Impact of team-versus ward-aligned clinical pharmacy on unintentional medication discrepancies at admission.

Background Medication reconciliation at admission to hospital reduces the prevalence of medication errors. Strategies are needed to ensure timely and efficient delivery of this service. Objective To investigate the effect of aligning clinical pharmacy services with consultant teams, by pharmacists attending post-admission ward rounds, in comparison to a ward-based service, on prevalence of unintentional unresolved discrepancies 48 h into admission. Setting A 243-bed public university teaching hospital in Ireland. Method A prospective, uncontrolled before-after observational study. A gold standard preadmission medication list was completed for each patient and compared with the patient's admission medication prescription and discrepancies were noted. Unresolved discrepancies were examined at 48 h after admission to determine if they were intentional or unintentional. Main outcome measured Number of patients with one or more unintentional, unresolved discrepancy 48 h into admission. Results Data were collected for 140 patients, of whom 73.5% were over 65 years of age. There were no differences between before (ward-aligned) and after (team-aligned) groups regarding age, number of medications or comorbidities. There was a statistically significant reduction in the prevalence of unintentional, unresolved discrepancy(s) per patient (67.3 vs. 27.3%, p < 0.001) and per medication (13.7 vs. 4.1%, p < 0.001) between the groups, favouring the team-based service. The effect remained statistically significant having adjusted for patient age, number of medications and comorbidities (adjusted odds ratio 4.9, 95% confidence interval 2.3-10.6). Conclusion A consultant team-based clinical pharmacy service contributed positively to medication reconciliation at admission, reducing the prevalence of unintentional, unresolved discrepancy(s) present 48 h after admission.

Clinical pharmacist's contribution to medication reconciliation on admission to hospital in Ireland.

BACKGROUND: Medication reconciliation has been mandated by the Irish government at transfer of care. Research is needed to determine the contribution of clinical pharmacists to the process. OBJECTIVE: To describe the contribution of emergency department based clinical pharmacists to admission medication reconciliation in Ireland. MAIN OUTCOME MEASURE: Frequency of clinical pharmacist's activities. SETTING: Two public university teaching hospitals. METHODOLOGY: Adults admitted via the accident and emergency department, from a non-acute setting, reporting the use of at least three regular prescription medications, were eligible for inclusion. Medication reconciliation was provided by clinical pharmacists to randomly-selected patients within 24-hours of admission. This process includes collecting a gold-standard pre-admission medication list, checking this against the admission prescription and communicating any changes. A discrepancy was defined as any difference between the gold-standard pre-admission medication list and the admission prescription. Discrepancies were communicated to the clinician in the patient's healthcare record. Potentially harmful discrepancies were also communicated verbally. Pharmacist activities and unintentional discrepancies, both resolved and unresolved at 48-hours were measured. Unresolved discrepancies were confirmed verbally by the team as intentional or unintentional. A reliable and validated tool was used to assess clinical significance by medical consultants, clinical pharmacists, community pharmacists and general practitioners. RESULTS: In total, 134 patients, involving 1,556 medications, were included in the survey. Over 97 % of patients (involving 59 % of medications) experienced a medication change on admission. Over 90 % of patients (involving 29 % of medications) warranted clinical pharmacy input to determine whether such changes were intentional or unintentional. There were 447 interventions by the clinical pharmacist regarding apparently unintentional discrepancies, a mean of 3.3 per patient. In total, 227 (50 %) interventions were accepted and discrepancies resolved. At 48-hours under half (46 %) of patients remained affected by an unintentional unresolved discrepancy (60 % related to omissions). Verbally communicated discrepancies were more likely to be resolved than those not communicated verbally (Chi-square (1) = 30.029 p < 0.05). Under half of unintentional unresolved discrepancies (46 %) had the potential to cause minor harm compared to 70 % of the resolved unintentional discrepancies. None had the potential to result in severe harm. CONCLUSION: Clinical pharmacists contribute positively to admission medication reconciliation and should be engaged to deliver this service in Ireland.

Sources of pre-admission medication information: observational study of accuracy and availability.

OBJECTIVE: To identify the accessibility of sources of pre-admission medication (PAM) information, to quantify agreement between the PAM list and the 'gold-standard' PAM list (GS-PAML) and to categorise disagreements. METHODS: A random selection of patients with chronic illness admitted via accident and emergency to one of two study hospitals in the Republic of Ireland were recruited. For each patient, a GS-PAML was compiled and PAM lists were obtained from each relevant source, including patient own medications, general practitioner (GP) referral letter, past inpatient prescription (Kardex) and discharge summary, nursing home letter and personal communication with GP staff, community pharmacy staff and nursing home staff. Data were collected regarding availability for use of each source and allergy status. The GS-PAML was compared to each PAM, and disagreements were identified and categorised. KEY FINDINGS: Data were collected for 134 patients. Community pharmacy and nursing home staff were most accessible to researchers when undertaking the medication history (>90%), followed by GP staff (66%). Except for nursing home sources, agreement between PAML and GS-PAML was low (2-17% of patients, 44-77% of medications). The community pharmacy PAML most frequently agreed with the GS-PAML (17% of patients, 77% of medications) followed by GP staff (10% of patients, 69% of medications). Previous (within the last 6 months) discharge summaries (3% of patients, 49% of medications) and GP referral letters (2% of patients, 44% medications) agreed least frequently. Nursing home (100%) and GP (91%) staff provided most accurate allergy information. Drug omission (>35%) was the most common disagreement for all sources except nursing home staff. GP staff and community pharmacy PAMLs contained a considerable proportion of commission discrepancies. CONCLUSION: Community pharmacy and GP staff were identified as the most available and accurate sources of PAM information and should be prioritised when undertaking admission medication reconciliation in a busy clinical environment.