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The Impact of Delayed Medication Reconciliation for Patients Admitted to the General Internal Medicine Service at St. Joseph’s Healthcare Hamilton - A Retrospective Study

Holly Pileggi PharmD, RPh

Submitted to the Pharmacy Residency Advisory Committee in fulfillment of the requirements for the Certificate of the Ontario Hospital Residency Program

St. Joseph’s Healthcare Hamilton

September 30, 2016

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Acknowledgements I would like to acknowledge the following individuals for their assistance in the completion

of this study as well as the written report:

Dr. Anne Holbrook, Director, Division of Clinical Pharmacology and Toxicology, McMaster University and St. Joseph’s Healthcare Hamilton

Dr. Swetha Sriram Christine Wallace, RPh Tuan Dinh, MSc, RPh Cathy Burger, RPh

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Table of Contents

Abstract ..................................................................................................................................................................... 5

Background ............................................................................................................................................................. 6

Medication Reconciliation ............................................................................................................................ 6

Medication Reconciliation Process ............................................................................................................ 6

Discrepancies Found via Medication Reconciliation and Clinical Importance ........................ 7

Medication Reconciliation at St. Joseph’s Healthcare Hamilton .................................................... 7

Objectives/Outcomes .......................................................................................................................................... 9

Study Population ................................................................................................................................................ 10

Sample Size ........................................................................................................................................................... 10

Methods ................................................................................................................................................................. 10

Medication Discrepancies and Clinical Importance ......................................................................... 11

Results .................................................................................................................................................................... 13

Medication Reconciliations Completed According to the SJHH Policy ..................................... 14

Relationship of Time and Medication Discrepancies ...................................................................... 14

Relationship of Time and Clinically Important Medication Discrepancies ............................. 17

Medication Discrepancies .......................................................................................................................... 20

Medication Discrepancies and Health Links Patients ..................................................................... 20

Discussion ............................................................................................................................................................. 21

Timing of Medication Reconciliation ..................................................................................................... 21

Factors Predictive of the Number of Discrepancies ........................................................................ 22

Frequency of Medication Discrepancies .............................................................................................. 23

Clinically Important Medication Discrepancies ................................................................................ 23

Differences Between Reviewers .............................................................................................................. 23

Medication Discrepancies and Health Links Patients ..................................................................... 24

Study Strengths and Limitations ............................................................................................................. 24

Conclusion............................................................................................................................................................. 25

References ............................................................................................................................................................ 26

Appendix A: Algorithm and Definitions for Determining Clinical Importance of Medication Discrepancies ....................................................................................................................................................... 28

Appendix B: List of Medications Proven to Cause Adverse Drug Events ..................................... 30

Appendix C: List of Medications Known to Cause Hospitalization or Presentation to an Emergency Department .................................................................................................................................. 31

Appendix D: ISMP List of High Alert Medications in Community/Ambulatory Care .............. 32

Appendix F: Data Collection Sheet .............................................................................................................. 40

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Appendix G: SJHH Medication Reconciliation Form ............................................................................. 42

Appendix H: Clinically Important Medication Discrepancies ........................................................... 43

Appendix I: Disagreements Between Reviewer 1 and Reviewer 2 ................................................ 46

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Abstract Background Medication reconciliation is an accreditation standard that identifies discrepancies between a patient’s home and admission medications. Completing medication reconciliation within 48 hours of admission is a policy at St. Joseph Healthcare Hamilton (SJHH). Prioritization is given to General Internal Medicine (GIM) patients over age 65 and the target completion rate is 100%. The aim of this study was to assess GIM medication reconciliation performance at SJHH and to evaluate the impact of delaying medication reconciliation. Objectives To determine the number of medication reconciliations completed within 48 hours of admission for General Internal Medicine (GIM) patients over the age of 65 at a large academic teaching hospital in Ontario. Secondary objectives included an assessment of the number of medication discrepancies and determination of the clinical importance. Methods Eligible patients included those admitted to the GIM service at SJHH over the age of 65. Charts were reviewed for a medication reconciliation form and the time from admission to completion of the form was documented. The medication discrepancies were recorded, and two independent reviewers assessed their clinical importance using the National Coordinating Council for Medication Error Reporting and Prevention algorithm. Results 153 eligible patients admitted from January-April 2016 were included. 93 (61%) had medication reconciliation completed, with 36 (37%) completed within 48 hours of admission. The timing of medication reconciliation did not affect the number of medication discrepancies identified (IRR=1.18, p=0.49) or clinically important medication discrepancies identified (IRR=1.48, p=0.29). However, the number of medications per patient significantly affected both outcomes respectively (IRR=1.10 p<0.001, IRR=1.11 p=0.001). Conclusion The current medication reconciliation program at SJHH is only reaching 61% of a priority group of GIM seniors, with only 37% reached within 48 hours of admission. Timing was not associated with the number of discrepancies found. To achieve 100% completion of medication reconciliation, a new process and additional resources would be required.

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Background Medication Reconciliation Medication reconciliation is a formalized process by which healthcare professionals obtain an accurate medication history throughout transitions of patient care.1-4 Medication reconciliation requires a systematic and comprehensive review of all medications a patient is taking, known as a best possible medication history (BPMH), to ensure that the medications being added, changed or discontinued during transitions of care are appropriate.4 Medication Reconciliation Process

Admission to hospital is an example of transition of care where medication reconciliation is completed.1,3,4 At the point of admission, medication reconciliation can be conducted proactively or retroactively.3,4 In the retroactive model, a primary medication history is taken by a healthcare professional and from that the admission orders are written (Figure 1). 3,4 After the admission orders are written, the BPMH is collected by another healthcare professional after which a final healthcare professional, often a pharmacist, compares the admission orders to the patient’s BPMH and discrepancies are documented and resolved. 3,4

The process of medication reconciliation has been consistently found to reduce the incidence of clinically important medication discrepancies, differences between a patient’s admission and home medications.5-11 Based on the fact that medication reconciliation reduces medication discrepancies, in 2005 Accreditation Canada made medication reconciliation one of the Required Organization Practices (ROP).1,12 In addition, the World Health Organization recognizes medication reconciliation as one of five key areas of patient safety.13

Figure 1 illustrates the retroactive process of medication reconciliation3

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Discrepancies Found via Medication Reconciliation and Clinical Importance Medication discrepancies between a patient’s home and admission medications can be classified as clinically important or not.5-9 The clinical importance of a medication discrepancy is based on the likelihood of the discrepancy to cause harm. Tools such as the adverse event reporting algorithm developed by the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) [Appendix A] and lists of high risk medications [Appendix B, C, D] can help determine clinical importance.14-17 Other considerations for clinical importance may include the prescription versus non-prescription status of a medication, as well as a patient’s admitting diagnosis.5-9 A recent Canadian systematic review found that 19-75% of patients admitted to hospital had at least one unintentional medication discrepancy found via medication reconciliation and 11-59% of the discrepancies were clinically important.18 Of interest, current literature does not suggest that there is a reduction in patient harm as a result of medication reconciliation despite the fact that there is clearly a reduction in clinically important medication discrepancies because of medication reconcilation.19 This illustrates that medication discrepancies are a surrogate measure of patient harm; however, they are still the most common measure for medication reconciliation benefit in the literature.5-11 Medication Reconciliation at St. Joseph’s Healthcare Hamilton At St. Joseph’s Healthcare Hamilton (SJHH) the medication reconciliation process follows the retroactive model. An SJHH policy implemented in February 2015 states that any healthcare professional that has successfully completed the SJHH BPMH training course may conduct the BPMH interview with the most responsible pharmacist subsequently reconciling the admission orders to the BPMH [Appendix E].4 Within SJHH there are medication reconciliation technicians who are BPMH trained and prioritize patients for whom a BPMH will be completed. Currently prioritization is based on two factors: age over 65 as they have a Ontario Drug Benefit Profile and an admission to the General Internal Medicine (GIM) service.20 The current target completion rate for this prioritized population at SJHH is 100%. Although not practice at this time, another strategy of prioritization could involve the Ontario-based Health Links program, which identifies the 5% of patients who consume 20% of healthcare resources.21 Once prioritized, the medication reconciliation technicians complete the BPMH in an electronic BPMH application (eBPMH). Finally, the pharmacist completes the process by reconciling the BPMH to the admission orders and documenting the medication discrepancies found. Accreditation Canada and the Institute of Safe Medication Practices (ISMP) recommend that medication reconciliation is conducted in a timely manner after patient admission.3,12 At SJHH the medication reconciliation policy states that the BPMH, identification and communication of discrepancies to the prescriber shall be completed no later than 24-48 hours following admission.4

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While the SJHH policy is to have medication reconciliation completed within 48 hours of admission, this timeliness of medication reconciliation is not always possible. This may result in a higher potential for adverse events as clinically important medication discrepancies may go unnoticed for a significant duration of the patient’s admission. Therefore, the aim of this study was to assess the proportion of medication reconciliations completed within 48 hours of admission for GIM patients at SJHH and to assess the clinical importance of delaying medication reconciliation to more than 48 hours after admission.

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Objectives/Outcomes Primary Objective

1. To determine the number of medication reconciliations completed according to the SJHH policy for GIM patients

Primary Outcome

1. Proportion of medication reconciliations completed within 48 hours of admission for GIM patients over 65 at SJHH

Secondary Objectives

1. To determine if the time to medication reconciliation affects the number of medication discrepancies

2. To determine the clinical importance of delaying medication reconciliation to greater than 48 hours after admission

3. To determine if Health Links patients experience more clinically important medication discrepancies than non-Health Links patients

Secondary Outcomes 1. Difference in the mean number of medication discrepancies for patients admitted to

GIM service who receive medication reconciliation within 48 hours of admission as compared to those who receive medication reconciliation greater than 48 hours after admission

2. Mean number of clinically important medication discrepancies identified via medication reconciliation when completed greater than 48 hours after admission as compared to when medication reconciliation is completed within 48 hours of admission

3. Mean number of clinically important medication discrepancies identified via medication reconciliation for Health Links compared to non-Health Links patients

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Study Population Inclusion Criteria

Patients admitted to the GIM service at SJHH Patients 65 years old or over and have an Ontario Drug Benefit (ODB) profile Patients with length of stay over 48 hours First chronological GIM admission between January 1 and April 1, 2016

Exclusion Criteria Patients 65 years old or over admitted to the GIM service admitted at SJHH from a

nursing home or long term care home Patients under the age of 65 Patients with a length of stay less than 48 hours Patients 65 years of age and older admitted to a non-GIM service within SJHH Subsequent admissions to GIM service following the first chronological admission

between January 1 and April 1, 2016 Sample Size In order to power for the secondary outcome, the difference in mean number of medication discrepancies between the groups, a sample size was calculated from aggregate data documented by GIM pharmacists from December 7th to December 11th 2015. The GIM pharmacists completed 11 medication reconciliations, and identified 25 medication discrepancies. The mean medication discrepancy rate was calculated as 2.27 with a standard deviation of 1.42. Using this result in a two-tailed t-test (α=0.05 β=0.2) and assuming a 50% difference in medication discrepancies between the groups with one covariate (number of medications), a minimum enrollment of 36 patients in each group was necessary to obtain sufficient power. Methods The retrospective study design was reviewed and accepted by the Hamilton Integrated Research and Ethics Board and is outlined in Figure 2. The Health Records department at SJHH electronically generated a list of patients admitted to the GIM service at SJHH from January 1 - April 1, 2016 in chronological order. The list was used to determine which patient charts to screen for inclusion. Patients meeting the inclusion criteria were assigned a study number to maintain patient confidentiality throughout the study. Patient age, serum creatinine on admission and admitting diagnosis were recorded on the data collection sheet [Appendix F]. In addition to the demographic data, the time of admission was recorded. The time of admission was defined as the time of presentation to the emergency room or the time of direct admission to the GIM service as documented on Provider Portal, a patient information viewer used by hospital clinicians to review clinical information. The electronic chart was searched via the Patient Document Manager, an electronic chart viewer within Provider Portal, for a medication reconciliation form [Appendix G]. The

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medication reconciliation form is a standardized form at SJHH that is intended to be completed for each medication reconciliation as per the SJHH policy.4 If a medication reconciliation form was found, the time the medication reconciliation was last edited in the eBPMH application was recorded as the time of completion. The difference in the time of admission compared to the time of medication reconciliation completion was calculated in hours to determine which study group the patient would be assigned to. If no medication reconciliation form was found it was recorded that no medication reconciliation was completed. Then the proportion of completed medication reconciliations for GIM patients over age 65 was calculated by dividing the number of medication reconciliations by the number of patients included. Medication Discrepancies and Clinical Importance Medication discrepancies from the medication reconciliation form were extracted from the medication reconciliation form where the pharmacist recorded them at the time of medication reconciliation completion. In addition, the number and generic name of all prescription and non-prescription medications were recorded. The mean number of medication discrepancies per patient for the medication reconciliation timing groups was calculated by dividing the total number of medication discrepancies for the timing group by the number of patients in said group. The Principal Investigator (PI) classified the medication discrepancies as clinically important or not based on the NCC MERP algorithm categories outlined below [Appendix A]10,11,14

Table 1: Determining Clinical Importance of Medication Discrepancies

Category NCC MERP Classification Study Classification A-C No potential harm Non-clinically important

medication discrepancy D Potential monitoring or intervention

needed to preclude harm Clinically important medication discrepancy

E-I Potential harm

A second healthcare professional, a medical resident, independently categorized the medication discrepancies, blinded to the categorization of the PI. The categorization completed by each of the two healthcare professionals was compared and disagreements were noted. When a disagreement in categorization occurred, a discussion between the two healthcare professionals took place until an agreement was met on the categorization of the discrepancies.

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No Patient over the age of 65 admitted to General Internal Medicine

Length of stay < 48 hours or admitted from nursing home/ long term care home Exclude

Record time and date of admission, date of birth, gender, age, serum creatinine, admitting diagnosis

and if the patient is Health Links

Yes

Exclude

Yes

No

Figure 2 illustrates the retrospective study design

Yes

Record: Time of medication reconciliation Number and generic name of prescription and non-

prescription medications Description of all medication discrepancies found via

medication reconciliation Clinical importance of all medication discrepancies

Record that medication

reconciliation was not completed

Medication reconciliation <48 hours of admission

Medication reconciliation ≥48 hours of admission

No medication reconciliation

completed

No

Yes

No

Yes

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Results A total of 733 patients were admitted to GIM between January 1 and April 1, 2016. After screening the charts for length of stay data and a medication reconciliation form, 153 patients were included in the study. A total of 93 patients (61%) had a medication reconciliation completed while 57 (37%) had it completed within 48 hours of admission. Thirty-six patients (24%) had their medication reconciliation completed more than 48 hours after admission and 60 patients did not have a medication reconciliation completed. The characteristics of the included patients were similar between the two groups as outlined in Table 2.

Table 2: Patient Characteristics

Characteristic Medication Reconciliation <48 Hours From Admission

Medication Reconciliation ≥48 Hours From Admission

No Medication Reconciliation

Patients (n, %) 57 (37) 36 (24) 60 (39)

Male (n, %) 26 (45.6) 16 (44.4) 29 (48.3) Female (n, %) 31 (54.4) 20 (55.6) 31 (51.7)

Age (mean, SD) 79.11 (8.85) 78.31 (7.24) 79.1 (9.18) Health Links (n, %) 1 (0.6) 2 (1.3) 3 (2.0)

Weekend Admission (n, %) 14 (24.6) 12 (33.3) 25 (42.7) Serum Creatinine on Admission (mean, SD)

119.37 (73.31) 161.64 (113.77) 143.48 (123.42)

Admitting Diagnosis (n, %) CHF Exacerbation COPD Exacerbation NSTEMI Pneumonia Renal Failure Sepsis Stroke

8 (14.0) 6 (10.5) 2 (3.5) 8 (14.0) 9 (15.8) 1 (1.8) 0 (0)

6 (16.7) 3 (8.3) 0 (0) 4 (11.1) 0 (0) 5 (13.9) 4 (11.1)

9 (15.0) 2 (3.3) 1 (1.7) 6 (10.0) 3 (5.0) 5 (8.3) 1 (1.7)

Number of Prescription Medications (mean, SD)

8.04 (4.08) 7.94 (3.83)

Number of Non-prescription Medications (mean, SD)

2.75 (1.56) 3.00 (2.34)

The prescription and non-prescription medications the patients included in the study were on were recorded as they could directly affect the clinical importance of the medication discrepancies. Between the two timing groups the number of prescription medications for each medication class was relatively similar (Table 3). The number of patients on specific non-prescription medications was also similar between the two groups (Table 4).

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Table 3: Prescription Medications by Medication Class

Medication Class

Medication Reconciliation <48 Hours From Admission (n, %)

Medication Reconciliation ≥48 Hours From Admission (n, %)

Antiarythmics 12 (2.6) 9 (3.2)

Anticoagulants 12 (2.6) 9 (3.2)

Antidepressants 17 (3.7) 16 (5.8) Antieleptics 2 (0.4) 1 (0.4)

Antihyperglycemics 28 (6.1) 11 (4.0) Antihypertensives 45 (9.8) 28 (10.1)

Anti-infectives 5 (1.1) 1 (0.4) Antineoplastics 9 (2.0) 4 (1.4)

Digoxin 0 (0) 1 (0.4)

Diuretics 29 (6.3) 17 (6.1) Glucocorticoids 8 (1.7) 4 (1.4)

Opioids 14 (3.1) 9 (3.2) Sedatives 12 (2.6) 11 (4.0)

Table 4: Non-Prescription Medications

Medication Class

Medication Reconciliation <48 Hours From Admission (n, %)

Medication Reconciliation ≥48 Hours From Admission (n, %)

Aspirin 24 (15.2) 15 (13.9)

Acetaminophen 20 (12.7) 10 (9.3)

Laxatives 10 (6.4) 10 (9.3) NSAIDs 3 (1.9) 3 (2.8)

Vitamin B12 14 (8.9) 4 (3.7) Vitamin D 25 (15.9) 16 (14.8)

Medication Reconciliations Completed According to the SJHH Policy There were 153 patients included in the study and 93 medication reconciliations completed; therefore, the proportion of completed medication reconciliations was 61%. Of the 93 medication reconciliations completed, 57 were completed within 48 hours of admission and so the proportion of medication reconciliations completed according to the SJHH policy was 37%. The average time to medication reconciliation was 53.02 hours (SD=58.07). Relationship of Time and Medication Discrepancies As reported, 93 medication reconciliations were completed during the study period, which resulted in the identification of a total of 176 discrepancies: 101 in the group with medication reconciliation within 48 hours of admission and 75 in those with delayed medication reconciliation (Figure 3).

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The mean number of medication discrepancies for the medication reconciliations completed within 48 hours of admission was 1.77 (SD=1.89) and the mean number of medication discrepancies for medication reconciliations completed outside of 48 hours of admission was 2.08 (SD=2.36) (Figure 4). Although the mean number of medication discrepancies was higher for the group with medication reconciliation completed outside of 48 hours of admission, the difference in the mean number of discrepancies for the two groups was not statistically significant when analyzed using a univariate linear regression model (p=0.49) (Table 5).

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Frequency of Medication Discrepancies

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Figure 3 illustrates the number of medication discrepancies patients in each medication reconciliation timing group

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Other characteristics were analyzed in the univariate linear regression model to determine their effect on the number of medication discrepancies. Table 5 captures characteristics that were evaluated as predictors of number of medication discrepancies. The results show that the only characteristic that significantly predicted the number of medication discrepancies was the number of medications including the number of prescription and non-prescription medications. Age, gender and being admitted on a weekday as compared to a weekend did not significantly affect the number of medication discrepancies.

Table 5: Characteristics Predicting the Number of Medication Discrepancies

Characteristic Incident Rate Ratio (95% CI) P-Value

Med Rec ≥ 48h 1.18 (0.75 – 1.86) 0.49

Gender 1.31 (0.83 - 2.06) 0.25 Age 1.01 (0.98 - 1.04) 0.60

Weekday Admission 0.70 (0.44 - 1.11) 0.13 Total Number of Medications 1.10 (1.07 - 1.13) <0.001

Prescription Medications 1.10 (1.05 - 1.16) <0.001 Non-Prescription Medications 1.24 (1.13 - 1.36) <0.001

1.77

2.08

1.6

1.65

1.7

1.75

1.8

1.85

1.9

1.95

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2.05

2.1

2.15

Med Rec <48h Med Rec ≥ 48h

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Relationship of Time to Medication Reconciliation and Discrepancies

All MedicationDiscrepancies

Figure 4 illustrates a comparison of the mean number of medication discrepancies between the two patient cohorts – i.e. those who had medication reconciliation completed within 48 hours of admission and those for whom medication reconciliation was delayed.

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A multivariate linear regression analysis of the characteristics listed in Table 5 demonstrated that only number of medications and age were independent predictors of the number of medication discrepancies (Table 6). Table 6: Characteristics Independently Predicting the Number of Medication Discrepancies Characteristic Incident Rate Ratio (95% CI) P-Value

Age 1.03 (1.00, 1.06) 0.02 Total Number of Medications 1.12 (1.08, 1.17) <0.001

Relationship of Time and Clinically Important Medication Discrepancies A total of 61 clinically important medication discrepancies were identified; 32 were identified in cases where the medication reconciliation completed outside of 48 hours of admission group, in contrast to 29 when medication reconciliation was completed within 48 hours of admission (Figure 5).

When assessing medication discrepancies for clinical importance, it was found that all of the clinically important medication discrepancies were related to prescription medications, specifically mainly the high-risk medications as outlined in Appendices B, C and D (Table 7). The number of clinically important medication discrepancies

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Number of Clinically Important Medication Discrepancies

Frequency of Clinically Important Medication Discrepancies

Med Rec < 48h

Med Rec ≥ 48h

Figure 5 illustrates the number of clinically important medication discrepancies patients in each medication reconciliation timing group had

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per NCC MERP categorization is illustrated in Figure 6. All of the clinically important medication discrepancies are listed in Appendix H.

Table 7: Clinically Important Medication Discrepancies by Medication Class

Medication Class Number of Clinically Important Medication Discrepancies (n)

Antihypertensives 17

Antihyperglycemics 4

Sedatives 3 Antidepressants/Antipsychotics 3

Antieleptics 3 Anticoagulants 2

Other 29

When classifying the clinical importance of medication discrepancies, there was some disagreement between the two independent investigators that affected whether or not the medication discrepancy would be classified as clinically

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NCC MERP Clinical Importance Category

Clinically Important Discrepancies by NCC MERP Categorization

Pharmacy Resident

Medical Resident

Figure 6 illustrates the number of clinically important medication discrepancies in each NCC MERP categorization. This figured also illustrates some of the classification differences between the pharmacy resident and medical resident. These differences in categorization did not affect whether or not the discrepancy was clinically important as Category D-F are all clinically important based on the algorithm.

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important or not. Of the 176 identified medication discrepancies, there were 18 disagreements (10.2%). These differences were resolved through discussion. All of the disagreements between investigators are listed in Appendix I. In terms of clinically important medication discrepancies per patient, there was a mean of 0.54 (SD=0.98) if medication reconciliation was completed within 48 hours of admission as compared to a mean of 0.81 (SD=1.39) if medication reconciliation took place more than 48 hours from admission (Figure 7). Although higher for the delayed medication reconciliation group, the difference in the means was not found to be statistically significant when analyzed with a univariate linear regression analysis (p=0.29) (Table 8).

Other characteristics were analyzed in the univariate linear regression model to determine their effect on the number of clinically important discrepancies (Table 8). Only total number of medications and the number of prescription medications were significant.

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Relationship of Time to Medication Reconciliation and Clinically Important

Discrepancies

Clinically ImportantMedication Discrepancies

Figure 7 illustrates a comparison of the mean number of clinically important medication discrepancies between the two patient cohorts – i.e. those who had medication reconciliation completed within 48 hours of admission and those for whom medication reconciliation was delayed.

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Table 8: Characteristics Predicting the Number of Clinically Important Medication Discrepancies Characteristic Incident Rate Ratio (95% CI) P-Value

Med Rec ≥ 48h 1.48 (0.72 - 3.06) 0.29 Gender 1.53 (0.74 - 3.14) 0.25

Age 0.99 (0.94 - 1.04) 0.77 Weekday Admission 0.73 (0.36 - 1.51) 0.40

Total Number of Medications 1.11 (1.04 - 1.18) 0.001

Prescription Medications 1.13 (1.04 - 1.22) 0.004 Non-Prescription Medications 1.18 (0.97 - 1.43) 0.098

A multivariate linear regression analysis of the characteristics listed above determined that the only independent predictor of the number of clinically important discrepancies was found to be the total number of medications (Table 9). Table 9: Characteristics Independently Predicting the Number of Clinically Important Medication Discrepancies

Characteristic Incident Rate Ratio (95% CI) P-Value

Total Number of Medications 1.11 (1.04, 1.18) <0.0014 Medication Discrepancies A univariate linear regression analysis was performed to determine if any of the characteristics listed in Table 8 predicted whether or not an individual would be more likely to have a medication discrepancy or clinically important medication discrepancy and none of the characteristics were found to be significant predictors. Medication Discrepancies and Health Links Patients Of the 153 patients included in the study, six were identified as Health Links patients. Only three of the six Health Links patients had medication reconciliation completed. The medication discrepancies for Health Links patients are described in Table 10.

Table 10: Health Links Patients Medication Discrepancies

Characteristic Medication Reconciliation <48 Hours of Admission

Medication Reconciliation ≥48 Hours of Admission

Patients 1 2

Number of Medication Discrepancies

1 9

Number of Clinically Important Medication Discrepancies

0 6

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The mean number of clinically important medication discrepancies was 3.00 (SD=4.25) for Health Links patients as compared to 1.02 (SD=1.31) for non-Health Links patients. Discussion This retrospective study examined the number of medication reconciliations completed according to the SJHH hospital policy, which states that medication reconciliation is to be completed within 48 hours of admission to hospital. More specifically this study aimed to assess the number of medication reconciliations completed for a prioritized patient population at SJHH – those over 65 and admitted to the GIM service. Timing of Medication Reconciliation The data identified that only 37% of medication reconciliations are being completed according to the SJHH policy for the above-mentioned priority patient population and that the timing of medication reconciliation did not significantly affect the number of medication discrepancies or the number of clinically important medication discrepancies. Despite there being no statistically significant difference in the number of clinically important medication discrepancies based on the timing of medication reconciliation, the data found that medication reconciliation is identifying clinically important medication discrepancies (61 found in 93 medication reconciliations). Therefore, while current resources dedicated to medication reconciliation for GIM patients are focused on timeliness (i.e. within 48 hours of admission), consideration should be focused on the completion of more medication reconciliations in order to capture more of the clinically important medication discrepancies. In order to increase the number of medication reconciliations completed at SJHH, a new medication reconciliation process would be required. Rather than the current retrospective model (as previously described), a proactive model of medication reconciliation would likely improve the time to completion, the volume of completed medication reconciliations and the number of discrepancies identified via the medication reconciliation process (Figure 8). In this proactive model, the admission medication orders would be written from the BPMH as opposed to the BPMH being obtained after the admission orders.

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Figure 8 illustrates the proactive process for completing medication reconciliation

Implementing the proactive model of medication reconciliation would likely require more resources in order to complete BPMHs before admission orders are written. An example of addition personnel to help complete BPMHs in a timely manner would be a healthcare professional stationed in the emergency room to collect the BPMHs before patients are even admitted. In addition, more personnel in pre-admission clinics would help capture BPMHs for patients who will be admitted to hospital. Essentially the proactive model requires personnel to complete BPMHs at all points of care where patients can be admitted to hospital. Looking into the future, SJHH will be implementing a new electronic computer system by 2018. Implementing the new electronic system could be an excellent opportunity to digitalize the medication reconciliation process and have the eBPMH completed and available online before the prescriber even meets the patient. Factors Predictive of the Number of Discrepancies This study identified that the number of medication discrepancies was significantly predicted by the total number of medications (including prescription and non-prescription) rather than the timing of medication reconciliation. It is expected that the more medication a patient is on, the more likely it is that a discrepancy can occur.22 Furthermore, age and total number of medications were found to independently predict the number of medication discrepancies - as an individual’s age increases, the trend is for the number of medications to increase as well.23 Since this study also found that the number of medications is predictive of the number of medication discrepancies, it is not surprising that age was a predictive factor of the number of medication discrepancies. The total number of medications and the number of prescription medications were both found to be predictive of the number of clinically important medication discrepancies. Non-prescription medications were not found to be predictive of

Safer Healthcare Now! Medication Reconciliation in Acute Care Getting Started Kit

September 2011 16

STEP 2: Reconciling the Medication &

STEP 3: Documenting and Communicating

Medication Reconciliation at Admission

The BPMH is the cornerstone to medication reconciliation. This next section will describe in detail the various models used to complete the reconciliation process at admission.

The goal of reconciliation on admission is to ensure there is clear communication about decisions the prescriber makes to continue, discontinue, or modify the medication regimen upon admission that the patient has been taking prior to admission. The overarching process at admission appears in the figure to the right. There are however, differing processes or models that have been developed to complete the admission reconciliation process.

Reconciliation Models

Admission medication reconciliation processes generally fit into two models: proactive process and retroactive process. The proactive process occurs when the BPMH is created first and is used to write admission medication orders (as shown graphically below).

Proactive Medication Reconciliation Process

1. Create the BPMH using a systematic process of interviewing the patient, family/caregiver and a review of at least one other reliable source of information;

2. Create admission medication orders (AMOs) by assessing each medication on the BPMH;

3. Compare the BPMH against the AMOs ensuring all medications have been assessed; identifying and resolving all discrepancies with the most responsible prescriber.

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discrepancies. In addition, total number of medications was found to be independently predictive of the number of clinically important medication discrepancies. Frequency of Medication Discrepancies This study identified that there was no pattern when assessing frequency of medication discrepancies by timing of medication reconciliation (Figure 4 and 5 respectively). Although, there was no pattern when assessing the timing of medication reconciliation, Figure 4 and 5 highlight that medication reconciliation found many medication and clinically important medication discrepancies. Identifying these medication discrepancies would reduce the potential for patient harm, thereby highlighting the importance of completing medication reconciliation. Since clinically important medication discrepancies are really a surrogate for patient harm, future studies should determine if clinically important medication discrepancies actually result in the clinically significant outcome of patient harm. Clinically Important Medication Discrepancies Most of the prescription medications leading to clinically important medication discrepancies as identified in this study were high risk medications as cited in Appendix B, C and D, specifically antihypertensives (28%), antihyperglycemics (7%), antidepressants/antipsychotics (5%) and sedatives (5%). Clinical importance is relevant to medication discrepancies. For example, an error in the dosing of an antihypertensive medication may potentially have negative outcomes; hypotension as a result of an excessive dose, may lead to falls, while under dosing or omission could potentially lead to acute hypertensive episodes. Currently at SJHH only 61% of medication reconciliations are completed within any time frame; a focus on completing more medication reconciliations provides an opportunity to resolve or even avoid more medication discrepancies. Differences Between Reviewers Two reviewers identified clinically important medication discrepancies. The disagreement between the Principal Investigator and the medical resident was specific to discrepancies regarding proton pump inhibitors or H2 receptor blockers. The Principal Investigator often rated these discrepancies as needing monitoring and the medical resident did not agree that monitoring was required. In general the medical resident rated most discrepancies as less likely to cause harm than the Principal Investigator. The differences may be due to the differences in training as pharmacists have knowledge of the many side effects of medications, which could cause a pharmacist to believe medication discrepancies are more likely to cause harm. In addition, physicians have more first hand experience with patients who have had medication discrepancies and from their experience may have found that the discrepancies rarely resulted in patient harm.

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Medication Discrepancies and Health Links Patients If the proactive process of medication reconciliation is not possible at SJHH, the prioritization of patients for medication reconciliation should be assessed, with consideration of Health Links patients as a priority group. In this study there were only six Health Links patients and no conclusions could be derived. Despite the low number of Health Links patients, they were found to have more clinically important medication discrepancies on average than non-Health Links patients and further study should be conducted to determine if Health Links patients have significantly more clinically important medication discrepancies than non-Health Links patients. Health links patients are currently flagged through a Local Health Integration Network (LHIN) based computer system; this system could be utilized to identify these patients for future studies to help in determining which patients should be prioritized for medication reconciliation. Study Strengths and Limitations This study was powered to detect a statistical difference between the difference in the mean number of discrepancies between the medication reconciliation timing groups. In addition, many characteristics such as timing, age, gender, weekday versus weekend admission and number of medications were analyzed to determine if they affected the number of medication discrepancies and number of clinically important medication discrepancies. However, several study limitations were introduced specifically by the medication reconciliation form currently used by Pharmacists. Specifically, unintentional and intentional medication discrepancies were not differentiated, as the standardized medication reconciliation form at SJHH does not provide information to discern the nature of the discrepancies. The medication reconciliation form also does not provide a standardized way to document the medication discrepancies and this was another limitation as pharmacists use the form differently, which could have affected the number of discrepancies. Additionally, using the time of completion of medication reconciliation as the time the medication reconciliation was last edited in the eBPMH application was a limitation as it is surrogate measure. The pharmacist could have completed the medication reconciliation before it was formally documented in the eBPMH application. This study also did not investigate the time to resolution of the medication discrepancies or if the medication discrepancies resulted in clinically relevant patient harm. As mentioned previously, measuring medication discrepancies is a surrogate for potential patient harm. Future prospective studies should be conducted so that the discrepancies can be followed through to resolution while using outcomes such as clinical harm as opposed to the surrogate measure of medication discrepancies. This study was limited to a specific patient population (GIM patients over the age of 65) at one hospital with a specific medication reconciliation program, which may reduce the study’s generalizability to other institutions.

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Finally, this study was limited in its ability to draw conclusions regarding Health Links patients due to the small number of patients included in the analysis. There were only six Health Links patients included in the study with only three of those individuals having had their medication reconciliation completed. With these results, it is not possible to determine the significance of the difference between mean number of clinically important medication discrepancies for Health Links patients compared to non-Health Links patients. Since Health Links patients are only 5% of the population, a future study would have to enroll more individuals than this study to ensure that there are enough Health Links patients to draw conclusions. Conclusion Currently at SJHH only 61% of a priority group of GIM seniors have a medication reconciliation completed with only 37% completed within 48 hours of admission. However, the timing of medication reconciliation was not found to significantly affect the number of medication discrepancies. To achieve 100% completion of medication reconciliation, a new process and additional resources would be required.

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References

1. Accreditation Canada, the Canadian Institute for Health Information, the Canadian Patient Safety Institute, and the Institute for Safe Medication Practices Canada. (2012). Medication Reconciliation in Canada: Raising The Bar – Progress to date and the course ahead. Ottawa, ON: Accreditation Canada.

2. WHO Collaborating Centre for Patient Safety Solutions. Assuring Medication Accuracy at Transitions in Care. Geneva: WHO, 2007.

3. Safer Healthcare Now! Medication Reconciliation in Acute Care: Getting Started Kit. 2011. Available at: https://www.ismp-canada.org/download/MedRec/Medrec_AC_English_GSK_V3.pdf. Accessed November 28, 2015.

4. St. Joseph’s Healthcare Hamilton Corporate Manual. Medication Reconciliation. 2015. Available at: mystjoes/policies/Policies/141-MED.pdf. Accessed November 28, 2015.

5. Cornish PL, Knowles SR, Marchesano R, et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005 Feb 28;165(4):424–9.

6. Coffey M, Mack L, Streitenberger K, et al. Prevalence and clinical significance of medication discrepancies at pediatric hospital admission. Acad Pediatr. 2009 Sep-Oct;9(5):360–5 e1

7. Kripalani S, Roumie CL, Dalal AK, et al. Effect of a Pharmacist Intervention on Clinically Important Medication Errors After Hospital Discharge: A Randomized Trial. Ann Intern Med. 2012 Jul 3;157(1):1–10.

8. Kwan et al. Pharmacist medication assessments in a surgical preadmission clinic. Arch Intern Med. 2007;167:1034-40

9. Tam VC et al. Frequency type and clinical importance of medication history errors at admission to hospital: a systematic review. Can Med Assoc J. 2005;173(5):511-15

10. Gleason KM, Groszek JM, Sullivan C, et al. Reconciliation of discrepancies in medication histories and admission orders of newly hospitalized patients. Am J Health Syst Pharm. 2004 Aug 15;61(16):1689–95.

11. Gleason KM, McDaniel MR, Feinglass J, et al. 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 May;25(5):441–7.

12. Accreditation Canada. Required Organizational Practices Handbook. 2014. Available at: https://accreditation.ca/sites/default/files/rop-handbook-2014-en.pdf. Accessed November 28, 2015.

13. Welcome to the high 5’s project. Available at: www.high5s.org/bin/view/Main/WebHome. Accessed January 24, 2016.

14. National Coordinating Council on Medication Error Reporting and Prevention. Available at: http://www.nccmerp.org/types-medication-errors. Accessed December 1, 2015.

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15. Bayoumi I, Dolovich L, Hutchison B and Holbrook A. Medication-related emergency department vists and hoispitalizations amoug older adults. Can Fam Physician. 2014;60: 217-222.

16. Budnitz DS, Lovegrove MC, Shehab N, Richards CL. Emergency Hospitalizations for Adverse Drug Events in Older Americans. N Engl J Med. 2011;365(21):2002-2012.

17. ISMP. List of High-Alert Medications in Acute Care Settings. Available at: https://www.ismp.org/communityRx/tools/ambulatoryhighalert.asp. Accessed February 10, 2016.

18. Mueller SK, Sponsler K, Kripalani S and Schnipper JL. Hospital based medication reconciliation practices: a systematic review. 2012;174(14):1057-1069.

19. Christensen M and Lundh A. Medication review in hospitalized patients to reduce morbidity and mortality. Cochrane Database Syst Rev. 2013;(2):CD008986.

20. Ministry of Health and Long Term Care. Ontario Drug Benefit (ODB) Program. Available at: http://www.health.gov.on.ca/en/public/programs/drugs/programs/odb/odb.aspx. Accessed December 10, 2015.

21. Ministry of Health and Long Term Care. About Health Links. Available at: http://news.ontario.ca/mohltc/en/2012/12/about-health-links.html?_ga=1.70681427.296029371.1439767350. Accessed December 20, 2015.

22. Karthikeyan M and Lalitha D. A prospective observational study of medication errors in general medicine department in a tertiary care hospital. Drug Metabol Drug Interact. 2013;28(1):13-21

23. Maher RL, Hanlon JT and Haijar ER. Clinical consequences of polypharmacy in the elderly. Expert Opin Drug Saf. 2014;13(1):10.

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Appendix A: Algorithm and Definitions for Determining Clinical Importance of Medication Discrepancies14

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Appendix B: List of Medications Proven to Cause Adverse Drug Events15

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Appendix C: List of Medications Known to Cause Hospitalization or Presentation to an Emergency Department16

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Appendix D: ISMP List of High Alert Medications in Community/Ambulatory Care17

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Appendix E: Medication Reconciliation Policy at St. Joseph’s Healthcare Hamilton4

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Appendix F: Data Collection Sheet Patient Number

DOB Gender

Admitting Diagnosis SCr on Admission

Health Links Patient (Yes/No)

Admission Date and Time

Time of Med Rec

Time to Med Rec from Admission (Hours)

Number of Non-Prescription Medications

Number of Prescription Medications

Home Medications (Generic Name)

Number of Clinically Important Medication Discrepancies (Category D-I Below)

Number of Non-Clinically Important Medication Discrepancies (Category A-C Below)

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Medication Discrepancy Description Category (A-I Based on NCC MERP Index) Reviewer 1

Category (A-I Based on NCC MERP Index) Reviewer 2

Number of Discrepancies between Reviewer 1 and Reviewer 2

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Appendix G: SJHH Medication Reconciliation Form4

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Appendix H: Clinically Important Medication Discrepancies

Medication Related to Discrepancy

Medication Reconciliation <48 Hour Medication Reconciliation ≥48 Hour

Antihypertensives Nifedipine ER 20mg daily not ordered

Amlodipine 5mg daily ordered instead of 2.5mg

Amlodipine 5mg daily was ordered on admission but the patient was not on this since October

Amlodipine 10mg daily was not ordered

Amlodipine 5mg daily was ordered instead of 2.5mg daily

Amlodipine 5mg daily ordered instead of 2.5mg daily

Ramipril 10mg daily ordered instead of 5mg daily

Metoprolol ordered as 50mg daily instead of 25mg BID

Metoprolol 100mg daily was ordered instead of 100mg BID

Atenolol 50mg daily ordered instead of 75mg daily

Metoprolol 50mg BID was not ordered, diltiazem was ordered instead

Hydrochlorothiazide 25mg daily was ordered instead of 75mg daily

Indapamide 2.5mg ordered instead of 5mg Amlodipine/atorvastatin 5/20mg not ordered Hydralazine 25mg BID not ordered Metoprolol 50mg daily ordered instead of 50mg

BID Metoprolol 50mg BID not ordered Metoprolol 25mg BID ordered instead of 12.5mg

BID Triamterene/hydrochlorothiazide 50/25mg daily

was not ordered

Hypoglycemics Metformin 1000mg daily ordered instead of 1500mg daily

Gliclizide MR 30mg BID not ordered

Insulin 4units TID was ordered instead of 4units at breakfast and 2 units at lunch and supper

Insulin aspart TID before meals was not ordered a sliding scale was ordered instead

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Metformin 500mg BID was ordered instead of 250mg daily

Metformin 1000mg BID ordered instead of 500mg BID

Sedatives Lorazepam 0.5mg daily not ordered

Zopiclone 7.5mg daily not ordered

Lorazepam 1mg qHS ordered instead of lorazepam 1mg BID PRN

Clonazepam 0.5mg daily ordered instead of 0.25mg BID

Anticoagulants Apixaban 2.5mg BID not ordered Warfarin 5mg daily ordered instead of 1.5mg daily Apixaban 2.5mg BID ordered instead of 5mg BID

Digoxin Digoxin 0.25mg daily not ordered

Antidepressants/Antipsychotics

Citalopram 20mg daily ordered instead of 10mg daily

Amitriptyline 10mg daily not ordered

Venlafaxine 150mg daily ordered instead of 75mg daily

Aripiprazole 4mg daily ordered instead of 2mg BID

Antieleptics

Pregabalin 150mg once daily ordered instead of BID

Gabapentin 300mg BID ordered instead of 300mg qam and 600mg qpm

Pregabalin 150mg once daily ordered instead of BID

Lamotrigine 25mg daily not ordered

NSAIDs Naproxen 500mg BID was ordered but the patient discontinued it months prior because of a GI bleed

Other Levothyroxine 250mcg daily ordered instead of 25mcg daily

Risedronate 35mg weekly was ordered daily instead of weekly

Potassium chloride SR 1800mg daily not ordered

Potassium chloride SR 600mg daily not ordered

Salbutamol 2 puffs 2-3 times a day not ordered

Tiotropium 18mcg daily not

Levodopa-carbidopa 100-25mg five times daily ordered instead of QID

Levodopa-carbidopa CR 100-25mg once daily not ordered

Levothyroxine 75mcg daily was ordered instead of 88mcg daily

Ipratropium 20mcg 2 puffs QID not ordered Salbutamol 4 puffs QID not ordered Baclofen 10mg PRN not ordered Hydrocodone bitartrate 5mL TID not ordered Symbicort 4puffs BID not ordered

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ordered Advair 250/25mcg 2 puffs BID

not ordered Creon 25 not ordered Tamsulosin CR 0.4mg daily not

ordered Dutasteride 0.5mg daily not

ordered Allopurinol 100mg BID not

ordered Advair 250/25 1 puff BID not

ordered Baclofen 10mg QID ordered

instead of TID Percocet ordered 2 tablets QID

instead of PRN

Ipratropium 2 puffs q4h PRN was not ordered Hydromorphone CR 6mg daily ordered instead of

6mg TID Fluticasone 250mg 2 puffs BID not ordered Tiotropium 18mcg daily not ordered Advair 250/25mcg 2 puffs BID not ordered

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Appendix I: Disagreements Between Reviewer 1 and Reviewer 2

Medication Reconciliation Discrepancy Reviewer 1 Rating Reviewer 2 Rating Agreement Rating Lorazepam 1mg qHS ordered instead of lorazepam 1mg BID PRN D C D

Sertraline 100mg not ordered E C C

Pantoprazole 40mg daily was ordered but patient stopped this med after stopping naproxen

D C C

Levothyroxine 75mcg daily was ordered instead of 88mcg daily D C D

Ranitidine 150mg BID not ordered D C C Gliclizide MR 30mg BID not ordered F C C

Pantoprazole 40mg BID not ordered D C C

Metoprolol 50mg daily ordered instead of 50mg BID D C D Omeprazole 20mg daily not ordered D C C

Clonazepam 0.5mg daily ordered instead of 0.25mg BID D C D Metformin 500mg BID was ordered instead of 250mg daily D C D

Metformin 1000mg BID ordered instead of 500mg BID D C D Atenolol 50mg daily ordered instead of 75mg daily D C D

Tamsulosin CR 0.4mg daily not ordered D C D

Citalopram 10mg daily ordered instead of 20mg daily E C C

Dutasteride 0.5mg daily not ordered D C D

Allopurinol 100mg BID not ordered D C D