Abstract
Adverse drug events are largely considered to be errors in which the severity of effects could be lessened or even prevented through more effective medication reconciliation practices. Transitions of care, particularly at the time of discharge from the hospital, represent a time of heightened error vulnerability that contributes to medication discrepancy occurrences. The observed vulnerability can be attributed to communication and care continuity gaps across health care settings and can often lead to preventable errors. Health IT tools developed through research can identify factors which increase the risk of medication discrepancies. Additionally, the implementations of optimized clinical workflow processes to form effective transitions of care are approaches to decreasing medication discrepancies which may lead to adverse drug events. While federal policies and certifying organizations have implemented quality initiatives to increase focus on medication reconciliation practices in the hospital and primary care settings, the same practices must be implemented after a patient is discharged to their homes or another health care facility in order to mitigate error vulnerabilities that occur at the transition of care. This paper provides an overview of health IT system capabilities and their applications within and across health care delivery settings to facilitate care coordination to ensure continuity of care.
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References
AHIMA, Long term and post acute care HIT collaborative and roadmap. Retrieved from http://www.ahima.org/advocacy/ltpachit.aspx, 2012
Agrawal, A., Medication errors: prevention using information technology systems. Br. J. Clin. Pharmacol 67:681–686, 2009.
Barnsteiner, J. H., Medication reconciliation. In Patient Safety and Quality: An Evidence- Based Handbook for Nurses (Chapter 38). Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK2648/, 2008
Bates, D. W., and Gawande, A. A., Improving safety with information technology. N Engl J Med 348:2526–34, 2003.
Boockvar, K. S., LaCorte, H. C., Giambanco, V., Fridman, B., and Siu, A., Medication reconciliation for reducing drug-discrepancy adverse events. Am. J. Geriatr. Pharmacology 4:236–43, 2006.
Boockvar, K. S., Liu, S., Goldstein, N., Nebeker, J., Siu, A., and Fried, T., Prescribing discrepancies likely to cause adverse drug events after patient transfer. BMJ Qual. Safety 18:32–36, 2009.
Chhabra, P. T., Rattinger, G. B., Dutcher, S. K. Hare, M. E., Parsons, K. L., & Zuckerman, I. H., Medication reconciliation during the transition to and from long-term care settings: A systematic review. Res. Soc. Admin. Pharm. J. 1–16, 2011
Coleman, E. A., Smith, J. D., Raha, D., and Min, S., Posthospital medication discrepancies: Prevalence and contributing factors. Arch. Intern. Med 165:1842–47, 2005.
Garg, A. X., Adhikari, N. K. J., McDonald, H., Rosas-Arellano, M. P., Devereaux, P. J., Beyene, J., Sam, J., Haynes, R. B., Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: A systematic review. JAMA 293:1223–1238, 2005.
Hunt, D. R., The Mysteries of Meaningful Use [PDF Document]. Retrieved from http://www.nhchc.org/wp-content/uploads/2011/10/MUWebinar2.pdf, 2012
HIMSS.org. EHR Usability 101. Retrieved from http://www.himss.org/ASP/topics_FocusDynamic.asp?faid=559, 2011
Keystone Health Information Exchange. Funding. Retrieved from: https://www.keyhie.org/funding.cfm, 2011
Koehler, B. E., Richter, K. M., Youngblood, L., Cohen, B. A., Prengler, I. D., Cheng, D., and Masica, A. L., Reduction of 30-day postdischarge hospital readmission or emergency department (ED) visit rates in high-risk elderly medical patients through delivery of a targeted care bundle. J. Hosp. Med. 4:211–218, 2009.
Kripalani, S., Jackson, A. T., Schnipper, J. L., and Coleman, E. A., Promoting effective transitions of care at hospital discharge: a review key issues for hospitalists. J Hosp Med 2:314–323, 2007.
Patrick, K., Griswold, W. G., Raab, F., and Intille, S. S., Health and the mobile phone. Am J Prev Med 35:177–181, 2008.
Rodenstein, C., IMPACT challenge grant. [PowerPoint Slides]. Retrieved from: http://www.nga.org/files/live/sites/NGA/files/pdf/1105HIECAROLE.PDF;jsessionid=D05D13024925AADAC7C7AEDD79BEBB9A, 2011
Tjia, J., Bonner, A., Briesacher, B. A., Mcgee, S., Terrill, E., and Miller, K., Medication discrepancies upon hospital to skilled nursing facility transitions. J Gen Intern Med 5:630–635, 2009.
Vira, T., Colquhoun, M., and Etchells, E., Reconcilable differences: Correcting medication errors at hospital admission and discharge. Qual Saf Health Care 15:122–126, 2006.
Visiting Nurse Services of New York. Work in progress. Retrieved from: http://www.vnsny.org/vnsny-research/policy-and-research/, 2011
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Cortelyou-Ward, K., Swain, A. & Yeung, T. Mitigating Error Vulnerability at the Transition of Care through the Use of Health IT Applications. J Med Syst 36, 3825–3831 (2012). https://doi.org/10.1007/s10916-012-9855-x
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DOI: https://doi.org/10.1007/s10916-012-9855-x