The error rate in admission medication orders for medically complex inpatients admitted from the emergency department (ED) decreased by 81% when a pharmacist or pharmacist-supervised pharmacy technician had earlier obtained the medication history, according to a research article published online on October 6, 2017, in BMJ Quality & Safety.1
Additionally, the rate of severe or life-threatening errors in the admission medication orders for medically complex patients decreased significantly when pharmacy personnel obtained the medication history. Moreover, the rate of errors in admission medication histories decreased with the involvement of pharmacy personnel in the history-taking process. Histories obtained through usual care had a mean of 8.0 errors per medically complex patient, histories obtained through usual care and the efforts of a pharmacist had a mean error rate of 1.4, and histories obtained through usual care and the efforts of a pharmacist-supervised pharmacy technician had a mean error rate of 1.5.
“The goal of our pharmacy program is to have a pharmacy technician take the admission medication [history] for every patient who is being admitted through our emergency department,” said principal investigator Joshua M. Pevnick, a physician in the department of medicine at Cedars-Sinai Health System in Los Angeles.
Chief Pharmacy Officer Rita Shane has set a broader goal for her pharmacy services department: obtain the medication history of every patient being admitted to a hospital bed and reconcile the discharge medication list for every patient before any prescription gets filled.
To achieve the first part of that goal, Shane said, the productivity of the pharmacy technicians must increase to the point that they obtain the admission medication history for every patient admitted through the ED. Then the pharmacists who have been obtaining some of the admission medication histories in the ED can instead work on obtaining histories for patients admitted directly to inpatient areas while continuing to answer questions from the technicians.
The study, Pevnick said, sought to quantify the benefit of ED-based pharmacy staff being the personnel primarily responsible for obtaining medication information from patients, caregivers, and other sources and reconciling that information before hospitalists or other healthcare professionals place their admission medication orders.
All 306 patients who were assigned to a study group were medically complex, which the research article defined as adults
- With 10 or more “active chronic” prescription medications in the health system’s electronic health record (68% of study patients),
- Whose problem list in the electronic health record stated a history of acute myocardial infarction or congestive heart failure (37%),
- Being admitted from a skilled nursing facility (15%),
- Who earlier received a transplant (3%), or
- With an active prescription for an anticoagulant, insulin, or narrow therapeutic index drug (88%).
“We wanted to focus on where the most harm would be” from inaccuracies in admission medication histories, Shane said.
Excluded from the study, the research article states, were earlier enrollees and patients being admitted to a trauma services unit or to a transplant services unit with pharmacist coverage.
In all, admission medication histories were analyzed for 48% of the 583 patients who were assessed for eligibility from 11 a.m. to 8 p.m. on Monday through Thursday during about 6 weeks in early 2014.
The analyses, according to the research article, were conducted by pharmacists expert in the skill of obtaining medication histories and by physicians who assessed whether an error in a history resulted in an error in a medication order and, if so, the severity of that error.
Shane said the pharmacists who obtained medication histories did not come from the facility’s corps of ED pharmacists who manage patients and work at the bedside. Rather, the study’s pharmacists were transitions-of-care pharmacists and pharmacy residents who had completed training in that skill.
When not obtaining admission medication histories, she said, these pharmacists made follow-up calls about recently discharged patients who had a low score for medication adherence and literacy, reconciled medication lists for patients being discharged to skilled nursing facilities, and supervised the pharmacy technicians who were participating in the study.
Shane said every pharmacy technician who participated in the study had earlier received a training manual, completed 40 hours of training, passed a test, and been deemed competent at obtaining admission medication histories.
Usual care, according to the research article, “commonly involve[d] multiple process variations,” one of which was an ED nurse obtaining a so-called rudimentary admission medication history.
Shane said she and her team continue to refine their program, working out ways to obtain more admission medication histories, particularly for patients at high risk for errors in admission medication orders.
“The lists are so contaminated that this is a public health issue,” she declared of the medication lists typically presented upon admission.
Acute care hospitals, such as 886-bed Cedars-Sinai Medical Center, are not required by the Centers for Medicare and Medicaid Services (CMS) to reconcile the medication lists of newly admitted patients.
The Joint Commission, which said it has accredited about 77% of the nation’s hospitals, has a safety goal on medication reconciliation. But the national accrediting organization states that hospitals can meet the intention of the requirement by making a “good faith effort” to obtain information on patients’ current medications.
“There’s a lot of wriggle room there,” Pevnick said of the allowance for a good faith effort. “Some people think that in certain situations . . . that can actually make things worse.”
He pointed to the possibility of problems resulting from healthcare professionals who, knowing only that medication reconciliation has been done, trust a list that has been compiled in good faith but “hasn’t been done well.”
Shane said justification to hospital administration for a program such as hers can be made on the basis of the facility being financially at risk for readmissions.
CMS’s Hospital Readmissions Reduction Program, for example, reduces payments to hospitals that readmit too many patients in the first 30 days after discharge.
“You want to have an accurate list because that’s going to drive the . . . inpatient orders and the discharge orders,” Shane said.
She said having pharmacy technicians obtain admission medication histories seems more cost-effective than having nurses at patients’ bedside work on those histories.
“We, interestingly enough, have a consulting company in here right now looking at operational efficiency,” Shane said in mid-December 2017. “And one of their recommendations was to put technicians in the ED to do med histories.”
The research article by Pevnick, Shane, and colleagues is one of several they have authored on medication reconciliation or management.
Pevnick receives funding from the National Institutes of Health and the ASHP Research and Education Foundation. The ASHP Foundation did not fund the study published in BMJ Quality & Safety.
- Pevnick JM, Nguyen C, Jackevicius CA et al. Improving admission medication reconciliation with pharmacists or pharmacy technicians in the emergency department: a randomised controlled trial. BMJ Qual Saf. Epub ahead of print. 2017 Oct 6.
[This news story appears in the February 1, 2018, issue of AJHP.]