clinically relevant admission order errors were also associated with older age and number of pre-admission medications. Clinically relevant discharge medication errors were more likely for every PAML error (IRR=1.31; 95% CI, 1.19-1.45) and number of medications changed prior to discharge (IRR=1.06; 95% CI, 1.01-1.11). CONCLUSIONS: Medication reconciliation errors are common at hospital admission and discharge. Errors in preadmission medication histories are associated with older age and number of medications and lead to more discharge reconciliation errors. A recent medication list in the EMR is protective against medication reconciliation errors.

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Section: Introductionmentioning

confidence: 99%

Effect of Patient- and Medication-Related Factors on Inpatient Medication Reconciliation Errors

et al. 2012

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“…8,23,26 Additional well-designed studies are needed demonstrating the association between specific interventions and clinical outcomes to inform system-based improvements and galvanise clinician buy-in.…”

Section: Call For Further Researchmentioning

confidence: 99%

“…[1][2][3][4][5][6][7][8][9][10][11] Incomplete or inaccurate information about patient medication use represents a major root cause of errors and, therefore, an important opportunity for systemic quality improvement. [12][13][14][15] Information gaps tend to occur at interfaces, or handoffs, in care (e.g.…”

Section: Introductionmentioning

confidence: 99%

Primary care provider perceptions and use of a novel medication reconciliation technology

Lesselroth¹,

Holahan²,

Adams³

et al. 2011

Journal of Innovation in Health Informatics

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“…This helps facilitate a smooth transition and minimizes any ITP-related disruptions. Lack of communication is a major, preventable source of medical error and is especially prevalent when the care teams are from two different facilities [41,44]. While distance, distractions, incongruent treatment goals/plans, uncertainty of timing, and contrasting information sources are all barriers to continuity of care, standardized medical handoffs can help reduce situational and informational confusion, reduce medical errors, and hopefully result in better and safer patient care [2].…”

Section: Communicationmentioning

confidence: 99%

“…so that the receiving physician is fully aware of the patient's condition and any other information pertinent to the situation in order to determine the appropriateness of the proposed transfer, assess patient suitability for transfer in the context of available clinical data, allocate appropriate level-of-care resources (e.g., ICU bed, operating room), and finalize the decision on transfer modality (e.g., ground versus air transport) [41,42]. Not only is it necessary for the referring and accepting physicians to be in close contact and discuss the transfer and any potential challenges, but it is also critical for the nurses from the receiving and transferring facilities to communicate details of care pertaining to the patient [43,44]. This helps facilitate a smooth transition and minimizes any ITP-related disruptions.…”

Section: Communicationmentioning

confidence: 99%

Interhospital Transfers: Managing Competing Priorities while Ensuring Patient Safety

Luster¹,

Yanagawa²,

Bendas³

et al. 2018

Vignettes in Patient Safety - Volume 2

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Interhospital patient transfers (IPTs) are highly complex logistical undertakings, involving a multitude of interdependent procedures, critical steps and a degree of unpredictability. Beginning with interfacility communication and patient acceptance agreement, a cascade of numerous handoffs takes place, ultimately culminating in safe arrival of the patient at the receiving facility. Due to the complexity of the IPT process, significant potential for critical errors and adverse patient safety (PS) outcomes exists. To minimize any associated risks, key PS considerations include checklists, handoffs, vehicle/aircraft safety, distance of travel, crew training, team factors, and many other critical components. Detailed knowledge of factors that may influence the risk of errors or adverse events is critical to optimizing both PS and clinical outcomes.

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Prescribing discrepancies likely to cause adverse drug events after patient transfer

Cited by 90 publications

References 25 publications

Effect of Patient- and Medication-Related Factors on Inpatient Medication Reconciliation Errors

Effect of Patient- and Medication-Related Factors on Inpatient Medication Reconciliation Errors

Primary care provider perceptions and use of a novel medication reconciliation technology

Interhospital Transfers: Managing Competing Priorities while Ensuring Patient Safety

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