Implementation of a Medication Reconciliation Risk Stratification Tool Integrated within an electronic health record: A Case Series of Three Academic Medical Centers.

Medication errors during transitions of care are common, dangerous and costly. Medication reconciliation can help mitigate this risk, but it is a complex and time-consuming process when performed properly. Increasingly, pharmacy staff have been engaged to help improve medication reconciliation. However, many organizations lack the resources and staff required to perform accurate medication histories and other reconciliation tasks on all patients. We describe how three academic medical centers implemented risk scoring systems to allocate limited pharmacy resources to patients with the highest likelihood of medication reconciliation related errors. We found that (1) development of a tailored medication risk scoring system and integration into the electronic health record is feasible, (2) workflow around the risk calculator is critical to the success of the implementation, and (3) the complex coordination of professional disciplines during the medication reconciliation process remains an ongoing challenge at all three institutions.

Impact of Protocolized Pharmacist Intervention on Critical Activated Partial Thromboplastin Time Values With Heparin Infusions.

Background: Unfractionated heparin (UFH) infusions are commonly managed with nurse-driven nomograms titrated to activated partial thromboplastin time (aPTT). In some patients, anti-Xa values may be more appropriate measures of anticoagulation. At the present institution, an update to the nurse-driven aPTT nomogram requires pharmacist notification and clinical assessment for critically supratherapeutic aPTT results. Objective: The purpose of this study was to evaluate the efficacy and safety of the nomogram update. Methods: A single-center, retrospective, pre-post analysis was conducted in patients treated with UFH who experienced a critical aPTT during the 6 months preceding and following the nomogram update. Patients with erroneous critical aPTT results were excluded. The primary endpoint was the time in therapeutic range (Rosendaal method) from the first critical aPTT until UFH discontinuation. Secondary endpoints included the proportion of patients transitioned to anti-Xa monitoring and the incidence of Bleeding Academic Research Consortium (BARC) 2, 3, 5 bleeding. Data were analyzed by the χ2 test. The study was institutional review board approved. Results: Of 277 UFH infusions, 142 belonged to the pre-implementation group and 135 to the post-implementation group. Baseline aPTTs were similar between the 2 groups. Time in therapeutic range was 58.1% versus 62.4% of between groups (P = .467). UFH was transitioned to pharmacist-driven anti-Xa monitoring in 16.2% versus 40.3% of patients (P < .001). BARC 2, 3, 5 bleeding occurred in 23.2% versus 13.4% of patients (P < .001). Conclusions: Application of these data suggest improved safety and efficacy outcomes with directed pharmacist management of UFH in patients with critically elevated aPTTs.

Influence of Psychotropic Medications on Readmission Rates of Patients Receiving a Pharmacist Discharge Medication Reconciliation.

BACKGROUND: Current literature suggests that patients with psychiatric disorders are at an increased risk for inpatient readmission. This study evaluated the impact of pharmacist-driven discharge medication reconcilliation (DMR) on readmission rates of patients discharged with one or more psychotropic medications. METHODS: This study was a retrospective review of patients receiving a pharmacist-driven DMR. The primary outcome was to compare the prevalence of 30-day readmission rates among patients who had a pharmacist DMR between patients who had at least one psychotropic medication upon discharge versus those without psychotropic medications. Secondary objectives were to (1) compare the number of medication discrepancies and pharmacist interventions prior to discharge and (2) compare prevalence of medical comorbidities between patients who had at least one psychotropic medication upon discharge versus those without psychotropic medications. RESULTS: A total of 151 subjects were included who had a DMR and either at least one psychotropic medication at discharge (n = 69) or no psychotropic medications at discharge (n = 82). The 30-day readmission rates were similar between both groups (P = .609). The mean number of discrepancies (P < .001) and number of pharmacist interventions (P = .005) were significantly greater in patients who had at least one psychotropic medication upon discharge compared to those without psychotropic medication. CONCLUSIONS: The prevalence of 30-day readmissions was similar between the two groups; however, patients discharged with at least one psychotropic medication had a greater number of discrepancies requiring significantly more discharge interventions during a pharmacist DMR.

A Correlation of a Medication-Focused Risk Score to Medication Errors at Discharge.

Pharmacy transitions-of-care services at the time of hospital discharge are helpful in reducing medication errors. Validated risk tools are commonly used by pharmacists to identify patients at greatest benefit of these services. However, current tools lack assessment of medication-related risk factors and predict hospital readmissions rather than medication errors. To address this, a novel medication-focused risk tool (UCSD-Rx risk score) was created to help classify patients at a higher risk for medication errors. This study was split into 2 phases aimed to internally validate the risk score. Phase I of the study compared the predictability of 30-day unplanned readmissions between the UCSD-Rx risk score and a well-validated risk tool, the LACE+ index. To further specify our risk score for pharmacist use, phase II of the study analyzed the predictability of the risk score to medication errors at discharge. Phase I demonstrated similar classification performance of 30-day unplanned readmissions between the UCSD-Rx risk score (C-statistic, 0.66; 95% confidence interval [CI], 0.64-0.68; P < .0001) and the LACE+ index (C-statistic, 0.69; 95%CI, 0.67-0.71; P < .0001). In phase II, logistic regression showed an increasing UCSD-Rx risk score was predictive of individuals who would experience a medication error at discharge (odds ratio, 1.068; 95%CI, 1.005-1.136; P = .035). Results of this study demonstrate that the UCSD-Rx risk score is a promising tool targeted for pharmacist use to identify patients that may benefit most from transitions-of-care services prior to discharge.