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The role of clinical pharmacist trainees in medication reconciliation process at hospital admission

International Journal of Clinical Pharmacy volume 42, pages 796–804 (2020)Cite this article

Abstract

Background Medication discrepancies are a common occurrence following hospital admission and carry the potential for causing harm. However, little is known about the prevalence and potential risk factors involved in medication discrepancies in China. Objective To determine the frequency of medication discrepancies and the associated risk factors and evaluate the potential harmsof errors prevented by pharmacist trainees performing medication reconciliation process. Setting A tertiary hospital in Shanxi, China. Method Medication reconciliation was conducted at admission to four clinical departments including cardiology, nephrology, endocrinology and pneumology department between 2019 Feb 1st and 2019 Aug 31st by clinical pharmacist trainees. All unintentional medication discrepancies were presented to the expert panel to evaluate. Associations between unintentional medication discrepancies and various factors were examined. Main outcome measure The primary outcome was the prevalence of unintentional medication discrepancies as well as the associated risk factors. Results Overall, 331 patients were included (mean age 59.7 ± 15.2 years; 176 men). The reconciliation process identified 511 drug discrepancies, 98 of which were unintentional medication discrepancies; these occurred in 74 patients. The most common unintentional medication discrepancies type was omission (40.8%), followed by incorrect dose (25.5%), and 73.5% could have caused patients moderate to significant harm and complications. 5 or more drugs and 2 or more chronic diseases at admission associated with unintentional medication discrepancies in a logistic regression analysis. Conclusion Medication reconciliation performed by pharmacist trainees upon admission can reduce unintentional medication discrepancies. Patients taking 5 or more drugs and experiencing more than two chronic diseases were found to be particularly at risk.

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References

  1. National Transitions of Care Coalition. Improving transitions of care: findings and considerations of the “Vision of the National Transitions of Care Coalition.” National Transitions of Care Coalition website. https://www.ntocc.org/s/IssueBriefs-lsld.pdf. Accessed 9 Apr 2019.

  2. Mazhar F, Akram S, Al-Osaimi YA, Haider N. Medication reconciliation errors in a tertiary care hospital in Saudi Arabia: admission discrepancies and risk factors. Pharm Pract (Granada). 2017;15(1):864–72.

    Article  Google Scholar 

  3. Marinović I, Marušić S, Mucalo I, Mesarić J, Bačić VV. Clinical pharmacist-led program on medication reconciliation implementation at hospital admission: experience of a single university hospital in Croatia. Croat Med J. 2016;57(6):572–81.

    PubMed  PubMed Central  Article  Google Scholar 

  4. Feigenbaum P, Neuwirth E, Trowbridge L, Teplitsky S, Barnes CA, Fireman E, et al. Factors contributing to all-cause 30-day readmissions: a structured case series across 18 hospitals. Med Care. 2012;50(7):599–05.

    PubMed  Article  Google Scholar 

  5. Johnson A, Guirguis E, Grace Y. Preventing medication errors in transitions of care: a patient case approach. J Am Pharm Assoc. 2015;55(2):e264–74.

    Article  Google Scholar 

  6. Flood KL, Carroll MB, Le CV, Brown CJ. Reducing prescribing errors in the paediatric intensive care unit: an experience from Egypt. Acta Paediatr. 2011;100(10):e169–74.

    Article  Google Scholar 

  7. World Health Organization. Medication without harm global patient safety challenge on medication safety. Geneva: WHO; 2017. https://www.who.int/patientsafety/medication-safety/en/. Accessed 9 Apr 2019.

  8. World Health Organization. Standard implementation protocol for medication reconciliation. https://www.who.int/patientsafety/implementation/solutions/high5s/h5s-sop.pdf. Accessed 11 June 2018.

  9. Medication reconciliation to prevent adverse drug events. Available from: https://www.ihi.org/topics/adesmedicationreconciliation/Pages/default.aspx. Accessed 21 Mar 2019.

  10. Joint Commission on Accreditation of Healthcare Organizations, USA. Using medication reconciliation to prevent errors. Sentin Event Alert. 2006;35:1–4.

    Google Scholar 

  11. Almanasreh E, Moles R, Chen TF. The medication reconciliation process and classification of discrepancies: a systematic review. Br J Clin Pharm. 2016;82(3):645–58.

    Article  Google Scholar 

  12. Vira T, Colquhoun M, Etchells E. Reconcilable differences: correcting medication errors at hospital admission and discharge. Qual Saf Health Care. 2006;15(2):122–26.

    CAS  PubMed  PubMed Central  Article  Google Scholar 

  13. Anderegg SV, Wilkinson ST, Couldry RJ, Grauer DW, Howser E. Effects of a hospital wide pharmacy practice model change on readmission and return to emergency department rates. Am J Health Syst Pharm. 2014;71(17):1469–79.

    PubMed  Article  Google Scholar 

  14. Scullin C, Scott MG, Hogg A, McElnay JC. An innovative approach to integrated medicines management. J Eval Clin Pract. 2007;13(5):e781–88.

    Article  Google Scholar 

  15. Champion HM, Loosen JA, Kennelty KA. Pharmacy students and pharmacy technicians in medication reconciliation: a review of the current literature. J Pharm Pract. 2019;32(2):207–18.

    PubMed  Article  Google Scholar 

  16. Hu M, Yee G, Zhou N, Yang N, Jiang X, Klepser D. Development and current status of clinical pharmacy education in China. Am J Pharm Educ. 2014;78(8):157–65.

    PubMed  PubMed Central  Article  Google Scholar 

  17. Zeng Y, Yang J. Medication reconciliation for patients over 70 years old with type 2 diabetes in endocrinology department. China Pharm. 2017;20(2):305–08.

    Google Scholar 

  18. Wang HX, Zhu XT, Xie C, Qian YL, Sun SS, Hang YF. Primary medication reconciliation service provided by clinical pharmacist for chronic kidney disease in our hospital. Chin Pharm J. 2018;53(12):2148–51.

    Google Scholar 

  19. Cornish PL, Knowles SR, Marchesano R, Ahmed R, Akram S, Carnovale C. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005;165(4):424–29.

    PubMed  Article  Google Scholar 

  20. WHO Collaborating Centre for Drug Statistics Methodology. Anatomic therapeutic chemical (ATC) classifcation index with defned daily doses (DDDs). WHO Collaborating Centre for Drug Statistics Methodology, Oslo, Norway. https://www.whocc.no/atc_ddd_index/. Accessed 5 Jan 2019.

  21. Pippins JR, Gandhi TK, Hamann C, Ndumele CD, Labonville SA, Diedrichsen EK, et al. Classifying and predicting errors of inpatient medication reconciliation. J Gen Intern Med. 2008;23:1414–22.

    PubMed  PubMed Central  Article  Google Scholar 

  22. Cheema E, Alhomoud FK, Kinsara ASA, Alsiddik J, Barnawi MH, Al-Muwallad MA, et al. The impact of pharmacists-led medicines reconciliation on healthcare outcomes in secondary care: a systematic review and meta-analysis of randomized controlled trials. PLoS ONE. 2018;13(3):e0193510.

    PubMed  PubMed Central  Article  Google Scholar 

  23. Breuker C, Macioce V, Mura T, Castet-Nicolas A, Audurier Y, Boegner C, et al. Medication errors at hospital admission and discharge: risk factors and impact of medication reconciliation process to improve healthcare. J Patient Saf. 2017. https://doi.org/10.1097/PTS.0000000000000420.

    PubMed  Article  Google Scholar 

  24. Lee YY, Kuo LN, Chiang YC, Hou JY, Wu TY, Hsu MH, et al. Pharmacist-conducted medication reconciliation at hospital admission using information technology in Taiwan. Int J Med Inform. 2013;82(6):522–27.

    PubMed  Article  Google Scholar 

  25. Mazhar F, Haider N, Ahmed Al-Osaimi Y, Ahmed R, Akram S, Carnovale C. Prevention of medication errors at hospital admission: a single-centre experience in elderly admitted to internal medicine. Int J Clin Pharm. 2018;40(6):1601–13.

    PubMed  Article  Google Scholar 

  26. Leguelinel-Blache G, Arnaud F, Bouvet S, Dubois F, Castelli C, Roux-Marson C, et al. Impact of admission medication reconciliation performed by clinical pharmacists on medication safety. Eur J Intern Med. 2014;25(9):808–14.

    PubMed  Article  Google Scholar 

  27. Reeder T, Mutnick A. Pharmacist- versus physician-obtained medication histories. Am J Health Syst Pharm. 2008;65(9):857–60.

    PubMed  Article  Google Scholar 

  28. Al-Rashoud I, Al-Ammari M, Al-Jadhey H, Alkatheri A, Poffet G, Aldebasi T, et al. Medication discrepancies identified during medication reconciliation among medical patients at a tertiary care hospital. Saudi Pharm J. 2017;25(7):1082–85.

    PubMed  PubMed Central  Article  Google Scholar 

  29. Mongaret C, Quillet P, Vo TH, Aubert L, Fourgeaud M, Michelet-Huot E, et al. Predictive factors for clinically significant pharmacist interventions at hospital admission. Medicine (Baltimore). 2018;97(9):e9865.

    Article  Google Scholar 

  30. Chung C, Gauthier V, Marques-Tavares F, Patrick Hindlet, Cohen A, Fernandez C, et al. Medication reconciliation: Predictors of risk of unintentional medication discrepancies in the cardiology department. Arch Cardiovasc Dis. 2019;112(2):104–12.

    PubMed  Article  Google Scholar 

  31. Ziaeian B, Araujo KL, Van Ness PH, Horwitz LI. Medication reconciliation accuracy and patient understanding of intended medication changes on hospital discharge. J Gen Intern Med. 2012;27(11):1513–20.

    PubMed  PubMed Central  Article  Google Scholar 

  32. Johnson A, Guirguis E, Grace Y. Preventing medication errors in transitions of care: A patient case approach. J Am Pharm Assoc. 2015;55(2):e264–76.

    Article  Google Scholar 

  33. Rodríguez Vargas B, Delgado Silveira E, Iglesias Peinado I, Bermejo VT. Prevalence and risk factors for medication reconciliation errors during hospital admission in elderly patients. Int J Clin Pharm. 2016;38(5):1164–71.

    PubMed  Article  Google Scholar 

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Author notes

  1. Qian Guo and Hui Guo contributed equally to this manuscript and share first authorship.

Affiliations

  1. Department of Pharmacy, Second Hospital of Shanxi Medical University, No.382, Wuyi Road, Taiyuan, Shanxi, China

    Qian Guo, Junli Song, Donghong Yin, Yan Song, Shuyun Wang, Xiaoxia Li & Jinju Duan

  2. Department of Pharmacy, Shanxi Cardiovascular Disease Hospital, Taiyuan, China

    Hui Guo

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  1. Qian Guo
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Correspondence to Jinju Duan.

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Guo, Q., Guo, H., Song, J. et al. The role of clinical pharmacist trainees in medication reconciliation process at hospital admission. Int J Clin Pharm 42, 796–804 (2020). https://doi.org/10.1007/s11096-020-01015-2

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  • DOI: https://doi.org/10.1007/s11096-020-01015-2

Keywords

  • China
  • Hospital admission
  • Medication discrepancy
  • Medication reconciliation
  • Pharmacist trainee
  • Prevalence
  • Risk factors