Evaluation of Pharmacist-Managed Medication Reconciliation Process after Hospital Discharge at an Internal Medicine Clinic

This paper is to analyze the impact of ambulatory care pharmacists on reduction of 30-day readmission rates of HDF （hospital discharge follow-up） patients and to assess a link between readmission rates and medication appointment compliance as well as medication discrepancies. This was a retrospective, single-center study that included all adult patients scheduled for HDF appointments at the UIM （university internal medicine） clinic of the MUSC （Medical University of South Carolina） from May 1, 2013 through December 31, 2013. A total of 470 patients were included with 190 patients attended their scheduled HDF appointments with their PCPs （primary care providers） and the ambulatory care pharmacists, and 280 patients attended their scheduled HDF appointments only with their PCPs. The 30-day readmission rate was 22% in patients who attended HDF appointments with both of the healthcare providers versus 41% in patients who attended HDF appointments only with their PCPs （P 〈 0.05）. Medication errors and discrepancies are common during transitions of care. However, ambulatory care pharmacists play a crucial role in significantly reducing 30-day readmission rates after hospital discharge by providing thorough and complete medication reconciliation services.

Quality Improvement Project of Pharmacist-Assisted Medication Reconciliation and Regimen Review Following Veteran Discharge to Hospice

The Joint Commission NPSG （National Patient Safety Goals） requires that medication reconciliation be performed upon any transition of care （NPSG 03.06.01）. The hospice clinical pharmacist, in delivering pharmaceutical care, performs medication regimen reviews to identify medication-related problems. This project aims to improve the medication reconciliation process upon transition from inpatient units to non-VA （Veterans Affairs） hospice care by identifying and resolving medication discrepancies and medication-related problems. Patients discharged from inpatient to non-VA hospice care from October 2013-March 2014 were included. Medication reconciliation was performed by the pharmacist via telephone with the patient/caretaker and the hospice agency within two weeks of discharge. The patient＇s primary care provider was contacted via telephone when changes were recommended, and upon agreement, medication lists were updated electronically. A total of 18 patients were included. The results found that following medication reconciliation and regimen review, the mean number per patient of VA medications discontinued and non-VA medication documented was 5.7 and 10.8 respectively. The mean number per patient of medication discrepancies and medication-related problems was 14.4 and 8.6 respectively. This quality improvement project demonstrates the vulnerability of patients to medication discrepancies and medication-related problems and highlights the role of pharmacists in resolving these issues during this transition of care.

An opportunity for improvement with a medication reconciliation programme

Medication reconciliation is priority in safety. Between 54% and 67% of hospitalized patients have at least one unintended discrepancies (UDs) between pharmacological treatment of a hospital inpatient and treatment that they were previously taking at home. Quasi-experimental pre-post study performed. The objective is to assess the impact of an intervention aimed at decreasing UDs between medication prescribed on admission and patient’s regular treatment. Patients who were hospitalised for more than 24 hours and were undergoing treatment prior to admission which involved taking three or more medicines were included. The number of patients included was 331 and 3781 medicines were reconciled. The incidence of UDs decreased significantly from 7.24% to 4.18%. Omission was the most common UD, with a significant decrease from 5.8% to 3.4%. Respect to clinical impact, we observed that error type C (error reached patient without causing harm) predominates, how- ever, experienced a statistically significant decrease from 5.3% to 2.4%.

Clinical Pharmacist and Physician Team Collaboration to Improve Medication Safety and Cost Savings in an Inpatient Medicine Unit： A Prospective Cohort Study

Background： To prevent adverse drug events and promote patient safety, medication reconciliation is critical in all patient care settings. The purpose of this study was to identify medication discrepancies occurring in an inpatient medicine unit and to analyze the clinical and economic benefit of clinical pharmacist and physician team collaboration. Methods： A prospective cohort study in which pharmacist attended daily team rounds and assisted with medication management and medication reconciliation on admission and discharge in an academic hospital with internal medicine residents. All interventions related to medication management were categorized based on error type, severity of harm, preventable, non-preventable and potential adverse drug events. The economic outcome associated with these medication errors was analyzed. Results： There were 160 admissions and 179 pharmacist recommendations with a 91% acceptance rate from physicians. There were 145 discharges during the study period of which 104 medication discrepancies were identified. Eighty nine of the medication discrepancies were corrected by the pharmacist within 72 hours of discharge. Pharmacist identified 11 actual adverse drug events. Cost savings from pharmacist interventions during the study period was $11,652 and cost avoidance from intercepting potential and actual adverse drug events was $256,806. Conclusion： Collaboration of pharmacist with a physician team improved medication safety and led to significant cost savings and cost avoidance.

Preoperative Medication Management, Compliance and Adverse Events in Adult Patients Undergoing Elective Surgery: A Historical Chart Review

Purpose: Medication compliance for chronic medications has been well studied, but there is a gap in the literature regarding compliance within the perioperative period. Our objective was to determine the incidence of patient non-compliance with preoperative medication instructions for adult non-emergent surgery. Additional objectives were to identify predictors of compliance, describe medication instructions by drug type, and explore the impact of non-compliance. Patients and Methods: This historical chart review evaluated preoperative compliance to medication instructions in 393 adults undergoing non-emergent surgeries at Hamilton Health Sciences between May 1, 2012, and April 30, 2013. Seven patient factors (age;sex;American Society of Anesthesiologists class;number of medications;type of surgery;time between preoperative appointment to surgery;the individual collecting the medication list) were evaluated as potential predictors of non-compliance and analyzed using logistic regression analysis. Consequences of non-compliance were assessed by impact on intraoperative blood pressure, blood glucose level, drop in hemoglobin, bronchospasm, and case delays. Results: One hundred forty-six (37.2%) patients were non-compliant with one or more medication reconciliation instructions provided by the anesthesiologist. No significant associations were observed for any patient risk factors and non-compliance. Non-compliance was not associated with any clinically significant consequences. Conclusions: Our study shows that 37.15% of adult patients undergoing non-emergent surgery were non-compliant with medication instructions, although patients did not receive any written instructions for 46% of their medications. We did not identify any predictive patient factors or adverse outcomes associated with non-compliance.

Reducing Readmission Rates in Heart Failure and Acute Myocardial Infarction by Pharmacy Intervention

Background： Hospital readmissions are common, costly and largely preventable. Objectives： To evaluate the impact of a pharmacy-led medication discharge and post discharge counseling program on 30 day readmission rates for HF （heart failure） and AMI （acute myocardial infarction）. Methods： Three month prospective, quality improvement, pilot study with I-IF and AMI patients who received pre-discharge and post-discharge medication counseling from December 2013 to February 2014 whose 30 day readmission rates were compared to readmission rates from the previous fiscal year.Results： Fifty-one patients were included in the study. Primary endpoint of30-day readmission rates showed a 33.9% decrease for AMI and a 50.1% decrease for HF in readmission rates compared to the previous fiscal year, with a potential annual savings of $458,800. The study also identified 25.5% of patients having at least one medication error that was identified through medication reconciliation. Conclusions： Pharmacy provided medication reconciliation and medication discharge counseling reduced readmission rates as well as decreased medication errors. There is also a potential for significant health cost savings.

Patient Perceptions and Effects of Single Community Pharmacy Systems： Key Elements for Transitions of Care

The primary objective of the study was to evaluate baseline patient perception on single versus multiple community pharmacy systems. The secondary objective was to determine effects of a pharmacist provided educational intervention on perception of using a single community pharmacy system. This was a prospective survey based study implemented in a single grocery store chain pharmacy and one location of a large retail pharmacy. An anonymous pre-survey was administered to eligible patients. The primary investigator then delivered a brief educational intervention followed by an anonymous post survey. This aimed to determine if there was a change in perception of components assessed in the pre-survey. Data analysis was performed using descriptive statistics. Subjects reported using approximately 1.5 pharmacies. Major reasons included cost, location, and immunizations. 63% of subjects answered that their pharmacist will not have an accurate medication list when using multiple pharmacies, however, 92% of subjects responded that the pharmacist should be aware of all medications they take. Education on multiple pharmacy use may help protect against its risks. Cognizance of medications filled at other pharmacies and close communication between patients and pharmacists may help foster pharmacist-patient relationships while reducing the risk of multiple pharmacy use.