PITTSBURGH An interdisciplinary medication-reconciliation intervention conducted over 2 months at two Boston-area hospitals was associated with a substantial decrease in the number of unintentional medication discrepancies with potential for causing patient harm.
Unintentional medication discrepancies that occur between preadmission and admission or at patient discharge are a major cause of potential adverse drug events (PADEs). To reduce the risk of PADEs at times of patient transition into and out of hospitals and other care settings, the Joint Commission called for all institutions to implement medication-reconciliation programs beginning in January 2006 as one of its National Patient Safety Goals (www.jcipatientsafety.org/14711
Yet little information is available regarding what programs are most likely to be successful, how best to implement these systems, and which patients are most likely to benefit from them, Dr. Jeffrey L. Schnipper said at the annual meeting of the Society of General Internal Medicine.
Dr. Schnipper of Brigham and Women's Hospital, Boston, and his associates conducted a randomized, controlled trial of one such program on general medical units at two academic medical centers. The intervention consisted of a Web application called a preadmission medication list (PAML) builder, along with a "process redesign," which involved restructuring the way that physicians, nurses, and pharmacists enter patient medication notes into charts.
On admission, the ordering physician took a comprehensive medication history, input the initial PAML, and laid out a plan for the patient's medication during hospitalization. The nurse confirmed the accuracy of the instructions and let the physician know if there were any errors. The pharmacist reconciled the PAML with the physicians' admission orders and also checked for errors.
During the patient's hospital stay, the physician, nurse, and pharmacist worked together as a team to update the orders as needed. At discharge, the physician reviewed the PAML and current medications and created a set of discharge orders, while the nurse and pharmacist again contributed to the process.
Study pharmacists took "gold standard" medication histories using all available resources and those results were compared with the PAML and the admission and discharge orders. If any discrepancies were found, the study pharmacist would seek out the reason for it. Two blinded physician adjudicators then evaluated each error and its potential for harm.
A total of 162 patients were randomized to the intervention floor/team, while 160 patients received the usual care on other floors with other teams. About two-thirds of the patients were judged subjectively by the pharmacist at the time of admission to have low to medium understanding of their own medications, Dr. Schnipper said.
The number of PADEs per patient differed significantly between the two groups, with 1.44 per control patient versus 1.05 per intervention patient. The number of patients needed to treat to prevent one PADE was just 2.6, "not a lot of patients," Dr. Schnipper noted. The intervention was associated with a greater reduction in PADEs at discharge than in PADEs at admission. Despite the intervention's success, there was still an average of one PADE per patient, he said.