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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.
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