Category: Professional Posters
Purpose: A complete and accurate list of a patient’s medications upon admission to the hospital is vital to preventing discrepancies in hospital medication orders. Discrepancies may include unintentional additional or omitted medications or variations in dosage, frequency, or route from the patient’s home list and the intended hospital medication orders. Such discrepancies can interfere with tests, treatments and medications administered throughout the admission and potentially negatively impact outcomes. A pharmacy-driven admission medication history service was implemented with the primary goal to reduce discrepancies during medication reconciliation and, thereby, improve the safety and quality of care in a rural community teaching hospital.
Methods: Our hospital completed an evaluation during fall 2017 to determine the rate of unintentional medication discrepancies per medication upon hospital admission and discharge. To validate the quality of medication histories obtained upon admission, a pharmacist or pharmacy intern collected the gold standard medication list for 15 randomly identified patients admitted to a medical-surgical or stepdown unit. Post discharge, a retrospective chart review was completed comparing medication histories along with admission and discharge medication reconciliation lists to the gold standard list. Data collected included the number of gold standard home medications, time to complete the medication history interview with appropriate documentation, and frequency and description of medication discrepancies. Discrepancies were classified as addition, omission, incorrect dosing, frequency, or route of administration. A pharmacy-driven medication history service was implemented summer 2018 and data collected from October 1, 2018 to March 31, 2019. The service consists of pharmacy technicians who collect admission medication histories on more than 90% of hospital admissions. The service is staffed 0800 to 2000 weekdays and 0700 to 1530 weekends. The admission medication histories may initially be obtained by either nursing or medical staff during non-routine hours of the pharmacy service and confirmed by a pharmacy technician within 24 hours of admission. The same evaluation process was utilized as a component of the performance improvement plan for the recently developed pharmacy-driven service.
Results: Prior to implementation of a pharmacy-driven admission medication history service, 44.9% of medications listed in medication histories upon admission, 29% of medications reconciled upon admission and 18.2% of medications reconciled upon discharge contained at least one discrepancy. Pharmacy technician ownership for collecting medication histories has resulted in decreased unintentional discrepancies in the medication reconciliation process. When collected by pharmacy technicians, our study demonstrates unintentional discrepancy rates in 5.5% of medications listed in the histories, 13.5% upon admission reconciliation, and 9% upon discharge reconciliation. Based on these improved quality and patient safety outcomes, pharmacy technicians now collect medication histories on more than 90% of patients within 24 hours of admission as part of our organization’s standard of care during hospital admission. Before implementation, nurses and medical staff within our institution reported spending 15 minutes or less per admission completing a medication history interview and documentation; pharmacy technicians spend an average of 30 minutes per admission interviewing the patient or caregiver, reviewing pharmacy dispensing records and documenting the medication history. This pharmacy-driven service has allowed nurses to reallocate an additional 1,262 hours to direct patient care over the 6-month evaluation period which may have otherwise been devoted to medication history collection.
Conclusion: A pharmacy-driven admission medication history service was implemented at a rural community teaching hospital. This service demonstrated a reduction in medication discrepancies during admission and discharge medication history and reconciliation, such that more complete and accurate information was available during inpatient admission. Not only did this expand direct pharmacy patient care services, but it also provided additional role and skill development opportunities for pharmacy technicians in our institutional setting. Further, pharmacy ownership of the admission medication history process enabled our organization to recapture substantial nursing time to be reallocated to direct patient care in their respective scope of practice.