Medication Reconciliation in a Rural Trauma Population

Study objective

Medication errors during hospitalization can lead to adverse drug events. Because of preoccupation by health care providers with life-threatening injuries, trauma patients may be particularly prone to medication errors. Medication reconciliation on admission can result in decreased medication errors and adverse drug events in this patient population. The purpose of this study is to determine the accuracy of medication histories obtained on trauma patients by initial health care providers compared to a medication reconciliation process by a designated clinical pharmacist after the patient's admission and secondarily to determine whether trauma-associated factors affected medication accuracy.

Methods

This was a prospective enrollment study during 13 months in which trauma patients admitted to a Level I trauma center were enrolled in a stepwise medication reconciliation process by the clinical pharmacist. The setting was a rural Level I trauma center. Patients admitted to the trauma service were studied. The intervention was medication reconciliation by a clinical pharmacist. The main outcome measure was accuracy of medication history by initial trauma health care providers compared to a medication reconciliation process by a clinical pharmacist who compared all sources, including telephone calls to pharmacies. Patients taking no medications (whether correctly identified as such or not) were not analyzed in these results. Variables examined included admission medication list accuracy, age, trauma team activation mode, Injury Severity Score, and Glasgow Coma Scale (GCS) score.

Results

Two hundred thirty-four patients were enrolled. Eighty-four of 234 patients (36%) had an Injury Severity Score greater than 15. Medications were reconciled within an average of 3 days of admission (range 1 to 8) by the clinical pharmacist. Overall, medications as reconciled by the clinical pharmacist were recorded correctly for 15% of patients. Admission trauma team medication lists were inaccurate in 224 of 234 cases (96%). Admitting nurses' lists were more accurate than the trauma team's (11% versus 4%; 95% confidence interval 2.5% to 11.2%). Errors were found by the clinical pharmacist in medication name, strength, route, and frequency. No patients (0/20) with admission GCS less than 13 had accurate medication lists. Seventy of 84 patients (83%) with an Injury Severity Score greater than 15 had inaccurate medication lists. Ten of 234 patients (4%) were ordered wrong medications, and 1 adverse drug event (hypoglycemia) occurred. The median duration of the reconciliation process was 2 days. Only 12% of cases were completed in 1 day, and almost 25% required 3 or more (maximum 8) days.

Conclusion

This study showed that medication history recorded on admission was inaccurate. This patient population overall was susceptible to medication inaccuracies from multiple sources, even with duplication of medication histories by initial health care providers. Medication reconciliation for trauma patients by a clinical pharmacist may improve safety and prevent adverse drug events but did not occur quickly in this setting.

Introduction

In its monograph To Err Is Human, the Institute of Medicine estimates that there are approximately 100,000 deaths per year from medication errors in the United States.¹ The Harvard Medical Practice Study identified medication-related adverse events to be the most common medical error, accounting for 19% of all adverse events.² Another study found that some type of medication error occurs approximately once out of every 5 doses administered in hospitals. This equated to approximately 40 potentially harmful errors per day per 300 inpatients.³ Others have shown that more than half of the patients admitted had at least 1 medication error, and more than one-third of these errors could result in moderate to severe consequences for the patient.4, 5 Bates et al⁶ concluded that 6.5 adverse drug events occurred per 100 hospital admissions, as a result of medication errors. Furthermore, the authors found that an adverse drug event resulted in a 2.2-day increased hospital length of stay. Specifically, preventable adverse drug events led to a 4.6-day increase in length of stay. The authors estimated an increased cost of $2,595 for each adverse drug event and $4,685 for each preventable adverse drug events. For a 700-bed teaching hospital, this translates annually to $5.6 million for all adverse drug events.6, 7

Medication reconciliation is a process to reduce errors and harm associated with loss of medication information as the patient enters and moves through a new health care system. The Joint Commission has recognized medication reconciliation on hospital admission as a key provider problem and a national patient safety goal for 2006.⁸ Specifically, The Joint Commission has mandated reconciling medications on admission, at transition points in care, and at discharge. Fifty percent of medication errors and 20% of harmful adverse drug events occur at these times because of poor communication among health care providers.⁹ In addition, the importance of a complete medication history as taken by health care providers and the understanding and cooperation of patients is vital in maintaining a complete and accurate medication list.

In the case of trauma care, medication reconciliation is no less pertinent. During the trauma resuscitation phase, injuries sometimes preclude obtaining accurate health histories. Often family members have not arrived, and patient identities are unknown, which prevents obtaining the medication history from an existing medical record. Lack of access to accurate patient information introduces increased risk of missed or erroneous medication orders. Moreover, with an aging trauma population, comorbidity and consequent medication dependency may become increasingly relevant. For these reasons, we undertook a prospective study to determine the completeness of medication histories in trauma patients during the admission phase through a reconciliation process using a designated health care provider after hospital admission.