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Improving admission medication reconciliation with pharmacists or pharmacy technicians in the emergency department: a randomised controlled trial
  1. Joshua M Pevnick1,2,
  2. Caroline Nguyen3,
  3. Cynthia A Jackevicius4,5,6,7,8,
  4. Katherine A Palmer3,
  5. Rita Shane3,
  6. Galen Cook-Wiens9,
  7. Andre Rogatko9,
  8. Mackenzie Bear3,
  9. Olga Rosen3,
  10. David Seki3,
  11. Brian Doyle10,
  12. Anish Desai1,
  13. Douglas S Bell10
  1. 1Department of Medicine, Division of General Internal Medicine, Cedars-Sinai Health System, Los Angeles, California, USA
  2. 2Department of Biomedical Sciences, Division of Informatics, Cedars-Sinai Medical Center, Los Angeles, California, USA
  3. 3Department of Pharmacy Services, Cedars-Sinai Medical Center, Los Angeles, California, USA
  4. 4Department of Pharmacy Practice and Administration, College of Pharmacy, Western University of Health Sciences, Pomona, California, USA
  5. 5Department of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
  6. 6Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
  7. 7Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
  8. 8University Health Network, Toronto, Ontario, Canada
  9. 9Department of Biomedical Sciences, Biostatistics and Bioinformatics Research Center, Cedars-Sinai Health System, Los Angeles, California, USA
  10. 10General Internal Medicine and Health Services Research, UCLA, Los Angeles, California, USA
  1. Correspondence to Dr Joshua M Pevnick, Department of Medicine, Division of General Internal Medicine, Cedars-Sinai Health System, 8700 Beverly Blvd, B113, Los Angeles, CA 90048, USA; Joshua.Pevnick{at}cshs.org

Abstract

Background Admission medication history (AMH) errors frequently cause medication order errors and patient harm.

Objective To quantify AMH error reduction achieved when pharmacy staff obtain AMHs before admission medication orders (AMO) are placed.

Methods This was a three-arm randomised controlled trial of 306 inpatients. In one intervention arm, pharmacists, and in the second intervention arm, pharmacy technicians, obtained initial AMHs prior to admission. They obtained and reconciled medication information from multiple sources. All arms, including the control arm, received usual AMH care, which included variation in several common processes. The primary outcome was severity-weighted mean AMH error score. To detect AMH errors, all patients received reference standard AMHs, which were compared with intervention and control group AMHs. AMH errors and resultant AMO errors were independently identified and rated by ≥2 investigators as significant, serious or life threatening. Each error was assigned 1, 4 or 9 points, respectively, to calculate severity-weighted AMH and AMO error scores for each patient.

Results Patient characteristics were similar across arms (mean±SD age 72±16 years, number of medications 15±7). Analysis was limited to 278 patients (91%) with reference standard AMHs. Mean±SD AMH errors per patient in the usual care, pharmacist and technician arms were 8.0±5.6, 1.4±1.9 and 1.5±2.1, respectively (p<0.0001). Mean±SD severity-weighted AMH error scores were 23.0±16.1, 4.1±6.8 and 4.1±7.0 per patient, respectively (p<0.0001). These AMH errors led to a mean±SD of 3.2±2.9, 0.6±1.1 and 0.6±1.1 AMO errors per patient, and mean severity-weighted AMO error scores of 6.9±7.2, 1.5±2.9 and 1.2±2.5 per patient, respectively (both p<0.0001).

Conclusions Pharmacists and technicians reduced AMH errors and resultant AMO errors by over 80%. Future research should examine other sites and patient-centred outcomes.

Trial registration number NCT02026453.

  • healthcare quality improvement
  • health services research
  • human error
  • medication reconciliation
  • pharmacists

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Footnotes

  • Contributors JP had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design: JP, CN, CJ, KP, RS, AR, MB, DB. Acquisition, analysis or interpretation of data: JP, CN, CJ, KP, RS, GCW, AR, MB, OR, DS, BD, AD, DB. Drafting of the manuscript: JP, CN, GCW. Critical revision of the manuscript for important intellectual content: JP, CN, CJ, KP, RS, GCW, AR, OR, BD, DB. Statistical analysis: JP, CJ, GCW, AR. Administrative, technical or material support: JP, CN, KP, RS, MB, OR, DS, DB. Study supervision: JP, CN, KP, RS, DB.

  • Funding Joshua Pevnick was supported by the National Institute On Aging and the National Center for Advancing Translational Science of the National Institutes of Health under awards K23AG049181 and UCLA CTSI KL2TR000122. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

  • Competing interests JP currently receives funding from the American Society for Health-System Pharmacists Research and Education Foundation to design a toolkit for pharmacists to use in postdischarge medication management.

  • Ethics approval Cedars-Sinai Medical Center Institutional Review Board.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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