Implementation of admission medication reconciliation at two academic health sciences centres: challenges and success factors.

Admission Medication Reconciliation (Med Rec) is an organizational practice designed to ensure patients' pre-admission medications are ordered correctly upon hospital admission. We describe the implementation of admission Med Rec at two academic health sciences centres, each having designed distinctly different processes. Common challenges encountered included the multi-step, inter-professional nature of Med Rec, staffing resource and workload concerns and frequent medical staff turnover in a teaching environment. Both teams found that participation in a national safety collaborative enabled the pilot initially; however, they later found the outcome measures suggested by the collaborative less useful and switched to internal compliance measures for establishing maintenance and spread. Common themes were identified among the critical success factors, with unique variations at each centre. Both teams acknowledged accreditation standards to be a major accelerator of implementation and spread. Using different measures of implementation success at each centre, the majority of patient admissions on the pilot units are complying with admission Med Rec. However, very high levels of compliance remain elusive. At Sunnybrook Health Sciences Centre's pilot unit, 62-77% of patients are being screened by a pharmacist and 65-75% of high-risk patients identified are undergoing Med Rec by a pharmacist. At The Hospital for Sick Children's pilot unit, 72-88% of patients have a physician's primary medication history documented on a Med Rec form and 57-73% of patients are also undergoing Med Rec by a nurse or pharmacist.

Prospective trial of accelerated partial breast intensity-modulated radiotherapy.

PURPOSE: To examine the feasibility and acute toxicities of an accelerated, partial breast, intensity-modulated radiotherapy (IMRT) protocol. METHODS AND MATERIALS: Between February 2004 and August 2005, 55 patients with Stage I breast cancer and initial follow-up were enrolled at four facilities on a HealthONE and Western institutional review board-approved accelerated partial breast IMRT protocol. All patients were treated in 10 equal fractions delivered twice daily within 5 consecutive days. The first 7 patients were treated to 34 Gy, and the remaining 48 patients were treated to 38.5 Gy. RESULTS: The median follow-up after IMRT was 10 months (range, <1-19) and after diagnosis was 11.5 months (range, 2-21). No local or distant recurrences developed. The T stage distribution was as follows: T1a in 11 patients, T1b in 24, and T1c in 20. The median tumor size was 9 mm (range, 1-20 mm). Breast cosmesis was judged by the patient as poor by 2, good by 12, and excellent by 40 (1 patient was legally blind) and by the physician as poor for 1, good for 10, and excellent for 44 patients. Breast pain, as judged by patient, was none in 34, mild in 19, moderate in 2, and severe in 0 patients. There was a single report of telangiectasia but no incidents of significant edema. Compared with historic controls for whom three-dimensional treatment planning techniques were used, IMRT provided similar dose delivery to the target while reducing the volume of normal breast included in the 100%, 75%, and 50% isodose lines. CONCLUSION: This initial report prospectively explored the feasibility of accelerated partial breast IMRT. After short-term follow-up, the dose delivery and clinical outcomes were very acceptable. We believe this regimen deserves additional investigation under institutional review board guidance.

Unintended medication discrepancies at the time of hospital admission.

BACKGROUND: Prior studies suggest that unintended medication discrepancies that represent errors are common at the time of hospital admission. These errors are particularly worthy of attention because they are not likely to be detected by computerized physician order entry systems. METHODS: We prospectively studied patients reporting the use of at least 4 regular prescription medications who were admitted to general internal medicine clinical teaching units. The primary outcome was unintended discrepancies (errors) between the physicians' admission medication orders and a comprehensive medication history obtained through interview. We also evaluated the potential seriousness of these discrepancies. All discrepancies were reviewed with the medical team to determine if they were intentional or unintentional. All unintended discrepancies were rated for their potential to cause patient harm. RESULTS: After screening 523 admissions, 151 patients were enrolled based on the inclusion criteria. Eighty-one patients (53.6%; 95% confidence interval, 45.7%-61.6%) had at least 1 unintended discrepancy. The most common error (46.4%) was omission of a regularly used medication. Most (61.4%) of the discrepancies were judged to have no potential to cause serious harm. However, 38.6% of the discrepancies had the potential to cause moderate to severe discomfort or clinical deterioration. CONCLUSIONS: Medication errors at the time of hospital admission are common, and some have the potential to cause harm. Better methods of ensuring an accurate medication history at the time of hospital admission are needed.

Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review.

BACKGROUND: Over a quarter of hospital prescribing errors are attributable to incomplete medication histories being obtained at the time of admission. We undertook a systematic review of studies describing the frequency, type and clinical importance of medication history errors at hospital admission. METHODS: We searched MEDLINE, EMBASE and CINAHL for articles published from 1966 through April 2005 and bibliographies of papers subsequently retrieved from the search. We reviewed all published studies with quantitative results that compared prescription medication histories obtained by physicians at the time of hospital admission with comprehensive medication histories. Three reviewers independently abstracted data on methodologic features and results. RESULTS: We identified 22 studies involving a total of 3755 patients (range 33-1053, median 104). Errors in prescription medication histories occurred in up to 67% of cases: 10%- 61% had at least 1 omission error (deletion of a drug used before admission), and 13%- 22% had at least 1 commission error (addition of a drug not used before admission); 60%- 67% had at least 1 omission or commission error. Only 5 studies (n = 545 patients) explicitly distinguished between unintentional discrepancies and intentional therapeutic changes through discussions with ordering physicians. These studies found that 27%- 54% of patients had at least 1 medication history error and that 19%- 75% of the discrepancies were unintentional. In 6 of the studies (n = 588 patients), the investigators estimated that 11%-59% of the medication history errors were clinically important. INTERPRETATION: Medication history errors at the time of hospital admission are common and potentially clinically important. Improved physician training, accessible community pharmacy databases and closer teamwork between patients, physicians and pharmacists could reduce the frequency of these errors.

Cost of medications in patients admitted to a burn center.

BACKGROUND: Few studies have examined the cost associated with burn patients, and those which have been conducted have generally focused on overall hospitalization costs associated with these patients. No studies to date have examined the overall drug utilization and costs of medications used in the treatment of burn patients. OBJECTIVE: To describe the pattern of drug utilization and associated costs for the treatment of patients admitted to the Ross Tilley Burn Centre at Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, Canada. METHODS: A retrospective chart review was conducted based on the medical records of 30 adult patients (>18 years old) consecutively admitted to the burn center between 1 August 1999 and 30 September 1999. Charts were examined to determine drugs administered, doses and duration of use. Medications administered in the operating room were excluded from the analysis. Drug costs were calculated using hospital acquisition costs (1999 Canadian dollars [$Can]) and medications were categorized by pharmacological class according to the American Hospital Formulary Service. Demographic information for the patients was extracted from the burn center's database. The economic analysis was performed from the perspective of the hospital burn center. A descriptive statistical analysis was completed for all variables; the Pearson correlation coefficient was used to examine the relationship between certain variables. A sensitivity analysis was conducted to examine the impact of patient subgroups on certain variables RESULTS: Of the 28 patients included in the analysis, 19 were admitted with acute burn injuries, two with toxic epidermal necrolysis and seven for post-burn reconstructive surgery. Patients admitted for acute burns or toxic epidermal necrolysis had the highest associated drug costs. On average, patients received 13 different drugs representing four different pharmacological categories. The mean daily drug cost per patient was $Can18.39 and the mean expenditure per admission was $Can792.97. Opioid analgesics and sedatives accounted for the largest expenditure (50.9%), followed by anti-infective agents (23.4%). For patients admitted with acute burns, there was a good correlation between daily drug costs and mortality risk (r = 0.82, p < 0.001). The findings from this study group were used to extrapolate annual expenses for medications in the burn center and these were estimated to exceed $Can280 300 in 2003. CONCLUSION: The findings of this retrospective analysis serve to elucidate the patterns of drug utilization within a population of burn patients and confirm the significant impact of a burn center on an institution's drug expenditure.