The Impact of Real-Time Documentation of In-Hospital Medication Changes on Preventing Undocumented Discrepancies at Discharge and Improving Physician-Pharmacist Communication: A Retrospective Cohort Study and Survey.

Background: Transitional medication safety is crucial, as miscommunication about medication changes can lead to significant risks. Unclear or incomplete documentation during care transitions can result in outdated or incorrect medication lists at discharge, potentially causing medication errors, adverse drug events, and inadequate patient education. These issues are exacerbated by extended hospital stays and multiple care events, making accurate medication recall challenging at discharge. Objective: Thus, we aimed to investigate how real-time documentation of in-hospital medication changes prevents undocumented medication changes at discharge and improves physician-pharmacist communication. Methods: We conducted a retrospective cohort study in a tertiary hospital. Two pharmacists reviewed medical records of patients admitted to the acute medical unit from April to June 2020. In-hospital medication discrepancies were determined by comparing preadmission and hospitalization medication lists and it was verified whether the physician's intent of medication changes was clarified by documentation. By a documentation rate of medication changes of 100% and <100%, respectively, fully documented (FD) and partially documented (PD) groups were defined. Any undocumented medication changes at discharge were considered a "documentation error at discharge". Pharmacists' survey was conducted to assess the impact of appropriate documentation on the pharmacists. Results: After reviewing 400 medication records, patients were categorized into FD (61.3%) and PD (38.8%) groups. Documentation errors at discharge were significantly higher in the PD than in the FD group. Factors associated with documentation errors at discharge included belonging to the PD group, discharge from a non-hospitalist-managed ward, and having three or more intentional discrepancies. Pharmacists showed favorable attitudes towards physician's documentation. Conclusion: Appropriate documentation of in-hospital medication changes, facilitated by free-text communication, significantly decreased documentation errors at discharge. This analysis underlines the importance of communication between pharmacists and hospitalists in improving patient safety during transitions of care.

During transitions of care, communication failures among healthcare professionals can lead to medication errors. Therefore, effective sharing of information is essential, especially when intentional changes in prescription orders are made. Documenting medication changes facilitates real-time communication, potentially improving medication reconciliation and reducing discrepancies. However, inadequate documentation of medication changes is common in clinical practice. This retrospective cohort study underlines the importance of real-time documentation of in-hospital medication changes. There was a significant reduction in documentation errors at discharge in fully documented group, where real-time documentation of medication changes was more prevalent. Pharmacists showed favorable attitudes toward the physician's real-time documenting of medication changes because it provided valuable information on understanding the physician's intent and improving communication and also saved time for pharmacists. This study concludes that physicians' documentation on medication changes may reduce documentation errors at discharge, meaning that proper documentation of medication changes could enhance patient safety through effective communication.

Improving clinical reasoning and communication during handover: An intervention study of the BRIEF-C tool.

BACKGROUND: Existing handover communication tools often lack a clear theoretical foundation, have limited psychometric evidence, and overlook effective communication strategies for enhancing diagnostic reasoning. This oversight becomes critical as communication breakdowns during handovers have been implicated in poor patient care. To address these issues, we developed a structured communication tool: Background, Responsible diagnosis, Included differential diagnosis, Excluded differential diagnosis, Follow-up, and Communication (BRIEF-C). It is informed by cognitive bias theory, shows evidence of reliability and validity of its scores, and includes strategies for actively sending and receiving information in medical handovers. DESIGN: A pre-test post-test intervention study. SETTING: Inpatient internal medicine and orthopaedic surgery units at one tertiary care hospital. INTERVENTION: The BRIEF-C tool was presented to internal medicine and orthopaedic surgery faculty and residents who participated in an in-person educational session, followed by a 2-week period where they practised using it with feedback. MEASUREMENTS: Clinical handovers were audiorecorded over 1 week for the pre- and again for the post-periods, then transcribed for analysis. Two faculty raters from internal medicine and orthopaedic surgery scored the transcripts of handovers using the BRIEF-C framework. The two raters were blinded to the time periods. RESULTS: A principal component analysis identified two subscales on the BRIEF-C: diagnostic clinical reasoning and communication, with high interitem consistency (Cronbach's alpha of 0.82 and 0.99, respectively). One sample t-test indicated significant improvement in diagnostic clinical reasoning (pre-test: M=0.97, SD=0.50; post-test: M=1.31, SD=0.64; t(64)=4.26, p<0.05, medium to large Cohen's d=0.63) and communication (pre-test: M=0.02, SD=0.16; post-test: M=0.48, SD=0.83); t(64)=4.52, p<0.05, large Cohen's d=0.83). CONCLUSION: This study demonstrates evidence supporting the reliability and validity of scores on the BRIEF-C as good indicators of diagnostic clinical reasoning and communication shared during handovers.

Interdisciplinary videoconference model for identifying potential adverse transition of care events following hospital discharge to postacute care.

Discharge from hospitals to postacute care settings is a vulnerable time for many older adults, when they may be at increased risk for errors occurring in their care. We developed the Extension for Community Healthcare Outcomes-Care Transitions (ECHO-CT) programme in an effort to mitigate these risks through a mulitdisciplinary, educational, case-based teleconference between hospital and skilled nursing facility providers. The programme was implemented in both academic and community hospitals. Through weekly sessions, patients discharged from the hospital were discussed, clinical concerns addressed, errors in care identified and plans were made for remediation. A total of 1432 discussions occurred for 1326 patients. The aim of this study was to identify errors occurring in the postdischarge period and factors that predict an increased risk of experiencing an error. In 435 discussions, an issue was identified that required further discussion (known as a transition of care event), and the majority of these were related to medications. In 14.7% of all discussions, a medical error, defined as 'any preventable event that may cause or lead to inappropriate medical care or patient harm', was identified. We found that errors were more likely to occur for patients discharged from surgical services or the emergency department (as compared with medical services) and were less likely to occur for patients who were discharged in the morning. This study shows that a number of errors may be detected in the postdischarge period, and the ECHO-CT programme provides a mechanism for identifying and mitigating these events. Furthermore, it suggests that discharging service and time of day may be associated with risk of error in the discharge period, thereby suggesting potential areas of focus for future interventions.

Can hospitalists improve COVID-19 vaccination rates?

Three years after the start of the SARS-CoV-2 virus (COVID-19) pandemic, its effects continue to affect society and COVID-19 vaccination campaigns continue to be a topic of controversy and inconsistent practice. After experiencing spikes in COVID-19 cases, our University of California Davis Health Division of Hospital Medicine sought to understand the reasons underlying the low COVID-19 vaccination rates in our county and find approaches to improve the number of vaccinations among adults admitted to the inpatient setting. This quality improvement project aimed to increase COVID-19 primary and booster vaccine efforts through a multi-pronged approach of increased collaboration with specialised staff and optimisation of use of our electronic health record system.Our key interventions focused on developing a visual reminder of COVID-19 vaccine status using the functionality of our electronic medical record (EMR), standardising documentation of COVID-19 vaccine status and enhancing team-based vaccination discussions through team huddles and partnering with inpatient care coordinators. While our grassroots approach enhanced COVID-19 vaccination rates in the inpatient setting and had additional benefits such as increased collaboration among teams, system-level efforts often made a greater impact at our healthcare centre. For other institutions interested in increasing COVID-19 vaccination rates, our top three recommendations include integrating vaccination into pre-existing workflows, optimising EMR functionality and increasing vaccine accessibility in the inpatient setting.

Measures for Persons with Spinal Cord Injury to Monitor Their Transitions in Care, Health, Function, and Quality of Life Experiences and Needs: A Protocol for Co-Developing a Self-Evaluation Tool.

Evaluating the experiences of persons with spinal cord injury (PwSCI) regarding their transitions in care and changes in health, function, and quality of life is complex, fragmented, and involves multiple tools and measures. A staged protocol was implemented with PwSCI and relevant expert stakeholders initially exploring and selecting existing measures or tools through a modified Delphi process, followed by choosing one of two options. The options were to either support the use of the 10 selected tools from the Delphi method or to co-develop one unique condensed tool with relevant measures to evaluate all four domains. The stakeholders chose to co-develop one tool to be used by persons with SCI to monitor their transition experiences across settings and care providers. This includes any issues with care or support they needed to address at the time of discharge from acute care or rehabilitation and in the community at 3, 6, and 12 months or longer post-discharge. Once developed, the tool was made available online for the final stage of the protocol, which proposes that the tool be reliability tested prior to its launch, followed by validation testing by PwSCI.

"It's a stressful, trying time for the caretaker": an interpretive description qualitative study of postoperative transitions in care for older adults with frailty from the perspectives of informal caregivers.

BACKGROUND: Older adults with frailty have surgery at a high rate. Informal caregivers often support the postoperative transition in care. Despite the growing need for family and caregiver support for this population, little is known about the experience of providing informal care to older adults with frailty during the postoperative transition in care. The purpose of this study was to explore what is important during a postoperative transition in care for older adults with frailty from the perspective of informal caregivers. METHODS: This was a qualitative study using an interpretive description methodology. Seven informal caregivers to older adults [aged ≥ 65 years with frailty (Clinical Frailty Scale score ≥ 4) who had an inpatient elective surgery] participated in a telephone-based, semi-structured interview. Audio files were transcribed and analyzed using reflexive thematic analysis. RESULTS: Four themes were constructed: (1) being informed about what to expect after surgery; (2) accessible communication with care providers; (3) homecare resources are needed for the patient; and (4) a support network for the caregivers. Theme 4 included two sub-themes: (a) respite and emotional support and (b) occupational support. CONCLUSIONS: Transitions in care present challenges for informal caregivers of older adults with frailty, who play an important role in successful transitions. Future postoperative transitional care programs should consider making targeted information, accessible communication, and support networks available for caregivers as part of facilitating successful transitions in care.

Bridging the gap: a resident-led transitional care clinic to improve post hospital care in a safety-net academic community hospital.

The transitional period between hospital discharge and primary care follow-up is a vulnerable time for patients that can result in adverse health outcomes and preventable hospital readmissions. This is especially true for patients of safety-net hospitals (SNHs) who often struggle to secure primary care access when leaving the hospital due to social, economic and cultural barriers. In this study, we describe a resident-led postdischarge clinic that serves patients discharged from NYU Langone Hospital-Brooklyn, an urban safety-net academic hospital. In our multivariable analysis, there was no statistical difference in the readmission rate between those who completed the transitional care management and those who did not (OR 1.32 (0.75-2.36), p=0.336), but there was a statistically significant increase in primary care provider (PCP) engagement (OR 0.53 (0.45-0.62), p<0.001). Overall, this study describes a postdischarge clinic model embedded in a resident clinic in an urban SNH that is associated with increased PCP engagement, but no reduction in 30-day hospital readmissions.

Estimating the impact on patient safety of enabling the digital transfer of patients' prescription information in the English NHS.

OBJECTIVES: To estimate the number and burden of medication errors associated with prescription information transfer within the National Health Service (NHS) in England and the impact of implementing an interoperable prescription information system (a single digital prescribing record shared across NHS settings) in reducing these errors. METHODS: We constructed a probabilistic mathematical model. We estimated the number of transition medication errors that would be undetected by standard medicines reconciliation, based on published literature, and scaled this up based on the annual number of hospital admissions. We used published literature to estimate the proportion of errors that lead to harm and applied this to the number of errors to estimate the associated burden (healthcare resource use and deaths). Finally, we used reported effect sizes for electronic prescription information sharing interventions to estimate the impact of implementing an interoperable prescription information system on number of errors and resulting harm. RESULTS: Annually, around 1.8 million (95% credibility interval (CrI) 1.3 to 2.6 million) medication errors were estimated to occur at hospital transitions in England, affecting approximately 380 000 (95% CrI 260 397 to 539 876) patient episodes. Harm from these errors affects around 31 500 (95% CrI 22 407 to 42 906) patients, with 36 500 (95% CrI 25 093 to 52 019) additional bed days of inpatient care (costing around £17.8 million (95% CrI £12.4 to £24.9 million)) and >40 (95% CrI 9 to 146) deaths. Assuming the implementation of an interoperable prescription information system could reduce errors by 10% and 50%, there could be 180 000-913 000 fewer errors, 3000-15 800 fewer people who experience harm and 4-22 lives saved annually. CONCLUSIONS: An interoperable prescription information system could provide major benefits for patient safety. Likely additional benefits include healthcare professional time saved, improved patient experience and care quality, quicker discharge and enhanced cross-organisational medicines optimisation. Our findings provide vital safety and economic evidence for the case to adopt interoperable prescription information systems.

Improving Transitions in Care for the Child with Medical Complexity Using Betty Neuman's Systems Model.

Children with medical complexity are an increasing population with frequent use of intensive care services within hospitals. As children's health improves, they are often transferred to a general unit before being discharged to home. This transition often leads to an acute decline in health, resulting in emergent interventions. Betty Neuman's systems model provides the foundation to guide prevention interventions on stress mitigation to promote stability. An evidence-based transition bundle of care may be a valuable tool to prevent stress at the time of transfer from the intensive care unit and prevent deterioration.

Identifying and mapping measures of medication safety during transfer of care in a digital era: a scoping literature review.

BACKGROUND: Measures to evaluate high-risk medication safety during transfers of care should span different safety dimensions across all components of these transfers and reflect outcomes and opportunities for proactive safety management. OBJECTIVES: To scope measures currently used to evaluate safety interventions targeting insulin, anticoagulants and other high-risk medications during transfers of care and evaluate their comprehensiveness as a portfolio. METHODS: Embase, Medline, Cochrane and CINAHL databases were searched using scoping methodology for studies evaluating the safety of insulin, anticoagulants and other high-risk medications during transfer of care. Measures identified were extracted into a spreadsheet, collated and mapped against three frameworks: (1) 'Key Components of an Ideal Transfer of Care', (2) work systems, processes and outcomes and (3) whether measures captured past harms, events in real time or areas of concern. The potential for digital health systems to support proactive measures was explored. RESULTS: Thirty-five studies were reviewed with 162 measures in use. Once collated, 29 discrete categories of measures were identified. Most were outcome measures such as adverse events. Process measures included communication and issue identification and resolution. Clinic enrolment was the only work system measure. Twenty-four measures captured past harm (eg, adverse events) and six indicated future risk (eg, patient feedback for organisations). Two real-time measures alerted healthcare professionals to risks using digital systems. No measures were of advance care planning or enlisting support. CONCLUSION: The measures identified are insufficient for a comprehensive portfolio to assess safety of key medications during transfer of care. Further measures are required to reflect all components of transfers of care and capture the work system factors contributing to outcomes in order to support proactive intervention to reduce unwanted variation and prevent adverse outcomes. Advances in digital technology and its employment within integrated care provide opportunities for the development of such measures.

"I can't imagine having to do it on your own": a qualitative study on postoperative transitions in care from the perspectives of older adults with frailty.

BACKGROUND: Adults aged 65 and older have surgery more often than younger people and often live with frailty. The postoperative transition in care from hospital to home after surgey is a challenging time for older adults with frailty as they often experience negative outcomes. Improving postoperative transitions in care for older adults with frailty is a priority. However, little knowledge from the perspective of older adults with frailty is available to support meaningful improvements in postoperative transitions in care. OBJECTIVE: To explore what is important to older adults with frailty during a postoperative transition in care. METHODS: This qualitative study used an interpretive description methodology. Twelve adults aged ≥ 65 years with frailty (Clinical Frailty Scale score ≥ 4) who had an inpatient elective surgery and could speak in English participated in a telephone-based, semi-structured interview. Audio files were transcribed and analyzed using thematic analysis. RESULTS: Five themes were constructed: 1) valuing going home after surgery; 2) feeling empowered through knowledge and resources; 3) focusing on medical and functional recovery; 4) informal caregivers and family members play multiple integral roles; and 5) feeling supported by healthcare providers through continuity of care. Each theme had 3 sub-themes. CONCLUSION: Future programs should focus on supporting patients to return home by empowering patients with resources and clear communication, ensuring continuity of care, creating access to homecare and virtual support, focusing on functional and medical recovery, and recognizing the invaluable role of informal caregivers.

Telehealth-based transitional care management programme to improve access to care.

BACKGROUND: The transition from hospital to home is a vulnerable time for patients and families that can be improved through care coordination and structured discharge planning. LOCAL PROBLEM: Our organisation aimed to develop and expand a programme that could improve 30-day readmission rates on overall and disease-specific populations by assessing the impact of a telehealth outreach by a registered nurse (RN) after discharge from an acute care setting on 30-day hospital readmission. METHODS: This is a prospective observational design conducted from May 2021 to December 2022 with an urban, non-academic, acute care hospital in Westchester County, New York. Outcomes for patients discharged home following inpatient hospitalisation were analysed within this study. We analysed overall and disease-specific populations (congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and pneumonia (PNA)) as compared with a 40-month prestudy cohort. INTERVENTIONS: Patients were identified in a non-random fashion meeting criterion of being discharged home after an inpatient admission. Participants received a telephonic outreach by an RN within 72 hours of discharge. Contacted patients were asked questions addressing discharge instructions, medication access, follow-up appointments and social needs. Patients were offered services and resources based on their individual needs in response to the survey. RESULTS: 68.2% of the 24 808 patients were contacted to assess and offer services. Median readmission rates for these patients were 1.2% less than the prestudy cohort (11.0% to 9.8%). Decreases were also noted for disease-specific conditions (CHF (14.3% to 9.1%), COPD (20.0% to 13.4%) and PNA (14.9% to 14.0%)). Among those in the study period, those that were contacted between 24 and 48 hours after discharge were 1.2 times less likely to be readmitted than if unable to be contacted (254/3742 (6.8%) vs 647/7866 (8.2%); p=0.005). CONCLUSIONS: Using a multifaceted telehealth approach to improve patient engagement and access reduced 30-day hospital readmission for patients discharged from the acute care setting.

Implementation of a standardised accept note to improve communication during inter-hospital transfer: a prospective cohort study.

IMPORTANCE: The transfer of patients between hospitals (interhospital transfer, IHT), exposes patients to communication errors and gaps in information exchange. OBJECTIVE: To design and implement a standardised accept note to improve communication during medical service transfers, and evaluate its impact on patient outcomes. DESIGN: Prospective interventional cohort study. SETTING: A 792-bed tertiary care hospital. PARTICIPANTS: All patient transfers from any acute care hospital to the general medicine, cardiology, oncology and intensive care unit (ICU) services between August 2020 and June 2022. INTERVENTIONS: A standardised accept note template was developed over a 9-month period with key stakeholder input and embedded in the electronic health record, completed by nurses within the hospital's Access Centre. MAIN OUTCOMES AND MEASURES: Primary outcome was clinician-reported medical errors collected via surveys of admitting clinicians within 72 hours after IHT patient admission. Secondary outcomes included clinician-reported failures in communication; presence and 'timeliness' of accept note documentation; patient length of stay (LOS) after transfer; rapid response or ICU transfer within 24 hours and in-hospital mortality. All outcomes were analysed postintervention versus preintervention, adjusting for patient demographics, diagnosis, comorbidity, illness severity, admitting service, time of year, hospital COVID census and census of admitting service and admitting team on date of admission. RESULTS: Of the 1004 and 654 IHT patients during preintervention and postintervention periods, surveys were collected on 735 (73.2%) and 462 (70.6%), respectively. Baseline characteristics were similar among patients in each time period and between survey responders and non-responders. Adjusted analyses demonstrated a 27% reduction in clinician-reported medical error rates postimplementation versus preimplementation (11.5 vs 15.8, adjusted OR (aOR) 0.73, 95% CI 0.53 to 0.99). Secondary outcomes demonstrated lower adjusted odds of clinician-reported failures in communication (aOR 0.88; 0.78 to 0.98) and rapid response/ICU transfer (aOR 0.57; 0.34 to 0.97), and improved presence (aOR 2.30; 1.75 to 3.02) and timeliness (-21.4 hours vs -8.7 hours, p<0.001) of accept note documentation. There were no significant differences in LOS or mortality. CONCLUSIONS AND RELEVANCE: Among 1658 medical patient transfers, implementing a standardised accept note was associated with improved presence and timeliness of accept note documentation, clinician-reported medical errors, failures in communication and clinical decline following transfer, suggesting that improving communication during IHT can improve patient outcomes.

TransitionED: A protocol for Co-designing and implementing Canadian practice guidelines for transitions for youth with eating disorders.

OBJECTIVE: Limited guidelines inform the transition from paediatric to adult healthcare for youth and young adults (YYA) with eating disorders (EDs). This study will develop, implement, and evaluate Canadian Clinical Practice Guidelines for ED transition, including identifying the relevant measurement and evaluation tools for transition readiness and continuity of care. METHODS: This study consists of three phases. Phase 1 involves conducting a scoping review of the evidence on transition interventions, outcomes, and measurement tools for YYA with EDs, along with guideline development using the modified Delphi method. Phase 2 identifies the contextual/cultural factors relevant to guideline implementation and co-designing an implementation protocol with governance committees and research partners. Phase 3 involves the application and evaluation of the proposed guide lines using the implementation protocol, and assessing the acceptability and feasibility of a prototype transition intervention in two Canadian paediatric ED programs. CONCLUSIONS: Results will provide the knowledge needed to enhance the lives of YYA, improve the effectiveness of the ED care system, and support the scale of the transition guidelines across Canada. These guidelines will have international relevance by potentially informing the field on how to support young people with EDs transitioning in similar funding structures and systems of care.

Multicomponent Pharmacist Intervention Did Not Reduce Clinically Important Medication Errors for Ambulatory Patients Initiating Direct Oral Anticoagulants.

BACKGROUND: Anticoagulants including direct oral anticoagulants (DOACs) are among the highest-risk medications in the United States. We postulated that routine consultation and follow-up from a clinical pharmacist would reduce clinically important medication errors (CIMEs) among patients beginning or resuming a DOAC in the ambulatory care setting. OBJECTIVE: To evaluate the effectiveness of a multicomponent intervention for reducing CIMEs. DESIGN: Randomized controlled trial. PARTICIPANTS: Ambulatory patients initiating a DOAC or resuming one after a complication. INTERVENTION: Pharmacist evaluation and monitoring based on the implementation of a recently published checklist. Key elements included evaluation of the appropriateness of DOAC, need for DOAC affordability assistance, three pharmacist-initiated telephone consultations, access to a DOAC hotline, documented hand-off to the patient's continuity provider, and monitoring of follow-up laboratory tests. CONTROL: Coupons and assistance to increase the affordability of DOACs. MAIN MEASURE: Anticoagulant-related CIMEs (Anticoagulant-CIMEs) and non-anticoagulant-related CIMEs over 90 days from DOAC initiation; CIMEs identified through masked assessment process including two physician adjudication of events presented by a pharmacist distinct from intervention pharmacist who reviewed participant electronic medical records and interview data. ANALYSIS: Incidence and incidence rate ratio (IRR) of CIMEs (intervention vs. control) using multivariable Poisson regression modeling. KEY RESULTS: A total of 561 patients (281 intervention and 280 control patients) contributed 479 anticoagulant-CIMEs including 31 preventable and ameliorable ADEs and 448 significant anticoagulant medication errors without subsequent documented ADEs (0.95 per 100 person-days). Failure to perform required blood tests and concurrent, inappropriate usage of a DOAC with aspirin or NSAIDs were the most common anticoagulant-related CIMEs despite pharmacist documentation systematically identifying these issues when present. There was no reduction in anticoagulant-related CIMEs among intervention patients (IRR 1.17; 95% CI 0.98-1.42) or non-anticoagulant-related CIMEs (IRR 1.05; 95% CI 0.80-1.37). CONCLUSION: A multi-component intervention in which clinical pharmacists implemented an evidence-based DOAC Checklist did not reduce CIMEs. NIH TRIAL NUMBER: NCT04068727.

Improving hand therapy delivery during care transitions in multisystem trauma patients.

High-quality hand therapy is critical to maximising functional capacity and optimising overall outcomes following hand injuries. Therapy delivery requires clear communication between surgeons and occupational therapists. At Sunnybrook Health Sciences Centre (SHSC), Canada's largest tertiary care centre, suboptimal communication is a significant barrier to efficient hand therapy delivery in acute multisystem trauma patients. A baseline audit at SHSC found that 41% of hand therapy orders required clarification and 35% of patients waited over 24 hours before their order was fulfilled. In many cases, communication errors created unacceptably long delays that were suspected by surgeon stakeholders to impede patient outcomes. This highlighted an opportunity for investigation and system improvement.Using process mapping methodology, we outlined standard process involved in patient care and identified barriers to successful communication. We collaborated with key stakeholders to codesign a standardised template for care orders. We aimed to improve order clarity and consistency with the goal of reducing the incidence of clarification and delays.Postimplementation, the percentage of hand therapy orders requiring clarification was decreased to 24%. The number of patients waiting over 24 hours for therapy was also reduced; however, further investigation is required to verify this finding. In addition, essential order components were more consistently and comprehensively included. Next steps of this work include expanding the use of the order template outside of the multisystem trauma population and improving the communication of hand therapy at discharge from hospital.

Feasibility of a multidisciplinary Transitional Pain Service in spine surgery patients to minimise opioid use and improve perioperative outcomes: a quality improvement study.

INTRODUCTION: Spine surgery patients have high rates of perioperative opioid consumption, with a chronic opioid use prevalence of 20%. A proposed solution is the implementation of a Transitional Pain Service (TPS), which provides patient-tailored multidisciplinary care. Its feasibility has not been demonstrated in spine surgery. The main objective of this study was to evaluate the feasibility of a TPS programme in patients undergoing spine surgery. METHODS: Patients were recruited between July 2020 and November 2021 at a single, tertiary care academic centre. Success of our study was defined as: (1) enrolment: ability to enrol ≥80% of eligible patients, (2) data collection: ability to collect data for ≥80% of participants, including effectiveness measures (oral morphine equivalent (OME) and Visual Analogue Scale (VAS)-perceived analgesic management and overall health) and programme resource requirements measures (appointment attendance, 60-day return to emergency and length of stay), and (3) efficacy: estimate potential programme effectiveness defined as ≥80% of patients weaned back to their intake OME requirements at programme discharge. RESULTS: Thirty out of 36 (83.3%) eligible patients were enrolled and 26 completed the TPS programme. The main programme outcomes and resource measures were successfully tracked for >80% of patients. All 26 patients had the same or lower OME at programme discharge than at intake (intake 38.75 mg vs discharge 12.50 mg; p<0.001). At TPS discharge, patients reported similar overall health VAS (pre 60.0 vs post 70.0; p=0.14), improved scores for VAS-perceived analgesic management (pre 47.6 vs post 75.6; p<0.001) and improved Brief Pain Inventory pain intensity (pre 39.1 vs post 25.0; p=0.02). CONCLUSION: Our feasibility study successfully met or exceeded our three main objectives. Based on this success and the defined clinical need for a TPS programme, we plan to expand our TPS care model to include other surgical procedures at our centre.

Implementation of medication reconciliation at admission and discharge in Ministry of Defense Health Services hospitals: a multicentre study.

There is potential for many medication errors to occur due to the complex medication use process. The medication reconciliation process can significantly lower the incidence of medication errors that may arise from an incomplete or inaccurate medication history as well as reductions in length of hospital stay, patients' readmissions and lower healthcare costs.The quality improvement collaborative project was conducted as a pilot study in two hospitals, then implemented on a broader scale in 18 hospitals in Saudi Arabia. The goal of the project was to reduce the percentage of patients with at least one outstanding unintentional discrepancy at admission by 50%, over 16-month period (July 2020-November 2021). Our interventions were based on the High 5's project medication reconciliation WHO, and Medications at Transitions and Clinical Handoffs toolkit for medication reconciliation by Agency for Healthcare Research and Quality. Improvement teams used the Institute of Healthcare Improvement's (IHI's) Model for improvement as a tool for testing and implementing changes. Collaboration and learning between hospitals were facilitated by conducting learning sessions using the IHI's Collaborative Model for Achieving Breakthrough Improvement. The improvement teams underwent three cycles.By the end of the project significant improvements were observed. The percentage of patients with at least one outstanding unintentional discrepancy at admission showed a 20% reduction (27% before, 7% after; p value <0.05) (Relative Risk (RR) 0.74) with a mean reduction in the number of discrepancies per patient by 0.74. The percentage of patients with at least one outstanding unintentional discrepancy at discharge showed 12% reduction (17% before, 5% after; p value <0.05) (RR 0.71) with a mean reduction in the number of discrepancies per patient by 0.34.Compliance to medication reconciliation documentation within 24 hours of admission and discharge showed significant improvement by an average of 17% and 24%, respectively. Additionally, the implementation of medication reconciliation had a negative correlation with the percentage of patients with at least one outstanding unintentional discrepancy at admission and discharge.

Clinical pharmacist intervention to improve medication safety for hip fracture patients through secondary and primary care settings: a nonrandomised controlled trial.

BACKGROUND: Hip fracture patients face a patient safety threat due to medication discrepancies and adverse drug reactions when they have a combination of high age, polypharmacy and several care transitions. Consequently, optimised pharmacotherapy through medication reviews and seamless communication of medication information between care settings is necessary. The primary aim of this study was to investigate the impact on medication management and pharmacotherapy. The secondary aim was to evaluate implementation of the novel Patient Pathway Pharmacist intervention for hip fracture patients. METHODS: Hip fracture patients were included in this nonrandomised controlled trial, comparing a prospective intervention group (n = 58) with pre-intervention controls who received standard care (n = 50). The Patient Pathway Pharmacist intervention consisted of the steps: (A) medication reconciliation at admission to hospital, (B) medication review during hospitalisation, (C) recommendation for the medication information in the hospital discharge summary, (D) medication reconciliation at admission to rehabilitation, and (E) medication reconciliation and (F) review after hospital discharge. The primary outcome measure was quality score of the medication information in the discharge summary (range 0-14). Secondary outcomes were potentially inappropriate medications (PIMs) at discharge, proportion receiving pharmacotherapy according to guidelines (e.g. prophylactic laxatives and osteoporosis pharmacotherapy), and all-cause readmission and mortality. RESULTS: The quality score of the discharge summaries was significantly higher for the intervention patients (12.3 vs. 7.2, p < 0.001). The intervention group had significantly less PIMs at discharge (- 0.44 (95% confidence interval - 0.72, - 0.15), p = 0.003), and a higher proportion received prophylactic laxative (72 vs. 35%, p < 0.001) and osteoporosis pharmacotherapy (96 vs. 16%, p < 0.001). There were no differences in readmission or mortality 30 and 90 days post-discharge. The intervention steps were delivered to all patients (step A, B, E, F = 100% of patients), except step (C) medication information at discharge (86% of patients) and step (D) medication reconciliation at admission to rehabilitation (98% of patients). CONCLUSION: The intervention steps were successfully implemented for hip fracture patients and contributed to patient safety through a higher quality medication information in the discharge summary, fewer PIMs and optimised pharmacotherapy. TRIAL REGISTRATION: NCT03695081.

Transitions in mental health and addiction care for youth and their families: a scoping review of needs, barriers, and facilitators.

INTRODUCTION: Transitional-aged youth (TAY) with mental health and/or addictions (MHA) concerns and their families experience significant challenges finding, accessing, and transitioning through needed MHA care. To develop appropriate supports that assist TAY and their families in navigating MHA care, their experiences of transitions in the MHA care system must be better understood. This scoping review identifies and explores the needs, barriers, and facilitators for TAY and their families when transitioning through MHA care. METHODS: This scoping review commenced with a search of five relevant databases. Three research team members were involved in title, abstract, and full-text scanning and data extraction. Sources focusing on TAY anywhere between the ages of 12-29 years and meeting the study objectives were included. Extractions compiled background and narrative information about the nature and extent of the data. Analysis and synthesis of findings involved numerical description of the general information extracted (e.g., numbers of sources by country) and thematic analysis of narrative information extracted (e.g., family involvement in TAY help-seeking). RESULTS: A total of 5894 sources were identified. Following title and abstract scanning, 1037 sources remained for full-text review. A total of 66 sources were extracted. Findings include background information about extracted sources, in addition to five themes that emerged pertaining to barriers and facilitators to access and transitions through care and the needs and roles of TAY and families in supporting help-seeking and care transitions: holistic supports, proactive preparation, empowering TAY and families, collaborative relationships, and systemic considerations. These five themes demonstrate approaches to care that can ensure TAY and families' needs are met, barriers are mitigated, and facilitators are enhanced. CONCLUSION: This review provides essential contextual information regarding TAY with MHA concerns and their families' needs when seeking care. Such findings lend to an enhanced understanding of how MHA programs can support this population's needs, involve family members as appropriate, reduce the barriers experienced, and work to build upon existing facilitators.