Where: Auckland City Hospital, a 690-bed teaching hospital in New Zealand.
The issue: Reducing medication errors due to inaccurate recording of patients' medications on general medical wards.
Physician Peter N. Black, FRACP, had observed frequent and significant medication discrepancies at the hospital. To reduce these discrepancies, Dr. Black and colleagues developed a novel strategy that aimed not only to identify and reconcile the mismatches, but also to stop them before they happen.
“He knew of patients who had been re-admitted or had an increased length of stay as a result of medication discrepancies on admission or discharge from the hospital, said Amy Hai Yan Chan, a pharmacist and lead author of the study that resulted from the hospital's medication reconciliation project. Dr. Black initiated the project but died before the results were published in the Journal of General Internal Medicine in March.
How it works
One aspect of the project involved fairly typical medication reconciliation. Charts of patients who were at least 75 and on five or more medications were reviewed by a team including a nurse, a pharmacy student and a pharmacology resident. Medication lists were compared with data collected from patient interviews and other sources, including caregivers, primary care physicians, previous discharge summaries and medications brought to the hospital.
If a discrepancy was found, the team put a sticker into the clinical notes. The sticker listed all the discrepancies and asked the medical team looking after the patient to note whether the discrepancies were intentional or unintentional and indicate whether changes were made to the chart as a result of the sticker. If the team found a discrepancy that could cause moderate discomfort or clinical deterioration to the patient, the physicians were sent a text message, and if the risk for harm was severe, the doctors were contacted directly.
The other component of the program was an educational campaign for junior medical staff, including lectures by a clinical pharmacologist, posters, and reminders inserted in charts about medication reconciliation.
“There is a risk that medical staff may become desensitized to education measures or become too reliant on the medication reconciliation service rather than attempting to obtain complete histories at admission,” said Ms. Chan. The study leaders kept medical staff engaged by showing them graphs of their discrepancy rate and how it compared to other medical teams.
First, the project found that the hospital had a lot of unintentional medication discrepancies: 71.9% of studied patients had at least one discrepancy, with at least one patient having 12 discrepancies. But the researchers also found their efforts reduced the occurrence of discrepancies. The mean rate of discrepancies per admission fell from 2.6 during the first two weeks of the study to one per admission at the end of the 18-week intervention.
There wasn't any way to determine which components of the intervention were responsible for the success, but Ms. Chan thinks letting clinicians know when they had created a discrepancy was key. “Regular communication about medication discrepancies and reconciliation raises awareness in prescribers and can therefore influence their practice when they come to clerking their next patients.”
Further confirming the importance of feedback, she noted that other studies have implemented educational interventions without it, and didn't see a decline in the discrepancy rate equivalent to this program's.
Based on its success, the intervention was continued and expanded at Auckland City Hospital. “The results from the study enabled the funding of two medication reconciliation pharmacist posts at the hospital,” explained Ms. Chan. “These pharmacists perform medication reconciliation on patients 65 years or over and utilize the feedback sticker system.” The program is also in the process of expanding to departments outside of general medicine, including cardiology, neurology, urology and geriatrics.
The team has also developed a new means of getting interns and medical staff excited about lowering their discrepancy rates: candy. “The team with the lowest discrepancy rate for that month is awarded chocolate fish,” Ms. Chan said.
Words of wisdom
“Resources within a hospital are limited, and it is not possible to see every patient and perform medication reconciliation on them. It is therefore best to try to prevent these discrepancies from occurring in the first place,” Ms. Chan said.