Medication reconciliation errors in a tertiary care hospital in Saudi Arabia: admission discrepancies and risk factors
Background: Medication reconciliation is a major component of safe patient care. One of the main problems in the implementation of a medication reconciliation process is the lack of human resources. With limited resources, it is better to target medication reconciliation resources to patients who will derive the most benefit from it.
Objective: The primary objective of this study was to determine the frequency and types of medication reconciliation errors identified by pharmacists performing medication reconciliation at admission. Each medication error was rated for its potential to cause patient harm during hospitalization. A secondary objective was to determine risk factors associated with medication reconciliation errors.
Methods: This was a prospective, single-center pilot study conducted in the internal medicine and surgical wards of a tertiary care teaching hospital in the Eastern province of Saudi Arabia. A clinical pharmacist took the best possible medication history of patients admitted to medical and surgical services and compared with the medication orders at hospital admission; any identified discrepancies were noted and analyzed for reconciliation errors. Multivariate logistic regression was performed to determine the risk factors related to reconciliation errors.
Results: A total of 328 patients (138 in surgical and 198 in medical) were included in the study. For the 1419 medications recorded, 1091 discrepancies were discovered out of which 491 (41.6%) were reconciliation errors. The errors affected 177 patients (54%). The incidence of reconciliation errors in the medical patient group was 25.1% and 32.0% in the surgical group (p<0.001). In both groups, the most frequent reconciliation error was the omission (43.5% and 51.2%). Lipid-lowering (12.4%) and antihypertensive agents were most commonly involved. If undetected, 43.6% of order errors were rated as potentially requiring increased monitoring or intervention to preclude harm; 17.7% were rated as potentially harmful. A multivariate logistic regression model showed that patients aged ≥65 years, polypharmacy, and prescriptions for hypoglycemic drugs and warfarin were more likely associated with reconciliation errors.
Conclusion: There is a high failure rate in medication reconciliation process in patients admitted to the medical and surgical department. The reconciliation process proves to be a useful tool since nearly half of avoided reconciliation errors were unintentional and had the potential for harm. This strategy, based on our results and the difficulty of applying the process to all patients should be directed primarily to the patients at increased risk of error.
2. Rozich J, Resar R. Medication safety: one organization's approach to the challenge. J Clin Outcomes Manage . 2001;8(10):27-34.
3. Barnsteiner JH. Medication Reconciliation: Transfer of medication information across settings—keeping it free from error. Am J Nurs. 2005;105(3 Suppl):31-36.
4. World Health Organization. Assuring medication accuracy at transitions in care. Standard operating protocol fact sheet. Available at: http://www.who.int/patientsafety/implementation/solutions/high5s/ps_medication_reconciliation_fs_2010_en.pdf (accessed Oct 4, 2016).
5. Joint Commission on Accreditation of Healthcare Organizations, USA. Using medication reconciliation to prevent errors. Sentinel Event Alert. 2006;(35):1-4.
6. Medication Reconciliation to Prevent Adverse Drug Events. Available from: http://www.ihi.org/topics/adesmedicationreconciliation/Pages/default.aspx (accessed Dec 24, 2016).
7. Cornish PL, Knowles SR, Marchesano R, Tam V, Shadowitz S, Juurlink DN, Etchells EE. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005;165(4):424-429.
8. Boockvar K, Fishman E, Kyriacou CK, Monias A, Gavi S, Cortes T. Adverse events due to discontinuations in drug use and dose changes in patients transferred between acute and long-term care facilities. Arch Intern Med. 2004;164(5):545-550.
9. Gleason KM, Groszek JM, Sullivan C, Rooney D, Barnard C, Noskin GA. Reconciliation of discrepancies in medication histories and admission orders of newly hospitalized patients. Am J Health Syst Pharm. 2004;61(16):1689-1695.
10. Pickrell L, Duggan C, Dhillon S. From hospital admission to discharge: an exploratory study to evaluate seamless care. Pharm J. 2001;267(7172):650-653.
11. Aljadhey H, Alhusan A, Alburikan K, Adam M, Murray MD, Bates DW. Medication safety practices in hospitals: A national survey in Saudi Arabia. Saudi Pharm J. 2013;21(2):159-164. doi: 10.1016/j.jsps.2012.07.005
12. AbuYassin BH, Aljadhey H, Al-Sultan M, Al-Rashed S, Adam M, Bates DW. Accuracy of the medication history at admission to hospital in Saudi Arabia. Saudi Pharm J. 2011;19(4):263-267. doi: 10.1016/j.jsps.2011.04.006
13. Aljadhey H, Mahmoud MA, Hassali MA, Alrasheedy A, Alahmad A, Saleem F, Sheikh A, Murray M, Bates DW. Challenges to and the future of medication safety in Saudi Arabia: A qualitative study. Saudi Pharm J. 2014;22(4):326-332. doi: 10.1016/j.jsps.2013.08.001
14. NCC MERP Index for Categorizing Medication Errors. Available from: http://www.nccmerp.org/sites/default/files/indexColor2001-06-12.pdf (accessed Oct 4, 2016).
15. ISMP’s List of High-Alert Medications. Available from: https://www.ismp.org/tools/institutionalhighAlert.asp (accessed Oct 4, 2016).
16. Institute for Safe Medication Practices. ISMP’s List of High-Alert Medications. Available at: http://www.ismp.org/Tools/highAlertMedicationLists.asp (accessed Oct 4, 2016).
17. WHO Collaborating Centre for Drug Statistics Methodology. Purpose of the ATC/DDD system. Available at: https://www.whocc.no/atc_ddd_methodology/purpose_of_the_atc_ddd_system/ (accessed Oct 4, 2016).
18. Mekonnen AB, Abebe TB, McLachlan AJ, Brien JA. Impact of electronic medication reconciliation interventions on medication discrepancies at hospital transitions: a systematic review and meta-analysis. BMC Med Inform Decis Mak. 2016;16:112. doi: 10.1186/s12911-016-0353-9
19. Buckley MS, Harinstein LM, Clark KB, Smithburger PL, Eckhardt DJ, Alexander E, Devabhakthuni S, Westley CA, David B, Kane-Gill SL. Impact of a clinical pharmacy admission medication reconciliation program on medication errors in “high-risk” patients. Ann Pharmacother. 2013;47(12):1599-1610. doi: 10.1177/1060028013507428
20. Kwan Y, Fernandes OA, Nagge JJ, Wong GG, Huh JH, Hurn DA, Pond GR, Bajcar JM. Pharmacist medication assessments in a surgical preadmission clinic. Arch Intern Med. 2007;167(10):1034-1040.
21. Tam VC, Knowles SR, Cornish PL, Fine N, Marchesano R, Etchells EE. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. CMAJ. 2005;173(5):510-515.
22. Unroe KT, Pfeiffenberger T, Riegelhaupt S, Jastrzembski J, Lokhnygina Y, Colón-Emeric C. Inpatient medication reconciliation at admission and discharge: A retrospective cohort study of age and other risk factors for medication discrepancies. Am J Geriatr Pharmacother. 2010;8(2):115-126. doi: 10.1016/j.amjopharm.2010.04.002
23. Climente-Martí M, García-Mañón ER, Artero-Mora A, Jiménez-Torres NV. Potential risk of medication discrepancies and reconciliation errors at admission and discharge from an inpatient medical service. Ann Pharmacother. 2010;44(11):1747-1754. doi: 10.1345/aph.1P184
24. Vira T, Colquhoun M, Etchells E. Reconcilable differences: correcting medication errors at hospital admission and discharge. Qual Saf Health Care. 2006;15(2):122-126.
25. Varkey P, Cunningham J, O'Meara J, Bonacci R, Desai N, Sheeler R. Multidisciplinary approach to inpatient medication reconciliation in an academic setting. Am J Health Syst Pharm. 2007;64(8):850-854.
26. Almanasreh E, Moles R, Chen TF. The medication reconciliation process and classification of discrepancies: a systematic review. Br J Clin Pharmacol. 2016;82(3):645-658. doi: 10.1111/bcp.13017
27. Fitzgerald RJ. Medication errors: the importance of an accurate drug history. Br J Clin Pharmacol. 2009;67(6):671-675. doi: 10.1111/j.1365-2125.2009.03424.x
28. De Winter S, Spriet I, Indevuyst C, Vanbrabant P, Desruelles D, Sabbe M, Gillet JB, Wilmer A, Willems L. Pharmacist-versus physician-acquired medication history: a prospective study at the emergency department. Qual Saf Health Care. 2010;19(5):371-375. doi: 10.1136/qshc.2009.035014
29. Gleason KM, McDaniel MR, Feinglass J, Baker DW, Lindquist L, Liss D, Noskin GA. Results of the medications at transitions and clinical handoffs (MATCH) study: an analysis of medication reconciliation errors and risk factors at hospital admission. J Gen Intern Med. 2010;25(5):441-447. doi: 10.1007/s11606-010-1256-6
30. Pippins JR, Gandhi TK, Hamann C, Ndumele CD, Labonville SA, Diedrichsen EK, Carty MG, Karson AS, Bhan I, Coley CM, Liang CL, Turchin A, McCarthy PC, Schnipper JL. Classifying and predicting errors of inpatient medication reconciliation. J Gen Intern Med. 2008;23(9):1414-1422. doi: 10.1007/s11606-008-0687-9
31. Andersen S, Pedersen A, Bach K. Medication history on internal medicine wards: assessment of extra information collected from second drug interviews and GP lists. Pharmacoepidemiol Drug Saf. 2003;12(6):491-498.
32. Boockvar KS, Liu S, Goldstein N, Nebeker J, Siu A, Fried T. Prescribing discrepancies likely to cause adverse drug events after patient transfer. Qual Saf Health Care. 2009;18(1):32-36. doi: 10.1136/qshc.2007.025957
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