Addressing the risk of medication errors

The prescribing of medication is one of the most frequent, if not the most frequent, intervention in medicine. Polypharmacy is common and medication error happens frequently and is more likely to occur at transitions of care.¹

The population of patients who experience prescribing errors is varied. However, vulnerable populations, such as those who are older, hospitalised, and those with polypharmacy are at an even greater risk of experiencing a medication error. 

Ireland has a very fragmented healthcare system, resulting in the possibility of errors as patients move through the system from one level or location to the next. Fragmentation of healthcare is not unique to Ireland and has been described in other countries as the ‘health care (dis) continuum’.²

Care transitions and medication errors

A care transition is defined as the period when the patient moves between levels or stages of care. Movement between different levels of care – the community, hospital, and long-term care/nursing homes - creates opportunities for error. Furthermore, movement within these facilities – admission, transfer, and discharge – yet again presents the opportunity for discrepancies to occur. 

Types of errors may include the prescribing, administration, and dispensing of medication. Prescribing errors may result from a problem with the original prescription itself, ranging from illegible handwriting on the prescription to prescribing the wrong medication. 

Discrepancies in prescriptions may include the omission or unintentional discontinuation of medication (frequently a medication the patient is taking for a chronic condition, eg. inhalers, statins) the commission of an incorrect or unnecessary medication (eg. proton pump inhibitors intended for short-term use only), or an error regarding the dose, route of administration, or frequency. 

Errors can also arise from poor communication between healthcare providers or varied perceptions between different stakeholders, particularly between doctors and pharmacists, whose responsibility it is to check over a patient’s medication record. Lastly, discrepancies may also arise during the transfer of information, via identification, recording, and sharing of a patient’s medication history.

Errors that occur during these care transitions are costly, most importantly for the patient, but also for the caregivers, the institutions participating, and for the HSE. In primary care, the ‘triangle of community pharmacist (CP), GP and patient is important for providing optimal pharmaceutical care’.³ This foundation is essential for continuity of medication information for the care of patients who may later experience a transition of care (eg. needing acute hospital admission or long-term care).

Incidence and outcomes of errors

There is no national data on the incidence of medication errors in the Irish healthcare system. However, recent studies in Irish hospitals have identified medication error present in up to half of acute medical or surgical patients.^4,5 Errors pose a risk to patients at any stage of treatment, but if they occur in the beginning of care they are likely to perpetuate in a cascade throughout the patient’s treatment and through transitions of care (eg. on discharge). This may result in an increased number of primary care or emergency department visits. 

Additionally, higher risk patients, such as those who are older or with polypharmacy, are at increased risk for unplanned re-hospitalisation and an extended length of stay once admitted to the hospital.⁶ One Irish study undertaken in acute medical patients showed a 17% increased risk of error with each additional prescribed medication.⁴ In addition to the direct impact these errors have on the patient, the economic burden also warrants consideration.

The Health Information and Quality Authority (HIQA) recently highlighted the need for changes in the standards surrounding medicine reconciliation. In 2012, the Clinical Indemnity Scheme received reports of 6,017 medication-related adverse events. The largest category of medication adverse events (21.8%) related to incorrect reconciliation of medication on admission/discharge/transfer.⁷

Due to this, there has been an increased expectation on service providers to have ‘arrangements in place to ensure the safe and effective use of medications, including assessing, prescribing, dispensing, administering, documenting, reconciling, reviewing, and assisting people with their medications’.⁸

Medicines reconciliation

Medicines reconciliation is defined as ‘the process of obtaining and maintaining a complete and accurate list of the current medication use of a patient across healthcare settings’.⁹ This process seeks to prevent medication errors that occur during care transitions. As described by the Institute for Healthcare Improvement (IHI), the steps of medicine reconciliation are¹⁰: 

• Verification
• Checking
• Reconciliation.

Verification includes assessing the patient’s medication list from the previous centre of care and making sure it is both complete and accurate. Checking refers to making sure this list is the most current version and that there are no omissions or errors on this list, and that the information on it, including medication names, doses, routes, and frequency, are what the patient has been prescribed. Lastly, reconciliation involves making sure that any current healthcare worker caring for the patient has this verified and checked.

If any discrepancies are discovered, reconciliation also involves documenting these discrepancies and communicating the findings to the appropriate person. These steps of medicine reconciliation should ideally occur at all stages of transition. If done correctly, this process should result in a ‘complete list of medications, accurately communicated’ through all healthcare encounters.¹⁰

Types of medicines reconciliation

There are different ways in which medicine reconciliation can be facilitated in order to achieve optimal patient outcome and minimal medication error. Improvement of communication and due diligence by the healthcare provider is important. At the time of a care transition, a checklist for the patient should be used to ensure no errors have been made. 

HIQA describes the concept of ‘closing the loop’, which refers to the importance of complete and thorough communication and documentation between the outgoing and incoming service.⁸ Coupled with these improvements, a robust medicine reconciliation system should be implemented. 

Examples of this include involving the pharmacist in the medicines reconciliation process, creating an intra-professional collaboration surrounding the process of medicines reconciliation, combining medicine reconciliation with other interventions in the discharge process, or implementation of an electronic medication reconciliation system.¹¹

In many cases, the relationship between GPs and CPs is pre-existing and serves as a collaboration that prevents the aforementioned types of errors, and also serving as a good example to the importance of collaborative patient care.

Current efforts and research

In Ireland, there is a lack of an official protocol regarding engaging CPs in medicines reconciliation in the admission or discharge of patients to hospital. Regardless of this, there is evidence that CPs are both the most available and most accurate source of the patient’s pre-admission medications.¹²

There are a number of positive steps underway in Ireland to support enhanced medicines reconciliation, including HIQA’s minimum discharge dataset, a general practice messaging standard as well as a standard referral template, the HSE’s National Integrated Care Advisory Group Report, and the consideration of unique patient identifiers. 

There is still a dearth of information on the problem and solutions to medicines reconciliation at a community level in Ireland. However, a number of research projects are currently underway. 

To this end, the HRB Centre for Primary Care Research (HRB CPCR) at the Royal College of Surgeons in Ireland and Trinity College Dublin are undertaking a Cochrane systematic review entitled Interventions for improving medication reconciliation across transitions of care. This review aims to determine optimal methods of implementing medication reconciliation across transitions of care. 

Furthermore, the HRB CPCR in collaboration with the ICGP and the support of the Pharmaceutical Society of Ireland has recently distributed a nationwide questionnaire to GPs and CPs. The study, entitled Cross sectional survey of general practitioner and community pharmacists’ opinions on medication management at transitions of care in Ireland aims to examine respondent’s experiences in managing medications at transition of care.

Preliminary analysis of the survey results indicates that one of the most prominent themes in the responses of GPs (n = 587) and CPs (n = 362) is the lack of a formal system in place for checking the accuracy of a patient’s prescription post-transition as well as an overall poor level of communication between secondary and primary care. 

Many respondents noted: ‘they (the respondent) are the system’ – reconciling the prescriptions by hand or trying to track down the original prescribing doctor to no avail. Many others reported that they simply rely on the patients themselves to notify them of medication changes. Additionally, the ambiguity of whose responsibility it is to reconcile a patient’s medication appeared to vary based on the job role of the person responding. In other words, the perception of whose responsibility it is to reconcile the prescription seems to be unclear to those directly involved in this process. 

Limiting medication errors and increasing patient safety

In conclusion, medicines reconciliation is a process aimed to limit medication error and increase patient safety and outcomes across a patient’s experiences in various healthcare settings. There is a need for better medicine reconciliation processes in both primary care, hospital-based care, and long-term care facilities, and equally as important, a process that facilitates safer transitions between them is necessary. 

Authors: Hailey Carroll is a graduate medical student, RCSI and a research assistant with the HRB research project; Patrick Redmond, GP, lecturer, HRB Cochrane Fellow and PhD student, RCSI; Tamasine Grimes, senior research pharmacist (Tallaght Hospital) and associate professor in practice of pharmacy (TCD); and Rose Galvin is programme leader and senior research fellow, HRB Centre for Primary Care Research

References 

1. Redmond P, Grimes T, McDonnell R, Boland F, Hughes C, Fahey T. Tackling transitions in patient care: the process of medication reconciliation. Fam Pract. 2013 Oct;30(5):483–4. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24065714
2. Jenq G, Tinetti ME. The journey across the health care (dis)continuum for vulnerable patients: policies, pitfalls, and possibilities. JAMA. 2012 May 23;307(20):2157–8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22618921
3. Geurts MME, Talsma J, Brouwers JRBJ, de Gier JJ. Medication review and reconciliation with cooperation between pharmacist and general practitioner and the benefit for the patient: a systematic review. Br J Clin Pharmacol. 2012 Jul;74(1):16–33. Available from: DO - http://dx.doi.org/10.1111/j.1365-2125.2012.04178.x
4. Grimes TC, Deasy E, Allen A, O’Byrne J, Delaney T, Barragry J, et al. Collaborative pharmaceutical care in an Irish hospital: uncontrolled before-after study. BMJ Qual Saf. 2014 Feb 6:1–10. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24505112
5. Grimes TC, Duggan CA, Delaney TP, Graham IM, Conlon KC, Deasy E, et al. Medication details documented on hospital discharge: cross-sectional observational study of factors associated with medication non-reconciliation. Br J Clin Pharmacol. 2011 Mar;71(England LG - English DC - 20110202):449–57. Available from: DO - http://dx.doi.org/10.1111/j.1365-2125.2010.03834.x
6. Coleman EA, Smith JD, Raha D, Min SJ. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 2005 Sep 12;165(United States LG - English DC - 20050913):1842–7. 
7. Clinical Adverse Events Notified to the State Claims Agency under the terms of the Clinical Indemnity Scheme. Incidents occurring between 01/01/2012 and 31/12/2012 – Final Report. 2012. 
8. Health Intelligence and Quality Authority - Guidance for health and social care providers Principles of good practice in medication reconciliation. 2014. 
9. Karapinar-CCarkit F, Borgsteede SD, Zoer J, Egberts TC, van Tulder M. Effect of Medication Reconciliation on Medication Costs After Hospital Discharge in Relation to Hospital Pharmacy Labor Costs. Ann Pharmacother. 2012;46(3):329–38. 
10. Institute for Healthcare Improvement. How to Guide: Prevent Adverse Drug Events (Medication Reconciliation). 2012. Cambridge, Massachusetts; 2011. Available from: http://www.ihi.org/explore/adesmedicationreconciliation/Pages/default.aspx
11. Kwan JL, Lo L, Sampson M, Shojania KG. Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. Ann Intern Med. 2013 Mar 5;158(5 Pt 2):397–403. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23460096
12. Fitzsimons M, Grimes T, Galvin M. Sources of pre-admission medication information: observational study of accuracy and availability. Int J Pharm Pract. 2011 Dec;19(England LG - English DC - 20111108):408–16. Available from: DO - http://dx.doi.org/10.1111/j.2042-7174.2011.00154.