Articles of Interest
Standardizing Medication Reconciliation through Electronic Systems
The effectiveness of integrated health information technologies across the phases of medication management: a systematic review of randomized controlled trials.
McKibbon KA et al, Agency for Healthcare Quality and Research
J Am Med Inform Assoc. 2012;19:22-30
This review identified eighty seven randomized controlled trials assessing the effect of information technology on various aspects of medication safety, including studies of computerized provider order entry (CPOE). Although processes of care consistently improved, few studies showed actual improvement in clinical outcomes.
Making Inpatient Medication Reconciliation Patient Centered, Clinically Relevant and Implementable: A Consensus Statement on Key Principles and Necessary First Steps
Greenwald JL et al, Journal of Hospital Medicine, 10/2010
The consensus statement focuses on issues pertaining to continuum of care in a hospital setting. It also recommends several concrete steps that should be initiated immediately to reach the medication safety goal achievable through effective medication reconciliation.
Prevalence of Medication Administration Errors in Two Medical Units with Automated Prescription and Dispensing.
Rodriguez-Gonzalez CG et al, Journal of the American Medical Informatics Association (JAMIA), 2011 – JAMIA doi:10.1136/amiajnl-2011-000332
The aim of this study was to identify frequency of medication preparation errors and their potential risk factors in units using a computerized prescription order entry program and profiled automated dispensing cabinets. The study results showed that most frequent errors were use of wrong administrative techniques, wrong reconstitution/dilution, omission and wrong infusion speed.
Multimodal System Designed to Reduce Errors in Recording and Administration of Drugs in Anaesthesia: Prospective Randomised Clinical Evaluation.
Alan FM et al, British Medical Journal (BMJ), 09/2011 – BMJ 2011; 343:d5543
The objective of this study was to evaluate a new patented multimodal system (SAFERSleep) designed to reduce errors in the recording and administration of drugs in anaesthesia. The study revealed that automatic compilation of the anaesthetic record increased legibility but also increased lapses in a vigilance latency task and decreased time spent watching monitors.
Electronic Prescribing within an Electronic Health Record Reduces Ambulatory Prescribing Errors.
Abrahamson EL et al, Joint Commission Journal on Quality and Patient Safety, 10/2011 - Volume 37, Number 10, October 2011, pp. 470-478(9)
The study was conducted to assess the effect of an e-prescribing system with clinical decision support, including checks for drug allergies and drug-drug interactions, that was integrated within an EHR on rates of ambulatory prescribing errors. The preliminary findings suggest that e-prescribing systems may decrease ambulatory prescribing errors, which are occurring at high rates among community-based providers.
Medication reconciliation: From Admission to Discharge Using Electronically Generated Medication Forms from a Clinical Information System.
Latham BD & Lehman RK, American Society of Health-System Pharmacists Midyear Clinical Meeting Research Highlights, 2006
This brief article is about developing a concise and user-friendly way of recording medication information. This information can also be used to facilitate communication amongst healthcare professionals.
Collaborative Pharmacist and Nurse Before/After Study to Evaluate Patient Safety Using Electronically Standardized Admission and Discharge Medication Reconciliation in a Tertiary Care Hospital
Kramer JS, American Society of Health-System Pharmacists Midyear Clinical Meeting Research Highlights, 12/2006
This 35-page study evaluates the association between use of electronically standardized medication reconciliation at admission/discharge and patient safety.
Development of a Tool within the Electronic Medical Record to Facilitate Medication Reconciliation after Hospital Discharge
Schnipper JL et al, Journal of the American Medical Informatics Association (JAMIA), 2011
J Am Med Inform Assoc 2011;18:309e313. doi:10.1136/amiajnl-2010-000040
This article describes the design and implementation of the tool, attempts to improve use, provides informal feedback on the tool from clinicians, and talks about generalizable lessons learned to maximize the usability of the tool and its impact on patient safety.
Effect of an Electronic Medication Reconciliation Application and Process Redesign on Potential Adverse Drug Events
Schnipper JL et al, Archives of Internal Medicine, 2011
Arch Intern Med. 2009;169(8):771-780
This study measures the impact of an information technology–based medication reconciliation intervention on medication discrepancies with potential for harm (potential adverse drug events [PADEs]). The findings of this study suggest that software integration issues are likely important for successful implementation of computerized medication reconciliation tools.
Implementation of an Electronic System for Medication Reconciliation
Kramer JS et al, American Journal of Health-System Pharmacy, 2007
The aim of this study was to determine the feasibility of implementing an electronic system for targeted pharmacist- and nurse-conducted admission and discharge medication reconciliation and its effects on patient safety, cost, and satisfaction among providers and nurses.
Strategies, Procedures and Processes to Improve or Establish a Medication Reconciliation Program
Improving medication management through the redesign of the hospital code cart medication drawer
Rousek JB et al, Agency for Healthcare Quality and Research
Hum Factors. 2011;53:626-636
This article talks about a hospital code blue resuscitation cart that had been redesigned according to ergonomics principles provided easier and more reliable access to medications during simulated resuscitation scenarios.
Methods for assessing the preventability of adverse drug events: a systematic review
Hakkarainen KM et al, Agency for Healthcare Quality and Research
Drug Saf. 2012;35:105-126
This review identifies eighteen unique instruments for assessing the preventability of adverse drug events. However, there is not sufficient evidence to show the validity of these instruments, and many do not appear reliable for wider use.
Understanding medication safety in healthcare settings: a critical review of conceptual models
Liu W, Manias E and Gerdtz M, Agency for Healthcare Research and Quality
Nursing Inquiry 2011; 18: 290–302
This commentary explores how six conceptual models influence medication safety practices.
Medication Reconciliation
Barnsteiner JH, Patient Safety and Quality: An Evidence-Based Handbook for Nurses: Vol. 2
This fourteen page chapter provides introduction to the medication reconciliation process, talks about reconciliation in different health care settings. It also lays out steps to establish a medication reconciliation process.
Strategies to Improve Medication Reconciliation
Delmarva Foundation and Maryland Patient Safety Center, 03/2007
This three-page document lays out five strategies to improve medication reconciliation.
Reconciling Medications, Safe Practice Recommendations
Massachusetts Coalition for the Prevention of Medical Errors and Massachusetts Hospital Association, 11/2007
This seven-page document describes the safe practice recommendations for reconciling medicines. The core recommendation is to adopt a systematic approach to reconciling medicines, starting with reconciling at admission.
Reconciling Medications at Admission: Safe Practice Recommendations and Implementation Strategies
Rogers G et al, Joint Commission Journal on Quality and Patient Safety, 01/2006
January 2006 Volume 32 Number 1, Joint Commission on Accreditation of Healthcare Organizations, pages 37-50
Fifty hospitals collaborated in a patient safety initiative; the resulting implementation strategies most strongly correlated with success included actively engaging physicians and nurses, having an effective improvement team, using small tests of change, having an actively engaged senior administrator, and sending the team to multiple collaborative sessions.
National Patient Safety Goal 8 – Medication Reconciliation
Joint Commission, 2009
The Joint Commission hosted focus group calls with its ambulatory health care, behavioral health care, critical access hospitals, hospital, home care, long term care, and office-based surgery customers on the medication reconciliation National Patient Safety Goal. The outline addresses the ideal elements for the medication reconciliation goal. The article categorizes participant feedback into distinct themes.
Medication Reconciliation
Barnsteiner JH, American Journal of Nursing, 2005
This article provides a general understanding of the medication reconciliation process, talks about some effective strategies for implementing a medication reconciliation program, and concludes with some of the challenges in medication reconciliation.
Medication Reconciliation
University of Wisconsin Hospital and Clinics (UWHC) Medication Reconciliation Policy, Wisconsin, 04/2007
This seven-page document describes the procedures to record medications across the continuum of care.
Multidisciplinary Approach to Inpatient Medication Reconciliation in an Academic Setting
Varkey P et al, American Journal of Health-System Pharmacy, 04/2007
Am J Health-Syst Pharm. 2007; 64:850-4
The purpose of this study was to look at the effectiveness of a multidisciplinary medication reconciliation process in an inpatient family medicine unit of an academic hospital center.
Ensuring Medication Reconciliation
Georgia Kristen et al, Patient Safety and Quality Healthcare, 2007
This article describes the process of medication reconciliation and key elements to consider when developing a medication reconciliation process.
Medication Reconciliation: Whose Job Is It?
Poon EG, Agency for Healthcare Research and Quality, 09/2007
This commentary lists six points toward establishing a robust medication reconciliation process.
Pharmacist Involvement and Interventions
Severity and probability of harm of medication errors intercepted by an emergency department pharmacist
Patanwala AE et al, Agency for Healthcare Quality and Research
Int J Pharm Pract. 2011; 19:358-362
This study results showed that the medication errors identified by an emergency department pharmacist primarily occurred at the prescribing phase, and the majority had limited potential to harm patients.
Improving Patient Safety through Implementation of a Pharmacist-Conducted Admission Medication History and Discharge Medication Reconciliation Proces
Murphy EM et al, American Society of Health-System Pharmacists Award Winning Paper, 2007
This paper talks about discrepancies between physician’s prescription and home medicine regimens. It describes how pharmacist conducted medication reconciliation at admission and discharge can reduce and even eliminate such discrepancies.
The Development and Implementation of an Admitting Pharmacist in the Community Hospital Setting
Trimino E et al, American Society of Health-System Pharmacists Award Winning Paper, 2006
This paper describes the rationale behind appointing an admitting pharmacist, their unique role and importance to the admission’s process.
A Call to Action: Protecting U.S. Citizens from Inappropriate Medication Use
White Paper from Institute for Safe Medication Practices, 2007
This 16-page paper lays out the causes of inappropriate use of medications by US citizens and addresses this problem by showing how pharmacists can play a prominent role to prevent incorrect use of medicines.
In-Home Medication Reviews: A Novel Approach to Improving Patient Care through Coordination of Care
Willis JS et al, Journal of Community Health, 2011
J Community Health, DOI 10.1007/s10900-011-9405-3
The purpose of this study was to determine if trained undergraduate students, in conjunction with pharmacists, could provide in home medication reviews, and demonstrate benefit to the health and welfare of a senior population affiliated with a Patient Centered Medical Home (PCMH).
Role of Pharmacist Counseling in Preventing Adverse Drug Events after Hospitalization
Schnipper JL et al, Archives of Internal Medicine, 2006
The aim of this study was to identify drug-related problems during and after hospitalization and to determine the effect of patient counseling and follow-up by pharmacists on preventable adverse drug events (ADEs).
Pharmacist-Conducted Medication Reconciliation in an Emergency Department
Hayes BD et al, American Journal of Health-System Pharmacy, 2007
The aim of this study was to determine the effect of pharmacist conducted medication reconciliation in enhancing compliance with a hospital’s medication reconciliation policy.
Documentation of Pharmacists’ Interventions in an Emergency Department and Associated Cost Avoidance
Lada P & Delgado G, American Journal of Health-System Pharmacy, 2007
This study analyzed pharmacist interventions and resuscitation experiences, including pharmacist participation in a hospital emergency department (ED), and the potential costs avoided associated with the interventions made by the pharmacists.
Medication Reconciling Errors, Discrepancies and Adverse Events
A review of verbal order policies in acute care hospitals.
Wakefield DS et al, Agency for Healthcare Quality and Research
Jt Comm J Qual Patient Saf. 2012;38:24-33
Verbal orders, usually for medications, are commonly used in hospitals even though they are recognized as significant source of error. This survey of forty hospitals found wide variation in hospital policies regarding verbal orders, and a lack of a uniform standard on which providers were allowed to give or receive verbal orders and varying approaches to documenting these orders. Although specific methods, such as read-backs, can be used for improving the reliability of verbal orders, few hospitals have mandated the use of these communication tools. A case of a misunderstood verbal order that led to a serious error is discussed in this commentary.
Prescription and transcription errors in multidose-dispensed medications on discharge from hospital: an observational and interventional study
Alassaad A et al, Agency for Healthcare Quality and Research
J Eval Clin Pract. 2011 Dec 29
This article reveals that Medication reconciliation showed a high rate of prescribing and transcribing errors in the discharge medications of elderly patients at a Swedish hospital.
Reducing medical errors and adverse events
Pham JC et al, Agency for Healthcare Quality and Research
Annu Rev Med. 2012;63:447-463
The article describes numerous types of medical errors and adverse events, their impact, contributing factors, and strategies to address them.
Preventability of adverse drug events involving multiple drugs using publicly available clinical decision support tools
Wright A et al, Agency for Healthcare Quality and Research
Am J Health Syst Pharm. 2012;69:221-227
This retrospective study’s result showed that most preventable adverse drug events that arose from inadvertent drug duplication or drug–drug interaction could have been prevented through the use of existing decision support systems.
Anticoagulation Associated Drug Events
Piazza G et al, Agency for Healthcare Research and Quality
Am J Med. 2011; 124:1136-1142
Warfarin and other anticoagulant medications place patients, especially elderly ones, at high risk of adverse drug events (ADEs) due to their narrow therapeutic window. This study of anticoagulant-related ADEs identified the underlying cause of these events and found evidence that a large proportion is preventable. The results show that that more than two-thirds of anticoagulant-related ADEs were due to medication errors, usually at the medication administration stage. Also, a large proportion of the errors were attributable to incorrect transcription of orders. The persistent incidence of transcription errors in this study is especially surprising as the facility for this study already had a computerized provider order entry (CPOE) system. Fully electronic medication systems, which integrate CPOE, bar-coding, and electronic medication administration records, hold promise as a means of reducing both transcribing and administration errors.
Emergency hospitalizations for adverse drug events in older Americans
Budnitz DS et al, Agency for Healthcare Research and Quality
N Engl J Med. 2011;365:2002-2012
Partnership for Patients set an ambitious goal to reduce preventable readmissions by 20% in 2013. Adverse drug events contribute significantly to undesired outcomes and provide an ongoing area for prevention strategies. This study used a national surveillance database and examined nearly 100,000 emergency hospitalizations attributed to adverse drug events in elderly patients between 2007 and 2009. Investigators found that nearly half the hospitalizations were in adults older than 80 years and two-thirds were due to unintentional overdoses. The most common medications implicated were warfarin, insulin, oral antiplatelet agents, and oral hypoglycemic agents. The authors suggest that targeted strategies to minimize risk associated with these high-risk medications may reduce preventable hospitalizations in older adults.
The sensitivity of adverse event cost estimates to diagnostic coding error
Wardle G et al, Agency for Healthcare Quality and Research
Health Serv Res. 2011 Oct 27
This study suggests that diagnostic coding error may significantly underestimate the costs associated with adverse events.
Medical error: the second victim
The Agency for Healthcare Research and Quality
Wu AW. BMJ. 2000;320:726-727
This editorial describes the term “second victim” to describe clinicians who commit errors, acknowledging the significant emotional impact that errors can have on the clinicians involved. Subsequent research has shown that involvement in an error adversely affects providers’ emotional health and job satisfaction, and increases risk of burnout. Inspired by these findings, organizations have now developed innovative approaches for supporting second victims, primarily through encouraging debriefing and open discussion of errors. This commentary discusses the effect of committing a wrong-site procedure error on a resident physician.
The nature and causes of unintended events reported at 10 internal medicine departments
Lubberding S et al, Agency for Healthcare Research and Quality
Journal of Patient Safety 2011;7:224-231
This study analyzed unintended events reported by hospital staff to identify targets for intervention. The medication process and collaboration within the hospital were themes warranting further intervention.
Results of the Medications at Transitions and Clinical Handoffs (MATCH) Study: An Analysis of Medication Reconciliation Errors and Risk Factors at Hospital Admission
Gleason et al, Journal of General Internal Medicine, 12/2009
This study was designed to determine risk factors and potential harm associated with medication errors at hospital admission. The study findings suggest early identification and correction of admission medication errors may mitigate or prevent harm.
Medication Reconciliation Victory after an Avoidable Error
Cutler TW, Agency for Healthcare Research and Quality, 03/2009
This commentary identifies two important aspects in delivering safe care to the elderly. First, the continued use of Potentially Inappropriate Medications (PIM) in older patients is a problem. Second medication reconciliation can identify drug-related problems when performed across the continuum of care.
Medication Reconciliation at Hospital Discharge: Evaluating Discrepancies
Wong JD et al, The Annals of Pharmacotherapy, 11/2008
This study recognizes that hospital discharge is an interface of care when patients are at a high risk of medication discrepancies as they transition from hospital to home. Based on this premise, the study tries to identify, characterize, and assess the clinical impact of unintentional medication discrepancies at discharge.
Unintended Medication Discrepancies at the Time of Hospital Admission
Cornish P et al, Archives of Internal Medicine, 2005
This study was conducted to determine errors between physician admission orders and medication history obtained through interviews in patients reporting use of at least four regular prescription drugs.
Medication Discrepancies Identified at Time of Hospital Discharge in a Geriatric Population
Stitt DM et al, The American Journal of Geriatric Pharmacotherapy, 06/2011
The aim of this study was to identify and characterize discharge medication list discrepancies among geriatric patients and to describe characteristics associated with discrepancies.
Post Hospital Medication Discrepancies
Coleman EA et al, Archives of Internal Medicine, 2005
Arch Intern Med. 2005;165:1842-1847
The aim of this study was to determine the prevalence and contributing factors associated with post hospital medication discrepancies. The study population was community dwelling adults aged 65 years and older admitted to hospital with one of nine selected conditions.
Effect of Admission Medication Reconciliation on Adverse Drug Events from Admission Medication Changes
Boockvar KS et al, Archives of Internal Medicine, 2011
ARCH INTERN MED/VOL 171 (NO. 9), MAY 9, 2011, pages 860-861
The aim of this study was to estimate the effectiveness of inpatient medication reconciliation at the time of hospital admission on adverse drug events caused by admission prescribing. The study findings suggest that the optimal form of medication reconciliation should include tools to track prescribing changes that occurred on admission so that patients are not harmed by their unmonitored propagation during the hospitalization.
Prescribing Discrepancies Likely to Cause Adverse Drug Events after Patient Transfer
Boockvar KS, Quality and Safety in Healthcare Manuscript, 08/2009
This manuscript recognizes that medication prescribing discrepancies are used as a quality measure for patients transferred between sites of care. The objective of this study was to quantify the rate of adverse drug events (ADEs) caused by prescribing discrepancies and the discrimination of an index of high-risk transition drug prescribing.
The Incidence and Severity of Adverse Events Affecting Patients after Discharge from the Hospital
Forster AJ et al, Annals of Internal Medicine, 2003
Ann Intern Med. 2003;138:161-167
This cohort study was conducted to describe the incidence, severity, preventability, and “ameliorability” of adverse events affecting patients after discharge from the hospital and to develop strategies for improving patient safety during this interval.