A Multi-method Exploratory Evaluation of a Service Designed to Improve Medication Safety for Patients with Monitored Dosage Systems Following Hospital Discharge.

BACKGROUND AND OBJECTIVE: Medication safety problems are common post-hospital discharge, and an important global healthcare improvement target. The Transfers of Care Around Medicines (TCAM) service was launched by a National Health Service Trust in the North-West of England, initially focusing on patients with new or existing Monitored Dosage Systems (MDS). The TCAM service is designed to enable the prompt transfer of medication information, with referrals made by hospitals at discharge to a named community pharmacy. This study aimed to explore the utilisation and impact of the TCAM service on medication safety. METHODS: The evaluation included a descriptive analysis of 3033 anonymised patient referrals to 71 community pharmacies over a 1-year period alongside an assessment of the impact of the TCAM service on unintentional medication discrepancies and adverse drug events using a retrospective before-and-after study design. Impact data were collected across 18 general practices by 16 trained clinical pharmacists. RESULTS: Most patient referrals (70%, 2126/3033) were marked as 'completed' by community pharmacies, with 15% of completed referrals delayed beyond 30 days. Screening of 411 patient records by clinical pharmacists yielded no statistically significant difference in unintentional medication discrepancies or adverse drug event rates following TCAM implementation using a multivariable regression analysis (unintentional medication discrepancies adjusted odds ratio = 0.79 [95% confidence interval 0.44-1.44, p = 0.46]; and adverse drug events adjusted odds ratio = 1.19 [95% confidence interval 0.57-2.45, p = 0.63]), although there remained considerable uncertainty. CONCLUSIONS: The TCAM service facilitated a number of community pharmacy services offered to patients with monitored dosage systems; but the impact of the intervention on unintentional medication discrepancies and adverse drug event rates post-hospital discharge for this patient group was uncertain. The results of this exploratory study can inform the ongoing implementation of the TCAM service at hospital discharge and highlight the need to understand service implementation in different contexts, which may influence its impact on medication safety.

Analysis of the nature and contributory factors of medication safety incidents following hospital discharge using National Reporting and Learning System (NRLS) data from England and Wales: a multi-method study.

Introduction: Improving medication safety during transition of care is an international healthcare priority. While existing research reveals that medication-related incidents and associated harms may be common following hospital discharge, there is limited information about their nature and contributory factors at a national level which is crucial to inform improvement strategy. Aim: To characterise the nature and contributory factors of medication-related incidents during transition of care from secondary to primary care. Method: A retrospective analysis of medication incidents reported to the National Reporting and Learning System (NRLS) in England and Wales between 2015 and 2019. Descriptive analysis identified the frequency and nature of incidents and content analysis of free text data, coded using the Patient Safety Research Group (PISA) classification, examined the contributory factors and outcome of incidents. Results: A total of 1121 medication-related incident reports underwent analysis. Most incidents involved patients over 65 years old (55%, n = 626/1121). More than one in 10 (12.6%, n = 142/1121) incidents were associated with patient harm. The drug monitoring (17%) and administration stages (15%) were associated with a higher proportion of harmful incidents than any other drug use stages. Common medication classes associated with incidents were the cardiovascular (n = 734) and central nervous (n = 273) systems. Among 408 incidents reporting 467 contributory factors, the most common contributory factors were organisation factors (82%, n = 383/467) (mostly related to continuity of care which is the delivery of a seamless service through integration, co-ordination, and the sharing of information between different providers), followed by staff factors (16%, n = 75/467). Conclusion: Medication incidents after hospital discharge are associated with patient harm. Several targets were identified for future research that could support the development of remedial interventions, including commonly observed medication classes, older adults, increase patient engagement, and improve shared care agreement for medication monitoring post hospital discharge. Plain language summary: Study using reports about unsafe or substandard care mainly written by healthcare professionals to better understand the type and causes of medication safety problems following hospital discharge Why was the study done? The safe use of medicines after hospital discharge has been highlighted by the World Health Organization as an important target for improvement in patient care. Yet, the type of medication problems which occur, and their causes are poorly understood across England and Wales, which may hamper our efforts to create ways to improve care as they may not be based on what we know causes the problem in the first place.What did the researchers do? The research team studied medication safety incident reports collected across England and Wales over a 5-year period to better understand what kind of medication safety problems occur after hospital discharge and why they happen, so we can find ways to prevent them from happening in future.What did the researchers find? The total number of incident reports studied was 1121, and the majority (n = 626) involved older people. More than one in ten of these incidents caused harm to patients. The most common medications involved in the medication safety incidents were for cardiovascular diseases such as high blood pressure, conditions such as mental illness, pain and neurological conditions (e.g., epilepsy) and other illnesses such as diabetes. The most common causes of these incidents were because of the organisation rules, such as information sharing, followed by staff issues, such as not following protocols, individual mistakes and not having the right skills for the task.What do the findings mean? This study has identified some important targets that can be a focus of future efforts to improve the safe use of medicines after hospital discharge. These include concentrating attention on medication for the cardiovascular and central nervous systems (e.g., via incorporating them in prescribing safety indicators and pharmaceutical prioritisation tools), staff skill mix (e.g., embedding clinical pharmacist roles at key parts of the care pathway where greatest risk is suspected), and implementation of electronic interventions to improve timely communication of medication and other information between healthcare providers.

Understanding the implementation, impact and sustainable use of an electronic pharmacy referral service at hospital discharge: A qualitative evaluation from a sociotechnical perspective.

INTRODUCTION: The transition of patients across care settings is associated with a high risk of errors and preventable medication-related harm. Ensuring effective communication of information between health professionals is considered important for improving patient safety. A National Health Service(NHS) organisation in the North West of England introduced an electronic transfer of care around medicines (TCAM) system which enabled hospital pharmacists to send information about patient's medications to their nominated community pharmacy. We aimed to understand the adoption, and the implications for sustainable use in practice of the TCAM service. METHODS: We evaluated the TCAM service in a Clinical Commissioning Group (CCG) and NHS Foundation Trust in Salford, United Kingdom (UK). Participants were opportunistically recruited to take part in qualitative interviews through stakeholder networks and during hospital admission, and included hospital pharmacists, hospital pharmacy technicians, community pharmacists, general practice-based pharmacists, patients and their carers. A thematic analysis, that was iterative and concurrent with data collection, was undertaken using a template approach. The interpretation of the data was informed by broad sociotechnical theory. RESULTS: Twenty-three interviews were conducted with health care professionals patients and carers. The ways in which the newly implemented TCAM intervention was adopted and used in practice and the perceptions of it from different stakeholders were conceptualised into four main thematic areas: The nature of the network and how it contributed to implementation, use and sustainability; The material properties of the system; How work practices for medicines safety were adapted and evolved; and The enhancement of medication safety activities. The TCAM intervention was perceived as effective in providing community pharmacists with timely, more accurate and enhanced information upon discharge. This allowed for pharmacists to enhance clinical services designed to ensure that accurate medication reconciliation was completed, and the correct medication was dispensed for the patient. CONCLUSIONS: By providing pharmacy teams with accurate and enhanced information the TCAM intervention supported healthcare professionals to establish and/or strengthen interprofessional networks in order to provide clinical services designed to ensure that accurate medication reconciliation and dispensing activities were completed. However, the intervention was implemented into a complex and at times fragmented network, and we recommend opportunities be explored to fully integrate this network to involve patients/carers, general practice pharmacists and two-way communication between primary and secondary care to further enhance the reach and impact of the TCAM service.

Prevalence and Nature of Medication Errors and Medication-Related Harm Following Discharge from Hospital to Community Settings: A Systematic Review.

BACKGROUND: Little is known about the epidemiology of medication errors and medication-related harm following transition from secondary to primary care. This systematic review aims to identify and critically evaluate the available evidence on the prevalence and nature of medication errors and medication-related harm following hospital discharge. METHODS: Studies published between January 1990 and March 2019 were searched across ten electronic databases and the grey literature. No restrictions were applied with publication language or patient population studied. Studies were included if they contained data concerning the rate of medication errors, unintentional medication discrepancies, or adverse drug events. Two authors independently extracted study data. RESULTS: Fifty-four studies were included, most of which were rated as moderate (39/54) or high (7/54) quality. For adult patients, the median rate of medication errors and unintentional medication discrepancies following discharge was 53% [interquartile range 33-60.5] (n = 5 studies) and 50% [interquartile range 39-76] (n = 11), respectively. Five studies reported adverse drug reaction rates with a median of 27% [interquartile range 18-40.5] and seven studies reported adverse drug event rates with a median of 19% [interquartile range 16-24]. For paediatric patients, one study reported a medication error rate of 66.3% and another an adverse drug event rate of 9%. Almost a quarter of studies (13/54, 24%) utilised a follow-up period post-discharge of 1 month (range 2-180 days). Drug classes most commonly implicated with adverse drug events were antibiotics, antidiabetics, analgesics and cardiovascular drugs. CONCLUSIONS: This is the first systematic review to explore the prevalence and nature of medication errors and adverse drug events following hospital discharge. Targets for future work have been identified.

Availability of Antidotes in Kuwait: A National Audit.

BACKGROUND: Effective management of poisoning requires adequate stocking of antidotes in hospitals that provide emergency care. Antidote stocking represents a major challenge to hospitals all over the world, including Kuwait. OBJECTIVE: This study aimed to evaluate antidote stocking in public and private hospitals that provide emergency care in Kuwait. METHODS: A cross-sectional study using a self-administered questionnaire was conducted from January to December 2018. The questionnaire was designed to assess immediate and non-immediate availability of 41 antidotes in 6 public and 13 private hospitals in Kuwait that provided emergency care. The questionnaire was provided to the pharmacy departments of these hospitals, which were asked to report the availability of antidotes and the reasons for non-availability. Descriptive statistics were used to report demographical data and independent t-test analysis was used to analyze continuous variables. RESULTS: All of the six public hospitals in Kuwait and eight private hospitals returned the completed questionnaires. Among the 14 hospitals surveyed, none had a complete stock of all essential antidotes. The mean (standard deviation [SD]) availability of immediate antidotes in public hospitals was 79.6% (32.6%) compared to 52.1% (44.4%) in private hospitals. Moreover, the mean (SD) availability of non-immediate antidotes was 64.5% (37.7%) in public hospitals compared to 14.7% (22.8%) in private hospitals. CONCLUSIONS: Public and private hospitals in Kuwait have suboptimal stocks of essential antidotes. There is an urgent need to develop expert consensus guidelines to assist hospitals to reduce costs and improve patient care by adequately stocking essential antidotes.