Improving The accuracy Of Medicines Reconciliation on Hospital Discharge INTRODUCTION
Improve patient safety on transfer from secondary to primary care
Patients often receive new medications or have changes made to their existing medications at times of transitions in care. Although most of these changes are intentional (1), there is a substantial body of evidence that shows that when patients move between care providers there is a significant risk of miscommunication and unintended changes to medicines (2). That is why the Scottish Patient Safety Program (SPSP), since its launch in 2007, had a very clear focus on improving medicines reconciliation across all care boundaries (3). Although much work has been done and published in Scotland regarding medicines reconciliation on admission to hospitals as a result of SPSP, very little work seems to have been done however in regards to medicines reconciliation on hospital discharge. The aim of medicines reconciliation on discharge is to communicate a complete list of the patient’s medications to the next provider of services when a patient is referred or transferred to another setting outside the organisation (1), in order to reduce incidents of avoidable harm, improve patient safety and contribute to a reduction in avoidable medicines-related admissions and readmissions to hospital (2). Within our board, medications from a paper based in-patient chart are transcribed by the discharging junior doctor to an electronic system to populate a discharge document. Pharmacists then clinically check these discharge prescriptions to ensure that the medication section is both accurate and clinically appropriate before releasing the discharge document. Once the patient is discharged; the record is locked and transferred electronically to the patient’s GP. In Ninewells hospital, collective feedback from the surgical pharmacists indicated that the accuracy of discharge prescriptions prepared by the junior doctors was poor and could be improved, so we decided to undertake this quality improvement project to improve patient safety on transfer from secondary to primary care.
OBJECTIVES To examine the accuracy of discharge prescriptions to confirm if there was a problem and better understand some of the contributing factors To quantify the level of accuracy of discharge prescriptions to help determine a baseline for the problem To implement a test-of-change in an attempt to sustainably improve the accuracy of discharge prescriptions above the baseline
Sustained improvement in the accuracy of discharge prescriptions Promote accurate & reliable medicines reconciliation on discharge by encouraging doctors to, 1. Review the patient’s reconciled list of medicines on admission and use it as a vital source when completing the discharge document 2.Clearly communicate any changes in the patient’s drug history to the GP as part of the discharge document
Figure 1. The Model for Improvement.
RESULTS Base line data was collected during the first 4 weeks of this project and it showed that less than 50% of the discharge prescriptions produced by junior doctors were accurate, confirming the pharmacists’ views in this regards Figure 3 shows that once the new process was introduced, the accuracy of discharge prescriptions steadily and quickly improved to reach a median of 83% for the first 3 months and then it improved further to a median of 96 % Figure 4 shows that the new process was able to support the junior doctors to increase the percentage of patients with an accurate list of discharge medication from a base line of 61.5% to more than 90% Figure 5 shows that the new process was able to support the junior doctors to increase the percentage of patients with clearly communicated changes regarding their medication history to their GP as part of the discharge document % of Discharge prescription with accurate drug list & clear communication to the GP regarding any changes in drug history (prior to pharmacist verification) Median 1 (Base Line)
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AUTHORS 1. 2. Shady Botros and John Dunn 3. Pharmacy Department, Ninewells Hospital, NHS Tayside, Dundee, Scotland 4. 5. Email: 6. Acknowledgments: Website: For further information, please contact 7. The authors would like to acknowledge the efforts of both Gillian Allison 8. and Jennifer Bisset for the valuable input they had in delivering this work Phone: Chart 1. Label in 24pt Calibri. Shady Botros on
[email protected] 9. and helping in the data collection.
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Test of change introduced
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Figure 3. Run chart illustrating improvement in overall accuracy of discharge prescription over the period of the project with a clear shift in the median % of Discharge prescriptions with accurate drug list (prior to pharmacist verification) Median 1 (Base line) 100
% of discharge prescriptions with Gaps in GP communication regarding changes in drug history (prior to pharmacist verification)
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Figure 4. Run chart illustrating improvement in the accuracy of the drug list of the discharge prescription over the period of the project.
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The upper gastrointestinal surgical ward was selected as the pilot site for this quality improvement project. Discharge prescriptions were included for data collection if the patient’s medicines reconciliation on admission was reviewed by a pharmacist and the discharge prescription was being screened by the pharmacist at ward level. A data collection form was designed and tested as part of this project which took place over 8 months (October 2013 – June 2014). Using the improvement methodologies(4) (Figure 1), the following process was adopted as a testof-change for the duration of this project (Figure 2). Patient gets admitted by medical team and have their medicines reconciled at point of admission Ward pharmacist reviews and verifies the patient’s list of reconciled medicines on admission and attaches a green sticker to the medicines reconciliation form. This green sticker will need to be completed by the discharging doctor at the point of discharge At the point of discharge, the discharging doctor will complete the green sticker to confirm that they have reviewed the patient’s list of medicines on admission & have also clearly communicated any changes in the patient’s medication history to the GP in the discharge document The data was collected prospectively and presented as run-charts displaying the accuracy of discharge prescriptions over the time period of this project. A discharge prescription is deemed accurate if it had a complete list of the patient’s medication that is clinically appropriate at discharge and it clearly communicated any changes in the patient’s medication history to the GP. After a few months of sustainable results, the project was also replicated in one of the trauma orthopaedic surgery wards.
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Figure 5. Run chart illustrating improvement in clear communication to the GP regarding Changes in drug histories as part of the discharge document
DISCUSSION Our base line data of less than 50% accuracy in medicines reconciliation on discharge is similar to those reported by other studies where more than 70% of discharge prescriptions had at least one unintentional discrepancy (5). The two main factors contributing to these results were, 1. Lack of use of the patient’s reconciled medication list from admission as a vital source of information to generate a discharge prescription 2. Lack of clarity in communication to the primary care providers of any changes in the patient’s medication history and the reasons behind such changes A group discussion with the junior doctors confirmed the above findings with the main reasons cited for this behaviour being a combination of a lack of awareness and a lack of understanding of the importance of such steps to produce an accurate reconciled medication list at discharge. The newly designed process (Figure 2) addressed and helped resolve the two main contributing factors mentioned above and therefore achieved a great and sustainable improvement in the accuracy of medicines reconciliation at discharge (Figure 3) The most common gap in communication regarding changes in medication histories was around recording which drugs were being discontinued at discharge and the reasons behind that (Figure4)
REFRENCES 1. 2. 3. 4. 5.
Patient Safety Network. Medicines Reconciliation. Available at http://psnet.ahrq.gov/primer.aspx?primerID=1 Accessed [10th June 2015] Royal Pharmaceutical Society of Great Britain. Keeping the patient safe – Getting the medicines right: Final Report. June 2012. Health Improvement Scotland. Scottish Patient Safety Program (SPSP). Available from http://www.scottishpatientsafetyprogramme.scot.nhs.uk/ Accessed [10th June 2015] Institute for Healthcare Improvement. How to Improve. http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx Accessed [10th June 2015] Wong et al. Medication Reconciliation at hospital discharge: Evaluating Discrepancies. The annals of Pharmacotherapy. 2008;42(10):1373-1379.
