Authors (including presenting author) :
Li LLY(1)(2), Tsoi HHY(1)(2), Ewig C(2), Chong CH(1), Lo CCH(1), Mak KLK(1)
Affiliation :
(1)Department of Pharmacy, United Christian Hospital, (2)School of Pharmacy, The Chinese University of Hong Kong
Introduction :
Medication errors are not uncommon during transitions of care. Surgical patients are particularly at risk due to transfer of patients in and out of operating theatre, change of medications before and after surgical intervention, and frequent use of high risk medications such as anticoagulants. Clinical pharmacists involvement in medication reconciliation has been shown to improve the effectiveness of identifying and rectifying drug-related problems (DRPs), and to enhance medication safety. For this reason, medication reconciliation has been prioritized as one of five top patient safety strategies, within World Health Organization (WHO) Action on Patient Safety: High 5s Project.
Objectives :
This study aimed at identifying patients at risk for having drug-related problems, to allow clinical pharmacists to direct their efforts more efficiently in medication reconciliation process.
Methodology :
This was an observational study conducted at surgical wards in the United Christian Hospital. In the pre-intervention phase, clinical pharmacists provided usual medication reconciliation services for admission and discharge patients at one surgical ward. In the post-intervention phase, clinical pharmacists provided medication reconciliation services in two surgical wards by targeting high risk patients. High-risk patient screening criteria were identified based on literature review, these include at least one of the followings: 1) Patients older than 65 years of age; 2) Concurrent use of five or more regular medications; 3) An active order of anticoagulants, insulin or dual antiplatelets. Clinical pharmacists identified and recorded DRPs using documentation form based on Pharmaceutical Care Network Europe (PCNE). Following research ethics committee approval, data were collected prospectively over 3 months. The potential severity of the DRPs was rated according to The National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) index by four independent pharmacists.
Result & Outcome :
A total of 1183 patients including 738 admission cases and 445 discharge cases were reviewed by clinical pharmacists. For admission cases, a total of 618 patients (83.7%) were over 65 years, 501 patients (67.9%) were taking five or more regular medications, while 69 patients (9.35%) were on an active order of anticoagulants, insulin or dual antiplatelets. There were 150 DRPs identified, the proportion of DRPs with severity ratings of level 1, 2, 3 was 45.3%, 45.3% and 9.3% respectively (Cohen’s Kappa 0.513). The most frequent type of DRPs was medication omission (43.7%), followed by unnecessary medication (18.5%). The most frequent medication involved according to WHO ATC classification was medications for alimentary tract and metabolism (28.0%), followed by cardiovascular medications (20.0%), anti-infective for systemic use (14.7%) and nervous system medications (11.3%). There were 150 interventions recommended to physicians, of which 148 (98.7%) were accepted. By targeting high risk patients, the percentage of incidence of identified medication discrepancies increase significantly from 5.32% to 8.15% (p-value 0.021); while there was no statistically significant difference in terms of the severity level of identified medication discrepancies. Targeting high risk patients in medication reconciliation process in surgical wards can optimize clinical pharmacist resources, resulting in a higher percentage of incidences of unintended medication discrepancies being identified, although the potential severity of identified discrepancies may not be altered.
