Classifying and Predicting Errors of Inpatient Medication Reconciliation
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Failure to reconcile medications across transitions in care is an important source of potential harm to patients. Little is known about the predictors of unintentional medication discrepancies and how, when, and where they occur.
To determine the reasons, timing, and predictors of potentially harmful medication discrepancies.
Prospective observational study.
Admitted general medical patients.
Study pharmacists took gold-standard medication histories and compared them with medical teams’ medication histories, admission and discharge orders. Blinded teams of physicians adjudicated all unexplained discrepancies using a modification of an existing typology. The main outcome was the number of potentially harmful unintentional medication discrepancies per patient (potential adverse drug events or PADEs).
Among 180 patients, 2066 medication discrepancies were identified, and 257 (12%) were unintentional and had potential for harm (1.4 per patient). Of these, 186 (72%) were due to errors taking the preadmission medication history, while 68 (26%) were due to errors reconciling the medication history with discharge orders. Most PADEs occurred at discharge (75%). In multivariable analyses, low patient understanding of preadmission medications, number of medication changes from preadmission to discharge, and medication history taken by an intern were associated with PADEs.
Unintentional medication discrepancies are common and more often due to errors taking an accurate medication history than errors reconciling this history with patient orders. Focusing on accurate medication histories, on potential medication errors at discharge, and on identifying high-risk patients for more intensive interventions may improve medication safety during and after hospitalization.
KEY WORDSmedication errors medication systems, hospital continuity of patient care inpatients
We would like to acknowledge the tremendous efforts of the Partners Information Systems personnel involved in developing the medication reconciliation intervention (Barry Blumenfeld, MD; Carol Broverman, PhD; Eric Poon, MD, MPH; Cheryl Van Putten, PMP; Eric Godlewski, BA; Linda Moroni, MBA; Michael McNamara, BA; Sandra Smith, BA; Marilyn Paterno, MBI; Daniel Fuchs, BS; Oliver James, BS; Greg Rath, BA), the BWH medication reconciliation implementation team (Erin Graydon-Baker, MS, RRT; Christine McCormack, BA; John Poikonen, BA; Christina Pelletier, BA; Emily Maher, MD; Ellen Bergeron, RN, MSN; Jennie Kuzemchak, BA; Michael Cotugno, RPh; Andrea Giannattasio, BA), the MGH medication reconciliation implementation team (George Baker, MD; Sally Millar, RN; Margaret Clapp, BA), and BWH personnel John Orav, PhD, and Stuart Lipsitz, ScD, for biostatistical assistance, Elisabeth Burdick, MS, for statistical programming, Amy Bloom, MPH, for project management, and Emily Barsky, BA, and Emily Dattwyler, BA, for research assistance. We also thank Erin Hartman, MS (University of California, San Francisco) for generous in-kind editorial assistance.
This study was funded in part by an investigator-initiated grant from the Harvard Risk Management Foundation, including compensation for Elisabeth Burdick, Amy Bloom, and Emily Barsky, as well as internal funding from BWH, MGH, and Partners Healthcare. Dr. Pippins was supported by a National Research Service Award from the Health Resources and Services Administration (T32 HP11001–18). Dr. Schnipper was supported by a Mentored Clinical Scientist Award from the National Heart, Lung, and Blood Institute (K08 HL072806).
Conflict of Interest
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