Skip to main content
SpringerLink
Log in

Medication at discharge in an orthopaedic surgical ward: quality of information transmission and implementation of a medication reconciliation form

  • Research Article
  • Published:
International Journal of Clinical Pharmacy Aims and scope Submit manuscript

Abstract

Background Medication reconciliation (MedRec) at discharge is a cumbersome but necessary process to reduce the risk of medication errors at transitions of care. The main barriers to implementing such a process are the large number of professionals involved and a lack of collaboration among caregivers. Objective This study was designed to assess the need for a medication reconciliation form at discharge in an orthopaedic surgical ward. Setting The study was conducted in the orthopaedic surgery ward among inpatients at a 407-bed French teaching hospital. Method We first performed a retrospective audit to evaluate the quality of discharge medication information in the medical record, after which a 5-week prospective study was conducted in 2013. All patients admitted to the orthopaedic surgery unit who had at least two chronic diseases and three medications underwent MedRec at discharge. We designed a Best Possible Medication at Discharge List (BPMDL) to be completed by hospital staff and transmitted to community caregivers. Mean outcome measures We assessed the completeness of medication information in the medical records, discrepancies between medications noted on the BPMDL and those prescribed on the discharge order, and the value of the BPMDL for stakeholders. Results Thirty patients were included in the study. Only 4 % of medical records contained a discharge summary with complete medication information. In 67 % of cases, treatment discontinuations at admission were justified, and medications were reintroduced before discharge, while 107 treatments (45 %) were added but not prescribed on discharge orders. Discontinuations prior to discharge were justified in 60 % of cases (treatments were ended or supportive treatment was required during hospitalization). An average of 2.1 treatments were prescribed on discharge orders (vs. 9.4 prescribed on the BPMDL). Patients, general practitioners (GP), and physicians in long-term care settings (PLTCS) rated the format, content, and readability of the BPMDL as satisfactory, and it was found to be of value for patients and PLTCS to support medication information. Because of the very low response rate among GP (10 %), we were unable to determine their satisfaction with the MedRec discharge process. Conclusion The transmission of patient medication information at discharge is often lacking. As such, the BPMDL appears to have value to both patients and community health providers. Because this study was conducted within a single surgical unit, further study in other surgical wards is needed to assess generalizability.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Cornu P, Steurbaut S, Leysen T, De Baere E, Ligneel C, Mets T, et al. Discrepancies in medication information for the primary care physician and the geriatric patient at discharge. Ann Pharmacother. 2012;46(7–8):983–90.

    Article  PubMed  Google Scholar 

  2. Kripalani S, Roumie CL, Dalal AK, Cawthon C, Businger A, Eden SK, et al. Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: a randomized trial. Ann Intern Med. 2012;157(1):1–10.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Uitvlugt EB, Siegert CEH, Janssen MJA, Nijpels G, Karapinar-Çarkit F. Completeness of medication-related information in discharge letters and post-discharge general practitioner overviews. Int J Clin Pharm. 2015;37(6):1206–12.

    Article  PubMed  Google Scholar 

  4. WHO: Action on patient safety—High 5s. WHO. [cited 2015 Jan 11]. http://www.who.int/patientsafety/implementation/solutions/high5s/en/.

  5. Plus 1000 Lives: 1000 Lives Plus—an Official NHS Wales website. [cited 2015 Jan 11]. http://www.1000livesplus.wales.nhs.uk/home.

  6. 5 Million lives Campaign. [cited 2015 Nov 1]. http://www.ihi.org/resources/Pages/Tools/HowtoGuidePreventAdverseDrugEvents.aspx.

  7. Institute for Healthcare Improvement: 5 M lives campaign. How-to guide: adverse drug events (medication reconciliation). http://www.ihi.org/knowledge/Pages/Tools/HowtoGuidePreventAdverseDrugEvents.aspx.

  8. Walker SAN, Lo JK, Compani S, Ko E, Le M-H, Marchesano R, et al. Identifying barriers to medication discharge counselling by pharmacists. Can J Hosp Pharm. 2014;67(3):203–12.

    PubMed  PubMed Central  Google Scholar 

  9. Farley TM, Shelsky C, Powell S, Farris KB, Carter BL. Effect of clinical pharmacist intervention on medication discrepancies following hospital discharge. Int J Clin Pharm. 2014;36(2):430–7.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Meguerditchian AN, Krotneva S, Reidel K, Huang A, Tamblyn R. Medication reconciliation at admission and discharge: a time and motion study. BMC Health Serv Res. 2013;13:485.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Greenwald JL, Halasyamani LK, Greene J, LaCivita C, Stucky E, Benjamin B, et al. Making inpatient medication reconciliation patient centered, clinically relevant, and implementable: a consensus statement on key principles and necessary first steps. Jt Comm J Qual Patient Saf. 2010;36(11):504–13, 481.

  12. Clay BJ, Halasyamani L, Stucky ER, Greenwald JL, Williams MV. Results of a medication reconciliation survey from the 2006 Society of Hospital Medicine national meeting. J Hosp Med. 2008;3(6):465–72.

    Article  PubMed  Google Scholar 

  13. Riley-Lawless K. Family-identified barriers to medication reconciliation. J Spec Pediatr Nurs. 2009;14(2):94–101.

    Article  PubMed  Google Scholar 

  14. Hesselink G, Wollersheim H, Barach P, Schoonhoven L, Vernooij-Dassen M. D6—report on challenges in patient care and the factors that influence change in practice. [cited 2015 Nov 1]. http://www.handover.eu/upload/library/lxbb2k3dwzpw1ft5ni7do.pdf.

  15. European Union Network for Patient Safety (EUNetPaS): Good medications safety practices in Europe: results of implementation. [cited 2015 Jan 15]. http://hope.be/03activities/2_2-qualityofcare-patientsafety.html.

  16. Curatolo N, Gutermann L, Devaquet N, Roy S, Rieutord A. Reducing medication errors at admission: 3 cycles to implement, improve and sustain medication reconciliation. Int J Clin Pharm. 2015;37(1):113–20.

    Article  PubMed  Google Scholar 

  17. Wittich CM, Burkle CM, Lanier WL. Medication errors: an overview for clinicians. Mayo Clin Proc. 2014;89(8):1116–25.

    Article  PubMed  Google Scholar 

  18. Hohmann C, Neumann-Haefelin T, Klotz JM, Freidank A, Radziwill R. Providing systematic detailed information on medication upon hospital discharge as an important step towards improved transitional care. J Clin Pharm Ther. 2014;39(3):286–91.

    Article  CAS  PubMed  Google Scholar 

  19. Wong JD, Bajcar JM, Wong GG, Alibhai SMH, Huh J-H, Cesta A, et al. Medication reconciliation at hospital discharge: evaluating discrepancies. Ann Pharmacother. 2008;42(10):1373–9.

    PubMed  Google Scholar 

  20. Midlöv P, Holmdahl L, Eriksson T, Bergkvist A, Ljungberg B, Widner H, et al. Medication report reduces number of medication errors when elderly patients are discharged from hospital. Pharm World Sci. 2008;30(1):92–8.

    Article  PubMed  Google Scholar 

  21. Midlöv P, Bahrani L, Seyfali M, Höglund P, Rickhag E, Eriksson T. The effect of medication reconciliation in elderly patients at hospital discharge. Int J Clin Pharm. 2012;34(1):113–9.

    Article  PubMed  Google Scholar 

  22. Paquette-Lamontagne N, McLean WM, Besse L, Cusson J. Evaluation of a new integrated discharge prescription form. Ann Pharmacother. 2001;35(7–8):953–8.

    Article  CAS  PubMed  Google Scholar 

  23. Pérennes M, Carde A, Nicolas X, Dolz M, Bihannic R, Grimont P, et al. Medication reconciliation: an innovative experience in an internal medicine unit to decrease errors due to inacurrate medication histories. Presse Med. 2012;41(3 Pt 1):e77–86.

    Article  PubMed  Google Scholar 

  24. Pourrat X, Roux C, Bouzige B, Garnier V, Develay A, Allenet B, et al. Impact of drug reconciliation at discharge and communication between hospital and community pharmacists on drug-related problems: study protocol for a randomized controlled trial. Trials. 2014;15(1):260.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Pronovost P, Weast B, Schwarz M, Wyskiel RM, Prow D, Milanovich SN, et al. Medication reconciliation: a practical tool to reduce the risk of medication errors. J Crit Care. 2003;18(4):201–5.

    Article  PubMed  Google Scholar 

  26. Glintborg B, Andersen SE, Dalhoff K. Insufficient communication about medication use at the interface between hospital and primary care. Qual Saf Health Care. 2007;16(1):34–9.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Bergkvist A, Midlöv P, Höglund P, Larsson L, Bondesson A, Eriksson T. Improved quality in the hospital discharge summary reduces medication errors—LIMM: Landskrona Integrated Medicines Management. Eur J Clin Pharmacol. 2009;65(10):1037–46.

    Article  PubMed  Google Scholar 

  28. Kantelhardt P, Giese A, Kantelhardt SR. Medication reconciliation for patients undergoing spinal surgery. Eur Spine J. 2016;25(3):740–7.

    Article  PubMed  Google Scholar 

  29. Murphy EM, Oxencis CJ, Klauck JA, Meyer DA, Zimmerman JM. Medication reconciliation at an academic medical center: implementation of a comprehensive program from admission to discharge. Am J Health Syst Pharm. 2009;66(23):2126–31.

    Article  PubMed  Google Scholar 

  30. Unroe KT, Pfeiffenberger T, Riegelhaupt S, Jastrzembski J, Lokhnygina Y, Colón-Emeric C. Inpatient medication reconciliation at admission and discharge: a retrospective cohort study of age and other risk factors for medication discrepancies. Am J Geriatr Pharmacother. 2010;8(2):115–26.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Wilkinson ST, Pal A, Couldry RJ. Impacting readmission rates and patient satisfaction: results of a discharge pharmacist pilot program. Hosp Pharm. 2011;46(11):876–83.

    Article  Google Scholar 

  32. Dunn AS, Markoff B. Physician–physician communication: what’s the hang-up? J Gen Intern Med. 2009;24(3):437–9.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Roy CL, Kachalia A, Woolf S, Burdick E, Karson A, Gandhi TK. Hospital readmissions: physician awareness and communication practices. J Gen Intern Med. 2009;24(3):374–80.

    Article  PubMed  Google Scholar 

  34. Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;297(8):831–41.

    Article  CAS  PubMed  Google Scholar 

  35. Hesselink G, Schoonhoven L, Plas M, Wollersheim H, Vernooij-Dassen M. Quality and safety of hospital discharge: a study on experiences and perceptions of patients, relatives and care providers. Int J Qual Health Care. 2013;25(1):66–74.

    Article  PubMed  Google Scholar 

  36. Geurts MME, van der Flier M, de Vries-Bots AMB, Brink-van der Wal TIC, de Gier JJ. Medication reconciliation to solve discrepancies in discharge documents after discharge from the hospital. Int J Clin Pharm. 2013;35(4):600–7.

    Article  PubMed  Google Scholar 

  37. Surgery and Pharmacy in Liaison (SUREPILL) Study Group, Surgery and Pharmacy in Liaison SUREPILL Study Group. Effect of a ward-based pharmacy team on preventable adverse drug events in surgical patients (SUREPILL study). Br J Surg. 2015;102(10):1204–12.

    Article  Google Scholar 

  38. Chhabra PT, Rattinger GB, Dutcher SK, Hare ME, Parsons KL, Zuckerman IH. Medication reconciliation during the transition to and from long-term care settings: a systematic review. Res Social Adm Pharm. 2012;8(1):60–75.

    Article  PubMed  Google Scholar 

  39. van Sluisveld N, Zegers M, Natsch S, Wollersheim H. Medication reconciliation at hospital admission and discharge: insufficient knowledge, unclear task reallocation and lack of collaboration as major barriers to medication safety. BMC Health Serv Res. 2012;12:170.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgments

We would like to thank the whole entire team of the orthopaedic surgery unit, without whose support this work would not have been possible. We would also like to thank Kevan Wynd for his review and suggestions for our manuscript.

Funding

None.

Author information

Authors and Affiliations

  1. Service de Pharmacie, Assistance Publique des Hôpitaux de Paris, Hôpital Antoine Béclère, 157 rue de la porte de Trivaux, 92140, Clamart, France

    Anne-Solène Monfort, Niccolo Curatolo, André Rieutord & Sandrine Roy

  2. Service de chirurgie orthopédique, Assistance Publique des Hôpitaux de Paris, Hôpital Antoine Béclère, 92140, Clamart, France

    Thierry Begue

Authors
  1. Anne-Solène Monfort
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Niccolo Curatolo
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Thierry Begue
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. André Rieutord
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Sandrine Roy
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Anne-Solène Monfort.

Ethics declarations

Conflicts of interest

The authors declare that they have no conflict of interest.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Monfort, AS., Curatolo, N., Begue, T. et al. Medication at discharge in an orthopaedic surgical ward: quality of information transmission and implementation of a medication reconciliation form. Int J Clin Pharm 38, 838–847 (2016). https://doi.org/10.1007/s11096-016-0292-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11096-016-0292-7

Keywords

Search

Navigation