Pharmacist's role in

medication reconciliation and

reducing medication errors

Debbie Rigby

@DRugby56

Learning objectives

• Significant number of medication errors occur on

discharge

• Pharmacists have been shown to improve

medication reconciliation on admission and

discharge

• Collaborative medication reviews improve

clinical outcomes and reduce errors

230,000

$1.2B

Roughead L, et al. Literature Review: Medication Safety in Australia.

Sydney: Australian Commission on Safety and Quality in Health Care; 2013.

NPS Medication error report

• Medication errors continue to occur at all stages

of the medication process - prescribing, supply,

administration, monitoring and documentation.

• Up to 73% of these events are preventable,

meaning patient safety is being jeopardised and

avoidable burdens are being placed on our

health system

Easton K, Morgan T, Williamson M. Medication safety in the community: A

review of the literature. National Prescribing Service. Sydney, June 2009.

NPS Medication error report

• Documentation errors that occurred during

transfer of care had consistently high error

rates, with 52 to 88% of transfer documents

containing an error

Easton K, Morgan T, Williamson M. Medication safety in the community: A review of the literature. National Prescribing Service. Sydney, June 2009.

Patients with dementia

• Discharge planning and transitional care for

patients with dementia are not adequate and are

likely to lead to readmission and other poor

health outcomes.

Australasian Journal on Ageing 2015;34(1):9-14.

NPS Medication error report

• The most commonly reported contributing factor

of medication errors and adverse events was

poor communication, which is highlighted when

patients are transferred between hospital and

community settings.

Easton K, Morgan T, Williamson M. Medication safety in the community: A review of the literature. National Prescribing Service. Sydney, June 2009.

Pharmacy News 11th April 2011

Medication history accuracy

GP histories on ED

presentation

• 87% had one or

more discrepancies

in the patients’

regular medications

• 62% had one or

more regular

medication

discrepancies of

moderate–high

significance

Australian Family Physician 2014;43(10):710-3.

Medication history accuracy

• Clinical audit of admissions via ED conducted over a 2-

week period at a small regional hospital (n=48)

75% 1 or more discrepancy in their GP medication

list

50% Almost half of the discrepancies were related to

non-current medications being recorded

J Pharm Pract Res 2013;43:105-8.

19% Potential clinical significance of the

discrepancies was ‘moderate’ or ‘major’

Case example

GP medication list and

NIMC recorded that

the patient was taking

perhexiline 350 mg

mane.

J Pharm Pract Res 2013;43:105-8.

Medication history accuracy

• Compared medication history by medical staff to

pharmacist in metro hospital, n=100, av 11.5 meds/pt

83.9% Discrepancies for 966 medications

48.9% Complete omissions of medications

Pharmacy Practice 2007;5(2):78-84.

29% Cardiovascular disorders

Transition from hospital to

residential care

• Observational study following discharge from

metropolitan hospital (n=202)

18.3% Missed or significantly delayed doses in the 24

hours after discharge

61.9% Did not have their medication chart

written/updated

38.1% Did not have suitably packed medications

available for the first dose

Elliott R, et al. Australasian Journal on Ageing 2012;31(4):247–254.

Elliott R, et al. Australasian Journal on Ageing 2012;31(4):247–254.

Transition from hospital to

residential care

• Audit at metropolitan public hospital, n=114; mean age

83 years; median number of medications 10.5

36% Medications not

delivered to RACF

66%

No up-to-date

medication chart at

RACF in time for 1st

scheduled dose

40% Locum doctors called to

write medication chart

18% Medication doses missed

or delayed significantly

3.5 Average medications per

patient

60% Missed/delayed doses

moderate/high risk of ADE

J Pharm Pract Res 2012;42:246-7.

SOLUTIONS

ENABLERS

1. Organisational commitment to

patient engagement

2. Organisational culture and norms

3. Individual health care provider’s

orientation and actions

4. Understanding and negotiating

patient preferences

5. Enacting information sharing and

communication strategies

Australian Pharmaceutical Advisory Council. Guiding principles to achieve

continuity in medication management. Canberra: The Council; 2005.

• Patients with heart failure are prone to medication misadventure due to

polypharmacy, inappropriate medication use and frequent readmissions

• Liaison Pharmacist contacts GP, sends medication discharge summary,

organises appointment with GP approximately 2 days post-discharge to make

a Home Medicines Review (HMR) referral

• HMRs conducted average of 32 ± 22.61 days post-discharge (mean 25.5 days)

• For an optimal benefit, medication reviews should be conducted 7–10 days

after discharge, when the risk of medication misadventure is the largest

J Pharm Pract Res 2009; 39: 269-73.

• Hospital-initiated medication reviews (HIMR) - hospital

liaison pharmacist to participating accredited

pharmacists post-discharge from hospital

• HIMRs were conducted within 11.6 ± 6.6 days post-

discharge

• HIMRs can be facilitated in a more timely manner than

post-discharge HMRs

• Implementation study was conducted over 9 months at 3

hospitals in South Australia for ‘high-risk patients’

• HIMRs and HMRs took 6.5 ± 4.7 days and 11 ± 7.4 days,

respectively (p = 0.02)

J Pharm Pract Res 2011; 41: 27-32.

• 23 semi-structured interviews with key stakeholders -

hospital doctors, GPs, accredited pharmacists, hospital

& community pharmacists

• Consensus among medical and pharmacy stakeholders

was that streamlined and flexible pathways to post-

discharge medication reviews would enhance quality use

of medicines along the continuum of care

J Pharm Pract Res 2012; 42: 273-7.

• HMR conducted after discharge from cardiology unit

• 398 drug related problems were identified for 71 (93.3%)

patients with mean 5.6 problems (range 1–21)

Discharge

summaries

GP

referrals

HMR reports

Mean no. of drugs 8.7 8.9 10.8

Mean no. of diseases 4.1 4.7

• Retrospective cohort study using DVA claims data

• 45% reduction (hazard ratio, 0.55; 95% CI, 0.39 to 0.77)

in rate of hospitalization for heart failure among those

who had received a home medicines review compared

with the unexposed patients

Circ Heart Fail. 2009;2:424-428.

• Improved initiation of warfarin therapy

– Day 8, INR in therapeutic range 67% vs 42%

– Day 8, supra-therapeutic INR 4% vs 26%

• Significant decrease in haemorrhagic

complications (15% vs 36%) in the first 3 months

of therapy