Identifying discrepancies in electronic medical records through pharmacist medication reconciliation

doi:10.1331/JAPhA.2012.10123

Journal of the American Pharmacists Association

Volume 52, Issue 1, January–February 2012, Pages 59-68

https://doi.org/10.1331/JAPhA.2012.10123 Get rights and content

Abstract

Objectives

To describe the types and causes of medication discrepancies in the electronic medical record identified by pharmacist medication reconciliation during outpatient medical visits and to identify patient characteristics associated with the presence of discrepancies.

Design

Observational case series study.

Setting

Indigent primary care clinic in Pittsburgh, PA, from April 2009 to May 2010.

Patients

219 adults presenting for follow-up medical visits and self-reporting medication use.

Intervention

Medication reconciliation as part of patient interview and concurrent chart review.

Main outcome measures

Frequency, types, and reasons for medication discrepancies and demographic variables, patient knowledge, and adherence.

Results

Of 219 patients interviewed, 162 (74%) had at least one discrepancy. The most common type of discrepancy was an incorrect medication documented on the chart. The most common reasons included over-the-counter (OTC) use of medications and patients not reporting use of medications. The presence of one or more medication discrepancies was associated with the use of three or more medications. Patient factors such as gender, age, and race were not associated with discrepancies. Patients able to recall the strength for more than 75% of their medications had fewer discrepancies, while knowledge of the medication name, indication, or regimen had no association with discrepancies.

Conclusion

Pharmacists play a critical role in identifying discrepancies between charted medication lists and self-reported medication use, independent of adherence. Inaccuracies in charted medications are frequent and often are related to use of OTC therapies and lack of communication and documentation during physician office visits. Knowledge of patient-related variables and other reasons for discrepancies may be useful in identifying patients at greatest risk for discrepancies and interventions to prevent and resolve them.

Section snippets

Objectives

The current study sought to describe the types of and reasons for discrepancies between patient-reported medications and medications listed in EMRs as identified by pharmacist medication reconciliation in an ambulatory care setting. The secondary objective was to identify patient characteristics associated with the presence of discrepancies between patient-reported medications and medications listed in EMRs.

Methods

Following approval from the Duquesne University Institutional Review Board, patients from a primary care center (Catholic Charities Free Health Care Center) serving an indigent, uninsured population were recruited for participation in the study. The center, which is located in an urban setting, provides free medical and dental services to uninsured adults with household incomes less than 200% of the Federal Poverty Level. Patients eligible for care at the center cannot have private or

Results

A total of 219 patients who received a medication reconciliation intervention by a pharmacist or student pharmacist were included in the analysis. Patient interviews occurred during 2009–10 during a 13-month time frame. Baseline demographic characteristics are shown in Table 1.

Discussion

Discrepancies and inaccuracies in EMRs among outpatients occurred at an alarming rate in the current work—a finding that is similar to results from previous studies examining traditional documentation systems. These results indicate that despite the potential for improvements with use of EMRs, discrepancies continue to exist, suggesting that the method of documentation alone is not sufficient to have a considerable effect on the rate and types of discrepancies. Assuming that “usual care,” prior

Limitations

One limitation of the current work was that the clinical importance of the discrepancies identified was not described beyond the discrepancy reason. This limits our ability to accurately predict the discrepancies' effect on patient outcomes, including relative risk of harm to the patient. Another limitation was the use of convenience sampling, as this population (indigent adults aged 18–65 years) may not be representative of patients in all primary care centers and may differ as a result of

Conclusion

Medication reconciliation remains an important initiative for ensuring patient medication safety and is of concern in both outpatient and inpatient settings. Inaccuracies in charted medications remained a common occurrence in this setting, despite the use of an EMR system, and often are related to the use of OTC therapies and lack of communication and documentation during physician office visits. Patient-related factors such as number of medications and degree of medication-related knowledge

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Cited by (54)

Home medication inventory method to assess over-the-counter (OTC) medication possession and use: A pilot study on the feasibility of in-person and remote modalities with older adults
2024, Research in Social and Administrative Pharmacy
There is a need for reproducible methods to measure over-the-counter (OTC) medication possession and use. This is because OTC medications are self-managed, variably monitored by healthcare professionals, and in certain populations such as older adults some OTC medications may introduce risk and cause more harm than benefit.
(s): To develop and assess the feasibility of the Home Medication Inventory Method (HMIM), a novel method to measure possession and use of OTC medications.
We benchmarked, adapted, and standardized prior approaches to medication inventory to develop a method capable of addressing the limitations of existing methods. We then conducted a pilot study of the HMIM among older adults. Eligible participants were aged ≥60 years, reported purchasing or considering purchasing OTC medication, and screened for normal cognition. Interviews were conducted both in person and remotely. When possible, photographs of all OTC medications were obtained with participant consent and completion times were recorded for both in-person and remote modalities.
In total 51 participants completed the pilot study. Home medication inventories were conducted in-person (n = 15) and remotely (n = 36). Inventories were completed in a mean (SD) of 20.2 min (12.7), and 96 % of inventories completed within 45 min. A total of 390 OTC medications were possessed by participants, for a mean (SD) of 7.6 (6.3) per participant. No differences in duration of interviews or number of medications reported were identified between in-person and remote modalities. Anticholinergic medications, a class targeted in the pilot as potentially harmful to older adults, were possessed by 31 % of participants, and 14 % of all participants reported use of such a medication within the previous 2 weeks.
Implementing the HMIM using in-person and remote modalities is a feasible and ostensibly reproducible method for collecting OTC medication possession and use information. Larger studies are necessary to further generalize HMIM feasibility and reliability in diverse populations.
Impact of a pilot community pharmacy system redesign on reducing over-the-counter medication misuse in older adults
2021, Journal of the American Pharmacists Association
No interventions have attempted to decrease misuse of over-the-counter (OTC) medications for adults aged 65 years or older (older adults) by addressing system barriers. An innovative structural pharmacy redesign (the Senior Section) was conceptualized to increase awareness of higher-risk OTC medications. The Senior Section contains a curated selection of OTC medications and is close to the prescription department to facilitate pharmacy staff–patient engagement to reduce misuse.
This pilot study examined the Senior Section’s effectiveness at influencing OTC medication misuse in older adults.
A pretest–post-test nonequivalent groups design was used to recruit 87 older adults from 3 pharmacies. Using a hypothetical scenario, the participants selected an OTC medication that was compared with their medication list and health conditions, and their reported use was compared with the product labeling. Misuse outcomes comprised drug–drug, drug–disease, drug–age, and drug–label, with 5 subtypes. Patient characteristics were compiled into a propensity score matching logistic regression model to estimate their effects on the Senior Section’s association with misuse at pre- or postimplementation.
Patient characteristics were uniform between pre- and postimplementation, and, once entered into a propensity score matching model, drug–label misuse (exceeds daily dosage) statistically significantly lessened over time (z = –2.42, P = 0.015). In addition, the Senior Section reduced drug–label misuse (exceeds single dosage) for both the raw score model (z = –6.38, P = 0.011) and the model in which the patient characteristics propensity score was added (z = –5.82, P = 0.011). Despite these limited statistical effects, misuse was found to decrease after implementation for 7 of 11 comparisons.
These nascent outcomes begin providing an evidence base to support a well-conceived, pharmacy-based OTC medication–aisle redesign for reducing older adult OTC medication misuse. The Senior Section, when broadly implemented, creates permanent structures and processes to assist older adults to access risk information when selecting safer OTC medications.
Analysis of provider-generated revenue and impact on medication reconciliation from a pharmacist-led chronic care management service
2021, Journal of the American Pharmacists Association
Citation Excerpt :
Not only can CCM have a positive financial impact, but it may also have a positive impact on patient care through improved medication list accuracy resulting from pharmacist-led medication reconciliations. Studies have suggested that the majority of errors are attributed to medications remaining on the medication list that the patient is no longer taking.11,12 Johnson et al.11 retrospectively compared pharmacy fill records with electronic health record (EHR) medications lists at the Family Medicine Center in Oklahoma City over 13 months.
Published data on pharmacist-provided chronic care management (CCM) services is limited, particularly for programs led by community-based pharmacists.
The objective was to quantify the total revenue generated from a community pharmacist-led CCM service, including CCM billing and appointment referrals. A second objective was to identify the types and frequencies of medication discrepancies identified during medication reconciliation.
Realo Drugs is a group of 18 independent community pharmacies serving eastern North Carolina.
Exploration of revenue generated from a community pharmacist-led CCM service.
This retrospective analysis assessed interventions completed by pharmacists between April 1, 2018 through June 30, 2019. Data was extracted from the electronic health record (EHR), including revenue generated from CCM billing codes, appointment referrals made by the pharmacist resulting in a completed in-office appointment, and which patients received medication reconciliation. The types and frequencies of medication discrepancies were documented, including medication no longer being used by the patient, medication omission, and strength or dose mismatch. Descriptive statistics were used to analyze data.
Over 15 months with a total of 112 patients, a total of $26,148 was generated from CCM services, representing an average of $15.56 per patient per month. The majority (approximately 80%) of the revenue was generated from noncomplex patient encounters. Of the 239 medication reconciliations completed, 609 medication discrepancies were identified. The majority of medication discrepancies (67%) were categorized as “patient no longer takes medication listed on EHR medication list.” The second most common discrepancy was “patient takes medication not listed on the EHR medication list” (22%), followed by “strength/dose mismatch” (10%).
These data can demonstrate to provider partners the sources of revenue that can be provided through CCM services. In addition to revenue, pharmacists can positively impact patient care through identification of medication discrepancies through medication reconciliation.
A comparison between medication reconciliation by a pharmacy technician and the use of an online personal health record by patients for identifying medication discrepancies in patients’ drug lists prior to elective admissions
2021, International Journal of Medical Informatics
Medication discrepancies (MDs), defined as unexplained differences among medication regimens, cause important public health problems with clinical and economic consequences. Medication reconciliation (MR) reduces the risk of MDs, but is time consuming and its success relies on the quality of different information sources. Online personalized health records (PHRs) may overcome these drawbacks. Therefore, the aim of this study is to determine the level of agreement of identified MDs between traditional MR and an online PHR and the correctness of the identified MDs with a PHR.
A prospective cohort study was conducted at the cardiology, neurology, internal medicine and pulmonary department of the Amphia Hospital, the Netherlands. Two weeks prior to a planned admission all patients received an invitation from a PHR to update their medication file derived from the Nationwide Medication Record System (NMRS). At admission MR was performed with all by a pharmacy technician, who created the best possible medication history (BPMH) based on the NMRS data and an interview. MDs were determined as discrepancies between the available information from the NMRS and the input and alterations patients or pharmacy technician made. The number, correctness of patients’ alterations, type and severity of identified MDs were analysed.
Of 488 patients approached, 155 (31.8 %) patients who both used the PHR and had received MR were included. The mean number of MDs identified with MR and PHR was 6.2 (SD 4.3) and 4.7 (SD 3.7), respectively. 82.1 % of the drug information noted by the patient in the PHR was correct compared to the BPMH and 98.6 % had no clinically relevant differences between the lists.
Patients who used an online PHR can relatively accurately record a list of their medication. Further research is required to explore the level of agreement and the correctness of a PHR in other (larger) hospital(departments).
Descriptive analysis of medication errors notified by Primary Health Care: Learning from errors
2020, Atencion Primaria
El objetivo del presente estudio es describir los errores de medicación (EM) notificados en atención primaria analizando el ámbito, el daño y las causas, y orientando el análisis a las medidas para prevenir estos errores.
Ámbito: Atención primaria. Servicio Madrileño de Salud. 2016.
Estudio descriptivo transversal.
Todas las notificaciones de EM realizadas desde los centros de salud en el sistema de notificación de incidentes de seguridad entre el 1 de enero y el 17 de noviembre de 2016 (n = 1.839).
Ámbito donde ocurrió el error, daño real, daño potencial y causa del error. Fueron clasificadas por un investigador. Se comprobó la concordancia con otro investigador.
En el ámbito del centro de salud ocurrieron el 47% (IC95%: 44,8-49,3%) de los EM y en el entorno del paciente el 26,5% (IC95%: 24,5-28,6%). El 27,5% (IC95%: 24,1-30,8%) de los EM tenían potencialidad de daño grave. En el ámbito del centro de salud, la causa más frecuente fue la prescripción inadecuada: 27,4% (IC95%: 24,4-30,4%). En el entorno del paciente, la causa más frecuente fue el fallo en la comunicación profesional-paciente: 66% (IC95%: 61,8-70,2%), seguida por equivocaciones y despistes del paciente.
La mitad de los errores de medicación notificados desde atención primaria tiene lugar en el centro de salud mientras que los EM del paciente son la cuarta parte. Uno de cada 4 es un error potencialmente grave. Las causas más importantes son la prescripción inadecuada (incluyendo indicación o dosis incorrecta, interacciones, contraindicaciones y alergias), los fallos en la comunicación profesional-paciente y los despistes en la autoadministración del paciente. Parece prioritario implantar sistemas de ayuda a la prescripción, prácticas seguras efectivas en comunicación profesional-paciente y ayudas que eviten los despistes en la autoadministración del paciente.
Aim of this study is to determine the setting, causes, and the harm of medication errors (ME) which are notified by Primary Health Care.
Setting: Primary Care Regional Health Service of Madrid. 2016.
Descriptive and cross-sectional study.
All ME (1,839) which were notified by Primary Care Centres by notification system of safety incidents between January 1 st 2016 and November 17th 2016.
Setting, real harm, potential harm, and cause of error. These items were classified by one researcher. Concordance was checked with another researcher.
Just under half (47%) (95% CI: 44.8%-49.3%) of ME occurred in Primary Care Centre, 26.5% (95% CI: 24.5%-28.6%) of ME were patient medication errors, and 27.5% (95% CI: 24.1%-30.8%) of ME were potential severe harm errors. Prescribing errors were the cause of most ME in Primary Care Centre [27.4% (95% CI: 24.4%-30.4%)]. Communication between patients and doctors were the cause of most patient medication errors [66% (95% CI: 61.8%-70.2%)]. Patient mistakes and forgetfulness were also causes of patient medication errors.
Half of all mediation errors hppened at Primary Care Center while one quarter of them were patient medication errors.
One quarter of all ME were potential severe harm errors. The main causes were prescribing errors, failure of communication between patients and doctors, and patient mistakes and forgetfulness. Prescribing aid systems, communication improvements and patients aids should be implemented.
Prevalence of medication transfer errors in nephrology patients and potential risk factors
2019, European Journal of Internal Medicine
Citation Excerpt :
A review of Hias et al. [2] has identified sixteen significant variables, of which higher age and polypharmacy were the most frequently found risk factors for medication errors at admission. In ambulatory primary care patients the number of medications in use was significantly associated with the occurrence of medication discrepancies. [10] However, nephrology patients use, on average, much more medication than the average primary care patient.
Medication reconciliation in transitions of care can prevent medication transfer errors (MTE). MTE can cause patient harm. Since performing medication reconciliation for every patient is not always feasible, identification of potential risk factors of MTE could aid in targeting this intervention to the right patients.
To establish the proportion of patients with one or more MTE in the outpatient nephrology setting. Secondary patient characteristics associated with MTE, type and potential harm, and medication groups were investigated.
This retrospective observational cohort study was conducted in the Leiden University Medical Center, the Netherlands, between November 2017 and April 2018. The cohort involved patients in whom medication reconciliation was performed by a medical attendant using the electronic tool ‘Medical Dashboard’ prior to visiting the nephrologist. MTE were defined as unintended discrepancies between the medication in the hospital system and the result of the medication reconciliation. The proportion of patients with one or more MTE was calculated and the association of patient characteristics (age, sex, number of medications and kidney function (CKD-EPI)) with MTE was analyzed using multivariate logistic regression.
Of 380 patients, 235 patients (61.8%) had at least one MTE. On average patients used 10.3 medications. The number of medications per patient was significantly associated with MTE; OR 1.11 (95%CI 1.05–1.16). No association was found for age, sex, and kidney function.
In ambulatory nephrology patients 61.8% had at least one MTE. Nephrology patients using a higher number of drugs are more prone to MTE.

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: Disclosure: The authors declare no conflicts of interest or financial interests in any product or service mentioned in this article, including grants, employment, gifts, stock holdings, or honoraria.

: Acknowledgments: To Hildegarde J. Berdine, PharmD, BCPS, CDE, for general support.

: Previous presentations: American College of Clinical Pharmacy (ACCP) Annual Meeting, Anaheim, CA, October 18–21, 2009, and ACCP Annual Meeting, Charlotte, NC, April 23–27, 2010.

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ResearchIdentifying discrepancies in electronic medical records through pharmacist medication reconciliation

Abstract

Objectives

Design

Setting

Patients

Intervention

Main outcome measures

Results

Conclusion

Section snippets

Objectives

Methods

Results

Discussion

Limitations

Conclusion

J Am Pharm Assoc

J Am Pharm Assoc

Medication reconciliation review

Medication reconciliation National Patient Safety Goal to be reviewed, refined

Institute of Medicine

To err is human: building a safer health system

Accreditation program: ambulatory health care National Patient Safety Goals

Medication reconciliation

Am J Nurs

Multidisciplinary approach to inpatient medication reconciliation in an academic setting

Am J Health Syst Pharm

Research
Identifying discrepancies in electronic medical records through pharmacist medication reconciliation