MEDICATION SAFETY AT TRANSITIONS OF CAREElizabeth Isaac, PharmD, BCPSPGY-2 Medication Use Safety ResidentUMass Memorial Medical Center

Disclosures

I have no disclosures concerning possible financial or personal

relationship with commercial entities.

Objectives Review the types of transitions of care Understand the risk factors for medication

discrepancies at transitions of care Identify the types of patients and

medications most at risk for having a medication discrepancy during transitions of care

Develop strategies to prevent medication errors while transitioning care

Patient Case MB 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)

Patient Case: MB Allergies (from Pharmacy system)

Bactrim, doxycycline, nitrofurantoin, penicillins

A medication reconciliation was conducted based on an interview with the patient

Outpatient InpatientSNF/Rehabilitation Inpatient

Inpatient InpatientInpatient OutpatientInpatient SNF/Rehabilitation

SNF/Rehabilitation OutpatientOutpatient Outpatient

Types of transitions1

Outpatient areas Emergency DepartmentOutpatient clinics or offices“observation” patients

Source of information PatientPrevious inpatient records

Potential risks for errors -Potential disjointed past medical history-Medications from various sources or prescribers-Multiple pharmacies -Incomplete documentation

Types of transitions1

Outpatient InpatientOutpatient areas Emergency Department

Outpatient clinics or offices“observation” patients

Source of information -Patient-Previous inpatient records-Pharmacies or outpatient records

Examples -Emergency Department-Outpatient clinics or offices-“observation” patients

Types of transitions1

SNF/Rehabilitation Inpatient

Source of information

Facility paperworkPatientRecent discharge information

Potential 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 came

Source of information

-Facility paperwork-Patient-Recent discharge information

Types of transitions1

Inpatient InpatientExamples - ICU step-down / floor

- Floor ICU / step-down- Step-down floor

Potential risks for error

- Acuity of the patient- Prophylactic medications- Medications on hold

Examples - ICU step-down / floor- Floor ICU / step-down- Step-down floor

Types of transitions1

Inpatient Outpatient

Examples - Discharge to the community directly

- From ICU, step-down, or floor

Sources of information

- Discharge paperwork / summary

- Patient discharge instructions

Potential risks for error

- Lack of admitting privileges for PCPs

- Prophylactic medications- Closed formularies

Sources of information

- Discharge paperwork / summary

- Patient discharge instructions

Types of transitions1

Inpatient SNF/Rehabilitation

Examples - Similar to discharge to community

Potential risks for error

- Additional step in the healthcare process

- Closed formularies- Prophylactic medications- Notification to PCP- Care of patient from

additional provider

Examples - Similar to discharge to community

Types of transitions1

SNF/Rehabilitation Outpatient

Sources of information

- Discharge paperwork from hospital

- Discharge paperwork from rehab

- Medication administration records

- Previous medication reconciliations

Potential risk for errors

- Disjointed care- Delay in PCP notification /

information transfer- Medications which can now

be continued

Sources of information

- Discharge paperwork from hospital

- Discharge paperwork from rehab

- Medication administration records

- Previous medication reconciliations

Types of transitions1

Outpatient Outpatient

Example Ex: Primary care physician cardiologist

Potential risk for errors

- Changes in medication use or diagnoses are not always reflected in either providers documentation

Example - Primary care physician cardiologist

Regulatory Standards2 Joint Commission National Patient Safety Goal

03.06.01 To the best of one’s ability with the resources available Record 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 appointment

Type of medication reconciliation can vary by health care setting

The advent of the hospitalist3,4

Increasing demands on outpatient providers have shifted the inpatient care of the patient to hospitalists

Currently estimated between 10,000 and 12,000 hospitalists are practicing in the United States

Expected to grow to 30,000 in the next decade according to the Society of Hospital Medicine

Deficits in communication and information transfer between hospital-based and primary care physicians5

Purpose To 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 outcomes

Methods Meta-analysis Inclusion Case studies and controlled studies involving

information transfer at dischargeResults 1064 citations identified

55 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)

DEFICITS IN COMMUNICATION AND INFORMATION TRANSFER BETWEEN HOSPITAL-BASED AND PRIMARY CARE PHYSICIANS5

Deficits in communication and information transfer between hospital-based and primary care physicians5

Conclusions Transmission of information between

disciplines at discharge varies and is often inefficient and incomplete

Discharge summaries should be based on a standardized format

Effect on clinical outcomes was hard to measure

Deficits in communication and information transfer between hospital-based and primary care physicians5

The downside to the hospitalist Primary care physicians are less involved in

the care of the patient during hospitalization Only taking care of the patient temporarily Incomplete hospitalization records are often

tied to medication discrepancies Added burden to PCPs

Alert fatigue Delay in test results or discharge paperwork

Medication discrepancies during transitions of care: a comparison study6

Purpose To determine if medication discrepancies exist between patients who are cared for in a hospital by primary care physicians (PCPs) with admitting privileges vs. those without

Methods Single center, retrospective, chart reviewInclusion Patients from one of two outpatient offices

Admitted between January and July 2009Exclusion Patient records missing from primary care officeChart Review

Demographic 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 acceptable

Results 251 patient records evaluated 120 patients with physicians without admitting privileges vs.131 patient with physicians with admitting privileges

Medication discrepancies during transitions of care: a comparison study6

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 privileges

Most common discrepancy was the omission of a medication

Patients were more likely to follow up with their PCP if they had admitting privileges

Age, gender, healthcare coverage, and follow-up time did not have an effect on the discrepancy occurrences

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 discharge

Contributing to the utilization of “observation” status Observation stays within 30 days of hospital

discharge per 1000 beneficiaries increased from 4.7 to 5.8 from 2009-2010 to 2012-2013

Disjointed Care Hospital-based vs. primary care

physicians Delay in information “Observation” patients

Medication discrepancies

Medication Reconciliation8

A three step process of verifying medication use, identifying variances, and rectifying medication errors at interfaces of care

Complete reconciliation should include a conversation with the patient and a review of pharmacy or patient records

Barriers to accurate medication reconciliation

Patient health literacy Comorbidities Polypharmacy Multiple providers Frequent transitions Reconciler Closed formulary Pediatric dosing

High risk patients3

Elderly Patients with multiples medications and

comorbidities Patients with limited literacy skills Patients who do not speak English Pediatric patients

High Risk Medications3

Antithrombotics Insulin and other hypoglycemics Opiates Antiarrhythmics and other cardiovascular medications Chemotherapy Immunosuppressants Antiseizure medications Eye Medications Inhalers BEERs Criteria medications in patients over 65 years

of age

Medication errors in adult and pediatric patients8,9

Adult PediatricsPurpose - To examine the frequency and

potential severity of unintended medication variances hospital admission and discharge

- To review the potential impact of medication reconciliation

Review the occurrence rate of discrepancies in pediatric patients- Identify the rate and clinical

significance of discrepancies- Look for specific interventions for

pediatric reconciliation

Methods Prospective, single center study Meta-analysisInclusion Patients admitted to the 212 bed

Canadian community hospital in July 2002

1,739 citations reviewed10 studies included in analysis

Interventions

Study pharmacist conducted a comprehensive medication history on admission for all randomized patients Variances identified and discussed with patient’s teamDischarge medication lists compared with preadmission and hospital medication use

Results 60 patients chosen - 6 medication reconciliation at admission to inpatient ward

- 4 other settings or transitions of care

Reconcilable differences: correcting medication errors at hospital admission and discharge8

Medication discrepancies at Transitions in Pediatrics: A Review of the Literature9 Discrepancies at admission

22 – 72.3% with an unintended discrepancy In the ED

Pre- pharmacist implementation – 71% Post- pharmacist implementation – 38.3%

At transfer 0.53 unintentional discrepancy per patient

At discharge 43% of patients and 15% of medications

Medication discrepancies at Transitions in Pediatrics: A Review of the Literature9 Clinical impact of discrepancies

Estimated that up to 6% could lead to severe discomfort or clinical deterioration

23% could have potential to cause, and 71% were unlikely

No specific discrepancies identified

Adult study conclusions Impact of pharmacist reconciliation may have been falsely

low Economic analysis was favorable to pharmacy

involvement Pediatric study conclusions

Medication reconciliation tools used in the adult population may not be applicable to the pediatric population

Small, widely varied, studies are inconclusive of the clinical impact medication discrepancies have on pediatrics

Limitations to both studies

Medication errors in adult and pediatric patients8,9

Medication discrepancies and their impact

Drug-drug interactions Inappropriate medication use Withdrawal from medications Unintended consequences (seizures,

thrombosis, tachycardia) Over- or under- dose Hospital readmission Added health-care costs

Patient case

Patient Case

Patient Case A second medication reconciliation was

conducted Isosorbide and valsartan discontinued Provider notes all indicated isosorbide

and valsartan should be continued Patient discharged on medications

Error later realized by daughter

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 outcomes

The 30 day readmission rate has been a major endpoint for most studies, but some have looked at 90 and 180 day readmissions

When medication reconciliation works10-12

Types of interventions Implementation of a transition coach Pharmacist reconciliation, counseling, and

follow up

Overall, reduced readmission rates were seen with the high intensity interventions

Economically cost-neutral Lower rates of preventable ADE’s

When medication reconciliation works11

Discharge Checklist13

Pharmacist’s Role14 Obtaining a comprehensive medication history

using the three step process

Numerous studies have shown the benefit of involving a pharmacist across the continuum of care, especially in patients with multiple comorbidities and medications

Expanding 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

Pharmacist’s role14

Inpatient pharmacy Comprehensive medication reconciliation Involved in discharge planning

Community and Ambulatory care Use of MTM Providing patients with up-to-date medication lists Highlighting new medications for use

Long-term Care (LTCF) Perform medication reconciliation within 5 days of

readmittance to the LTCF Monthly medication reconciliation to assure appropriate

care

Assessment MB 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

Assessment Which 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

Questions?

References1. The 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.

2. The Joint Commission. National Patient Safety Goals. Hospital Accreditation Program. Jan 2014:1-17.

3. 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. 2007;2:314-23.

4. Society of Hospital Medicine. SMH Faq List. 2014. Available at: https://www.hospitalmedicine.org/AM/Template.cfm?Section=FAQs&Template=/FAQ/FAQListAll.cfm. Accessed on 23 April 2014.

5. 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;297:831-41.

6. 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.

7. Daughtridge GW, Archibald T, Conway PH. Quality improvement of care transitions and the trend of composite hospital care. JAMA. 2014;311:1013-14.

References8. Vira T, Colquhoun M, Etchells E. Reconcilable differences: correcting medication

errors at hospital admission and discharge. Qual Saf Health Care. 2006;15:122-26.9. Huynh C etal. Medication discrepancies at transitions in pediatrics: a review of the

literature. Pediatr Drugs. 2013;15:201-15.10. Kwan JL, Lo L, Sampson M, Shojania KG. Medication reconciliation during

transitions of care as a patient safety strategy. Ann Intern Med. 2013;158:397-403.11. 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.

12. Coleman EA, Parry C, Chalmers S, Min S. The care transitions intervention. Arch Intern Med. 2006;166:1822-28.

13. Soong C et al. Development of a checklist of safe discharge practices for hospital patients. Journal of Hospital Medicine. 2013;8:444-9.

14. Hume AL et al. Improving care transitions: current practice and future opportunities for pharmacists. Pharmacotherapy. 2012;32:e326-37.