Better Communications, Computerized Records Reduce
Adverse Drug Events
Up to 67% of inpatients have at least one unexplained
discrepancy in their prescription medication history
April 28, 2009 - Interventions that included
enhanced communication between a pharmacist and patients and physicians
and computerized organization of a patient's medications appear to be
associated with a decreased risk of adverse drug events, according to
two articles appearing in the April 27 issue of Archives of Internal
Medicine, one of the JAMA/Archives journals. Senior citizens are the
most frequent victims of these drug mistakes.
Adverse drug events (ADEs) and medication errors (MEs)
are common and costly threats to the quality of care. Such drug-related
problems are common in outpatients in the United States and added
together with other drug-related problems cost $77 billion to $177
billion annually, according to background information in the first
article.
While the incidence of these events among
inpatients is well recognized, such events often go unnoticed in the
outpatient setting and are more difficult to measure. Inpatient studies
suggest that a pharmacist may help reduce these events, but little is
known regarding the effect on outpatients.
Michael D. Murray, Pharm.D., M.P.H., of the
University of North Carolina at Chapel Hill, and colleagues examined the
effect of a pharmacist intervention on ADEs and MEs in outpatients with
heart failure or hypertension by combining data from two randomized
controlled trials.
The pooled analysis included 800 outpatient cases
of hypertension divided into complicated (535; patients had heart
failure or other cardiovascular complications) and uncomplicated (265).
Computer programs examined one-year electronic
record data to identify events classified as ADEs and preventable or
potential ADEs. Study participants were an average of 59 years old; 71
percent were women.
The intervention was provided by specifically
trained pharmacists, who spent more of their time instructing patients
on the appropriate use of their medications, drug monitoring, and
communication with patients' primary care physicians, with the goal of
improving adherence and medication use.
There were a total of 210 ADE or ME events, with
fewer of these events occurring in the intervention group. The five most
common events, occurring in a total of 68 participants, included receipt
of a prescription for a drug that should be avoided in elderly patients;
vaginal candidiasis (yeast infection) resulting from an orally
administered antibiotic; an increase in serum creatinine level
associated with a medication; inadequate monitoring after prescribing;
and prescription of multiple acetaminophen products.
Compared with the control group, the intervention
group had a 34 percent lower risk of any event, including a 35 percent
lower risk of ADEs and a 37 percent lower risk of MEs.
"In conclusion, this post hoc analysis of a
pharmacist intervention to improve medication use in adult outpatients
suggests a lower risk of adverse drug events and medication errors.
Further studies are needed to confirm this finding," the authors write.
This study was funded by the National Institutes of
Health.
Computerized Medications Associated With a Lower
Risk of Adverse Drug Events
An intervention that included computerized
identification of medications a patient is taking to help create a more
accurate medication list for patients checking in or out of a hospital
was associated with a lower rate of potential adverse drug events,
according to a second article in the April 27 issue of Archives of
Internal Medicine.
Efforts to improve the quality and safety of health
care include attention to unintentional medical discrepancies, defined
as unexplained differences among documented regimens across different
sites of care (e.g., prior to admission compared with hospital admitting
orders).
"Discrepancies are highly prevalent; up to 67
percent of inpatients have at least one unexplained discrepancy in their
prescription medication history at admission," the authors write.
Because medication discrepancies are an important
contributor to ADEs among hospitalized and recently discharged patients,
The Joint Commission on Accreditation of Healthcare Organizations has
designated medication reconciliation as a priority.
Medication reconciliation is a process of
identifying the most accurate list of all medications a patient is
taking, and using this list to provide correct medications for patients
anywhere within the health care system, according to background
information in the article.
Few studies have shown that medication
reconciliation efforts improve important patient outcomes.
Jeffrey L. Schnipper, M.D., M.P.H., of Brigham and
Women's Hospital and Harvard Medical School, Boston, and colleagues
conducted a study to determine the effects of a redesigned process for
medication reconciliation, supported by information technology (IT), on
potential ADEs (PADEs).
The trial, at general medical inpatient units in
two academic hospitals, included 322 patients, for whom a medication
history could be obtained before discharge. The intervention was a
computerized medication reconciliation tool (that included a Web-based
application that promotes the creation of a preadmission medication list
from several electronic sources) and process redesign, which involved
changes in the roles and workflows involving physicians, nurses, and
pharmacists.
The researchers found that among 162 patients
assigned to the intervention, there were 170 unintentional medication
discrepancies with potential for patient harm (1.05 PADEs per patient)
vs. 230 (1.44 PADEs per patient) among the 160 patients assigned to
usual care, a 28 percent risk reduction.
Ninety-eight PADEs were considered serious, i.e.,
to have potential to cause serious harm such as rehospitalization or a
change in health function, including 43 PADEs in the intervention group
(0.27 per patient) and 55 PADEs in those assigned to the usual care
group (0.34 per patient).
"We believe our intervention was successful because
it combined effective process redesign with IT. The new reconciliation
process encouraged interdisciplinary communication and cross-checks. The
Preadmission Medication List (PAML) Builder application facilitated
accurate medication histories by presenting several sources of available
medication information, and it displayed the PAML with current inpatient
medications during the discharge ordering process," the researchers
write.
This study was funded in part by an
investigator-initiated grant from the Harvard Risk Management Foundation
as well as internal funding from Brigham and Women's Hospital,
Massachusetts General Hospital and Partners HealthCare. Dr. Schnipper
was supported by a mentored clinical scientist award from the National
Heart, Lung and Blood Institute. Please see the article for additional
information, including other authors, author contributions and
affiliations, financial disclosures, funding and support, etc.
Editorial: The Change We Need in Health Care
In an accompanying editorial, David C. Goff Jr.,
M.D., Ph.D., and Philip Greenland, M.D., of the Feinberg School of
Medicine, Northwestern University, Chicago, write that significant
changes are needed in the U.S. health care system.
"As we look back at the results of over a decade of
attention to health care quality, we also look forward to the prospects
of stimulating real change in the health care system and breakthroughs
in health care quality. We believe that the time has come to quit
nibbling around the edges of a dysfunctional system.
Implementation of proven strategies to enhance
quality will require structural changes in our health care system to
align incentives so that (1) patients are protected from exposure to
medications of dubious cost-effectiveness; (2) providers are reimbursed
appropriately for efforts to implement quality initiatives; and (3)
payers are armed with information regarding quality and
cost-effectiveness during contract negotiations.
"Rising health care costs threaten our economic
future, yet many indicators of the quality of care in the United States
lag behind those reported from countries spending for less. In this time
of change, the status quo in health care is not acceptable."
Keep up with the latest news for senior citizens, baby
boomers
April 28, 2009 - Interventions that included
enhanced communication between a pharmacist and patients and physicians
and computerized organization of a patient's medications appear to be
associated with a decreased risk of adverse drug events, according to
two articles appearing in the April 27 issue of Archives of Internal
Medicine, one of the JAMA/Archives journals. Senior citizens are the
most frequent victims of these drug mistakes.