A newly developed algorithm for switching outpatient medications to medications listed in the hospital formulary: a prospective real-word evaluation in patients admitted electively to hospital.

PURPOSE: In many countries, outpatient and inpatient care are separated. During hospitalization, therefore, switching the outpatient medication to medication of the hospital formulary is required. METHODS: We newly designed a switching algorithm in six switching steps (S0-S5) and conducted a study at Bundeswehr Hospital Hamburg (300 beds, 80% civilians). We performed (i) a medication reconciliation to obtain information on outpatient medications and (ii) a medication review to solve drug-related-problems, e.g., drug-drug interactions. We applied (iii) the algorithm to switch medications to the hospital formulary. RESULTS: (i) We identified 475 outpatient medications (median per patient: 4; Q25/Q75 2/7) in 100 patients consecutively admitted to hospital (median age: 71; Q25/Q75: 64/80 years). Of 475 medications, the switching algorithm could not be used since product names were missing in 23.9% and strength in 1.7%. In 3.2%, switching was not required since medication was not prescribed during the hospital stay. (ii) Drug-drug interactions were identified in 31 of 79 patients with more than one medication. (iii) Of 475 medications, 18.5% were on the hospital formulary and therefore did not need to be  switched (S0), 0.2% were on a substitution-exclusion list not allowing switching (S1), 42.0% were switched to a generic medication of the hospital formulary (S2), 1.7% to a therapeutically equivalent medication (S3), 0.4% were patient-individually switched (S4), and for 8.2% a standardized/patient-individual switching was not possible (S5). CONCLUSIONS: Despite comprehensive medication reconciliation, patient- and medication-related information for switching medications to the hospital formulary was often missing. Once all the necessary information was available, standardized switching could be easily carried out according to a newly developed switching algorithm.

Stakeholder perceptions of and attitudes towards problematic polypharmacy and prescribing cascades: a qualitative study.

INTRODUCTION: Problematic polypharmacy is the prescribing of five or more medications potentially inappropriately. Unintentional prescribing cascades represent an under-researched aspect of problematic polypharmacy and occur when an adverse drug reaction (ADR) is misinterpreted as a new symptom resulting in the initiation of a new medication. The aim of this study was to elicit key stakeholders' perceptions of and attitudes towards problematic polypharmacy, with a focus on prescribing cascades. METHODS: qualitative one-to-one semi-structured interviews were conducted with predefined key stakeholder groups. Inductive thematic analysis was employed. RESULTS: Thirty-one stakeholders were interviewed: six patients, two carers, seven general practitioners, eight pharmacists, four hospital doctors, two professional organisation representatives and two policymakers. Three main themes were identified: (i) ADRs and prescribing cascades-a necessary evil. Healthcare professionals (HCPs) expressed concern that experiencing an ADR would negatively impact patients' confidence in their doctor. However, patients viewed ADRs pragmatically as an unpredictable risk. (ii) Balancing the risk/benefit tipping point. The complexity of prescribing decisions in the context of polypharmacy made balancing this tipping point challenging. Consequently, HCPs avoided medication changes. (iii) The minefield of medication reconciliation. Stakeholders, including patients and carers, viewed medication reconciliation as a perilous activity due to systemic communication deficits. CONCLUSION: Stakeholders believed that at a certain depth of polypharmacy, the risk that a new symptom is being caused by an existing medication becomes incalculable. Therefore, in the absence of harm, medication changes were avoided. However, medication reconciliation post hospital discharge compelled prescribing decisions and was seen as a high-risk activity by stakeholders.

Providing information about medication changes upon discharge from a geriatric unit: the community healthcare professionals' point of view.

INTRODUCTION: It is well known that polypharmacy is associated with adverse drug events. Accordingly, specialist geriatric units have to pay particular attention to the appropriateness of prescription and the withdrawal of potentially inappropriate medications. Even though community healthcare professionals are keen to received medication reconciliation results, the literature data show that the quality of communication between the hospital and the community needs to be improved. OBJECTIVE: To assess community healthcare professionals' opinions about the receipt of medication reconciliation results when a patient is discharged from a specialist geriatric unit. METHOD: We performed a qualitative study of general practitioners, community pharmacists and retirement home physicians recruited by phone in the Indre-et-Loire region of France. A grounded theory method was used to analyze interviews in multidisciplinary focus groups. RESULTS: The 17 community healthcare professionals first explained why the receipt of medication reconciliation results was important to them: clarifying the course and outcomes of hospital stays and reducing the lack of dialogue with the hospital, so that the interviewees could provide the care expected of them. The interviewees also described mistrust of the hospital and uncertainty when the modifications were received; these two concepts accentuated each other over time. Lastly, they shared their opinions about the information provided by the hospital, which could improve patient safety and provide leverage for treatment changes but also constituted a burden. PERSPECTIVES: Our participants provided novel feedback and insight, constituting the groundwork for an improved medication reconciliation form that could be evaluated in future research. Exploring hospital-based professionals' points of view might help to determine whether the requested changes in the medication reconciliation form are feasible and might provide a better understanding of community-to-hospital communication.

Pharmacist-led medication reconciliation service for patients after discharge from tertiary hospitals to primary care in Singapore: a qualitative study.

BACKGROUND: Medication discrepancies commonly occur when patients are transferred between care settings. Despite the presence of medication reconciliation services (MRS), medication discrepancies are still prevalent, which has clinical costs and implications. This study aimed to explore the perspectives of various stakeholders on how the MRS can be optimized in Singapore. METHODS: This is a descriptive qualitative study. Semi-structured interviews with 30 participants from the National Healthcare Group, including family physicians (N = 10), pharmacists (N = 10), patients recently discharged from restructured hospitals (N = 7) and their caregivers (N = 3) were conducted. All transcribed interviews were coded independently by three coders and inductive thematic analysis approach was used. RESULTS: Five core themes were identified. (1) The MRS enhanced healthcare services in various aspects including efficiency and health literacy; (2) There were several challenges in delivering the MRS covering processes, technology and training; (3) Issues with suitable patient selection and follow-up; (4) Barriers to scaling up of MRS that involve various stakeholders, cross-sector integration and environmental restrictions; and finally (5) Role definition of the pharmacist to all the stakeholders. CONCLUSION: This study identified the role of MRS in enhancing healthcare services and explored the challenges encountered in the provision of MRS from family physicians, pharmacists, patients and their caregivers. These findings supported the need for a shift of MRS towards a more comprehensive medication review model. Future improvement work to the MRS can be conducted based on the findings.

Health professionals' experience and perceived obstacles with managing patients' medication information in Norway: cross-sectional survey.

BACKGROUND: Access to correct and up to date medication information is crucial for effective patient treatment. However, persistent discrepancies exist. This study examines the experiences and challenges health professionals encounter while utilizing current digital solutions in the Norwegian healthcare system to manage patients' medication information. METHODS: A cross-sectional descriptive analysis using quantitative survey data was conducted to investigate how health professionals managed patients' medication information. Content analysis was used to analyze free-text responses concerning challenges they encountered when transferring medication information and to identify factors deemed necessary for implementing the Shared Medication List in Norway. RESULTS: A total of 262 doctors and 244 nurses responded to the survey. A higher percentage of doctors (72.2%) expressed concerns regarding obtaining accurate and updated medication lists than nurses (42.9%), particularly for patients with polypharmacy (35.3%) or transitioning between primary and specialist care services (27.6%). The patient's verbal information was the main source for hospital doctors (17%) to obtain an overview of the patient's medication usage, while general practitioners (19%) and nurses (working in both primary and specialist care services, 28% and 27% respectively) predominantly relied on electronic prescriptions. Doctors, in particular general practitioners, reported carrying excessive responsibilities in coordinating with other health actors (84.8%) and managing patients' medication information. The vast majority of both doctors (84.4%) and nurses (82.0%) were in favor of a Shared Medication List. However, about a third of doctors (36.3%) and nurses (29.8%) expressed the need for a more balanced responsibility in updating and managing patients' medication information, while ensuring compatibility with existing digital systems. CONCLUSIONS: Fragmented resources for medication information and unclear responsibilities were prevalent concerns among both professional groups. Doctors voiced more concern than nurses about the accuracy of patients' medication list. While both groups are positive about a shared medication list, successful implementation requires proactive training initiatives and clearer role clarification.

How much time do emergency department physicians spend on medication-related tasks? A time- and-motion study.

BACKGROUND: Medication-related problems are an important cause of emergency department (ED) visits, and medication errors are reported in up to 60% of ED patients. Procedures such as medication reconciliation and medication review can identify and prevent medication-related problems and medication errors. However, this work is often time-consuming. In EDs without pharmacists, medication reconciliation is the physician's responsibility, in addition to the primary assignments of examining and diagnosing the patient. The aim of this study was to identify how much time ED physicians spend on medication-related tasks when no pharmacists are present in the EDs. METHODS: An observational time-and-motion study of physicians in three EDs in Northern Norway was conducted using Work Observation Method by Activity Timing (WOMBAT) to collect and time-stamp data. Observations were conducted in predefined two-hour observation sessions with a 1:1 relationship between observer and participant, during Monday to Friday between 8 am and 8 pm, from November 2020 to October 2021. RESULTS: In total, 386 h of observations were collected during 225 observation sessions. A total of 8.7% of the physicians' work time was spent on medication-related tasks, of which most time was spent on oral communication about medications with other physicians (3.0%) and medication-related documentation (3.2%). Physicians spent 2.2 min per hour on medication reconciliation tasks, which includes retrieving medication-related information directly from the patient, reading/retrieving written medication-related information, and medication-related documentation. Physicians spent 85.6% of the observed time on non-medication-related clinical or administrative tasks, and the remaining time was spent standby or moving between tasks. CONCLUSION: In three Norwegian EDs, physicians spent 8.7% of their work time on medication-related tasks, and 85.6% on other clinical or administrative tasks. Physicians spent 2.2 min per hour on tasks related to medication reconciliation. We worry that patient safety related tasks in the EDs receive little attention. Allocating dedicated resources like pharmacists to contribute with medication-related tasks could benefit both physicians and patients.

Prescription of potentially inappropriate medications after an intensive care unit stay for acute respiratory failure.

BACKGROUND: Among survivors of critical illness, prescription of potentially inappropriate medications (PIM) at hospital discharge is thought to be an important, modifiable patient safety concern. To date, there are little empirical data evaluating this issue. RESEARCH QUESTION: The objective of this study was to determine the frequency of PIM prescribed to survivors of acute respiratory failure (ARF) at hospital discharge and explore their association with readmissions or death within 90 days of hospital discharge. STUDY DESIGN AND METHODS: Prospective multicenter cohort study of ARF survivors admitted to ICUs and discharged home. Prospective of new PIMs with a high-adverse-effect profile ("high impact") at discharge was the primary exposure. Potential inappropriateness was determined by a structured consensus process using Screening Tool of Older Persons' Prescriptions-Screening Tool to Alert to Right Treatment, Beers' criteria, and clinical context of prescriptions by a multidisciplinary team. Covariate balancing propensity score was used for the primary analysis. RESULTS: Of the 195 Addressing Post Intensive Care Syndrome-01 (APICS-01) patients, 169 (87%) had ≥1 new medications prescribed at discharge, with 154 (91.1%) prescribed with one or more high-impact (HI) medications. Patients were prescribed a median of 5 [3-7] medications, of which 3 [1-4] were HI. Twenty percent of HI medications were potentially inappropriate. Medications with significant central nervous system side-effects were most prescribed potentially inappropriately. Forty-six (30%) patients experienced readmission or death within 90 days of hospital discharge. After adjusting for prespecified covariates, the association between prescription of potentially inappropriate HI medications and the composite primary outcome did not meet the prespecified threshold for statistical significance (risk ratio: 0.54; 0.26-1.13; p = 0.095) or with the constituent endpoints: readmission (risk ratio: 0.57, 0.27-1.11) or death (0.7, 0.05-9.32). CONCLUSION: At hospital discharge, most ARF survivors are prescribed medications with a high-adverse-effect profile and approximately one-fifth are potentially inappropriate. Although prescription of such medications was not associated with 90-day readmissions and mortality, these results highlight an area for additional investigation.

Physician-led medication reviews in polypharmacy patients treated with at least 12 medications in a type 2 diabetes outpatient clinic: A randomised trial.

AIMS: Medication reviews can be used to promote appropriate pharmacotherapy and negate the harmful consequences of polypharmacy. This study aimed to evaluate the effect of physician-led medication reviews and increased cross-sectoral communication as a supplement to standard care in a type 2 diabetes outpatient clinic. METHODS: This pragmatic randomised clinical trial enrolled patients with type 2 diabetes treated with at least 12 medications. The subjects were randomised to either standard care (standard care consultation at the outpatient clinic) or standard care plus a medication review consultation and increased cross-sectoral communication. The primary outcome was the number of medications used after six months. Health-related quality of life was quantified using the EuroQoL 5-dimension 5-level (EQ5D-5 L) questionnaire. RESULTS: We recruited 50 participants with a median age of 72 (IQR 67-75) years. The mean number of medications per patient changed from 17.9 to 14.3 in the intervention group and 17.6 to 17.2 in the control group (rate ratio 0.81). The reasons for discontinuations were medication no longer indicated (60%), safety issues (20%), efficacy issues (15%) or patient preferences (5%). There was a significant difference in the change in health-related quality of life (EQ5D-5 L index score) in favour of the intervention (0.111, 95% CI 0.001 to 0.221). CONCLUSIONS: Physician-led medication reviews and increased cross-sectoral communication in patients with type 2 diabetes treated with at least 12 medications reduced the number of medications used and improved health-related quality of life. Implementing and further investigating similar interventions as standard care seems reasonable.

Implementation of clinical medication review in a geriatric ward to reduce potentially inappropriate prescriptions among older adults.

PURPOSE: The impact of several pharmaceutical interventions to reduce the use of potentially inappropriate medications (PIMs) and potentially omitted medications (POMs) has been recently studied. We aimed to determine whether clinical medication review (CMR) (i.e. a systematic and patient-centred clinical assessment of all medicines currently taken by a patient) performed by a geriatrician and a pharmacist added to standard pharmaceutical care (SPC) (i.e. medication reconciliation and regular prescription review by the pharmacist) resulted in more appropriate prescribing compared to SPC among older inpatients. METHODS: A retrospective observational single-centre study was conducted in a French geriatric ward. Six criteria for appropriate prescribing were chosen: the number of PIMs and POMs as defined by the STOPP/STARTv2 list, the total number of drugs prescribed, the number of administrations per day and the number of psychotropic and anticholinergic drugs. These criteria were compared between CMR and SPC group using linear and logistic regression models weighted on propensity scores. RESULTS: There were 137 patients included, 66 in the CMR group and 71 in the SPC group. The mean age was 87 years, the sex ratio was 0.65, the mean number of drugs prescribed was 9, the mean MMSE was 21 and at admission 242 POMs, and 363 PIMs were prescribed. Clinical medication review did not reduce the number of PIMs at discharge compared to SPC (beta = - 0.13 [- 0.84; 0.57], p = 0.71) nor did it reduce the number of drugs prescribed (p = 0.10), the number of psychotropic drugs (p = 0.17) or the anticholinergic load (p = 0.87). Clinical medication review resulted in more POMs being prescribed than in standard pharmaceutical care (beta = - 0.39 [- 0.72; - 0.06], p = 0.02). Cardiology POMs were more implemented in the medication review group (p = 0.03). CONCLUSION: Clinical medication review did not reduce the number of PIMs but helped clinicians introduce underused drugs, especially cardiovascular drugs, which are known to be associated with morbidity and mortality risk reduction.

An International, Multicenter Evaluation of Comprehensive Medication Management by Pharmacists in ICU Recovery Centers.

BACKGROUND: Post-intensive care syndrome (PICS) is defined as a new or worsening impairment in physical, cognitive, or mental health following critical illness. Intensive care unit recovery centers (ICU-RC) are one means to treat patients who have PICS. The purpose of this study is to describe the role of pharmacists in ICU-RCs. RESEARCH QUESTION: What is the number and type of medication interventions made by a pharmacist at an ICU-RC at 12 different centers? STUDY DESIGN AND METHODS: This prospective, observational study was conducted in 12 intensive care units (ICUs)/ICU-RCs between September 2019 and July 2021. A full medication review was conducted by a pharmacist on patients seen at the ICU-RC. RESULTS: 507 patients were referred to the ICU-RC. Of these patients, 474 attended the ICU-RC and 472 had a full medication review performed by a pharmacist. Baseline demographic and hospital course data were obtained from the electronic health record and at the ICU-RC appointment. Pharmacy interventions were made in 397 (84%) patients. The median number of pharmacy interventions per patient was 2 (interquartile range [IQR] = 1,3). Medications were stopped and started in 124 (26%) and 91 (19%) patients, respectively. The number of patients that had a dose decreased and a dose increased was 51 (11%) and 43 (9%), respectively. There was no difference in the median total number of medications that the patient was prescribed at the start and end of the patient visit (10, IQR = 5, 15). Adverse drug event (ADE) preventive measures were implemented in 115 (24%) patients. ADE events were identified in 69 (15%) patients. Medication interactions were identified in 30 (6%) patients. INTERPRETATION: A pharmacist plays an integral role in an ICU-RC resulting in the identification, prevention, and treatment of medication-related problems. This paper should serve as a call to action on the importance of the inclusion of a pharmacist in ICU-RC clinics.

Accuracy of medication histories derived from an Australian cloud-based repository of prescribed and dispensed medication records.

BACKGROUND: Obtaining accurate medication histories at transitions of care is challenging, but important for patient safety. Prescription exchange services (PES) securely transfer electronic prescription and dispensing records between prescribers and pharmacies, which is potentially useful data for determining medication histories. AIM: To evaluate the accuracy of PES-derived medication histories. METHODS: Prospective observational study, at two Australian tertiary-referral health services. A convenience sample of adult inpatients was recruited. The main outcome measure was: proportion of patients with ≥1 errors in their PES-derived pre-admission medication histories, compared with gold-standard best-possible medication histories, including prescribed and non-prescribed medications, obtained by pharmacists using multiple sources including patient/carer interview. RESULTS: Of 154 patients (median age 76 years; interquartile range (IQR) 64-84 years; median 10.0 pre-admission medications; IQR 6.0-14.0), 153 (99.4%) had ≥1 errors in their PES-derived medication history (median 6.0 errors per patient; IQR 4.0-9.0). Excluding when-required medications, 146 (94.8%) patients had >1 errors (median 4.0 errors per patient; IQR 2.0-6.0). Omission was the most common error, affecting 549 (33.3%) of 1648 current medications (median 3.0; IQR 1.0-5.0 per patient); 396 (72.1%) omissions were over-the-counter medicines. Dose-regimen errors affected 276 (25.1%) of 1099 current medications captured in PES-derived medication histories (median 1.0 error per patient; IQR 0.0-3.0). Commission errors (medications in PES-derived histories that were not current) affected 224 (16.9%) of 1323 medications (median 1.0 error per patient; IQR 1.0-2.0). CONCLUSIONS: Medication histories derived solely from a cloud-based medication record repository had a high error rate compared with patients' actual medication use. Like all medication history sources, data from cloud-based repositories need to be verified with additional sources including the patient and/or their carer.

The impact of medication reconciliation and review in patients using oral chemotherapy.

BACKGROUND AND AIM: Verifying and reviewing a patients medication list can detect and reduce drug related problems (DRPs). However little is known about its effects in patients using oral chemotherapy. The aim of this study was to evaluate the impact of these interventions and the adapted Medication Appropriateness Index (aMAI) as a tool to carry out a medication review. METHODS: A case-control study was carried out. The hospital pharmacist performed a medication reconciliation and medication review, using the aMAI tool, in 54 patients starting oral chemotherapy. Discrepancies, DRP's and associated pharmaceutical interventions were reported via the electronic patient record (EPR). After one month, the acceptance rate was measured and the aMAI score recalculated. Kappa statistics were used to test intra- and interrater reliability. RESULTS: The medication list in the EPR was incomplete in 74,1% of patients with an average of 2.4 errors per patient. After medication review, the aMAI score decreased significantly from 7.2 to 5.4 (SD = 4,7; p <0.001), indicating an improvement in the appropriateness of the drugs patients were taking. Acceptance rates were 41,4% and 53,2% for advices resulting from medication reconciliation and medication review respectively. Kappa values of 0.90 and 0.70 respectively indicate good intra- and interrater reliability. DISCUSSION AND CONCLUSION: The study shows that medication reconciliation can identify and address discrepancies. Furthermore, medication review seems to ensure that drug treatment better meets patient needs. The aMAI was a reliable tool. Future research will have to determine the clinical relevance of these interventions.

Comprehensive pharmacological geriatric assessment compared to usual care in an older adult with cancer in the absence of polypharmacy.

INTRODUCTION: Medication reconciliation as part of a Comprehensive Geriatric Assessment by a specialist pharmacist is a process that has been shown to be beneficial in terms of medication adherence in patients taking oral anticancer medication and potentially cost-effective in cancer patients. Medication review guidelines in older adults with cancer suggest using polypharmacy (≥ 5 medications) as an indication for medication review in older adults with cancer. CASE REPORT: We present a case where a medication review as part of a Comprehensive Geriatric Assessment in the absence of polypharmacy resulted in two pharmacist interventions when standard care resulted in no intervention. A 71-year-old male prescribed capecitabine for rectal cancer had a medication reconciliation done as standard care before starting an oral anticancer medication. He then proceeded to get a medication review as part of a Comprehensive Geriatric Assessment and was deemed to have a potentially excessive anticholinergic burden and underprescribed gastro protection. This case is interesting as it occurred in a patient who would not have met the current inclusion criteria for a medication review as part of a Comprehensive Geriatric Assessment. MANAGEMENT AND OUTCOME: As a result of the Comprehensive Geriatric Assessment, a letter was written to the patient's general practitioner, recommending a change to anti-depressant therapy to optimise anticholinergic burden, as well as introducing a proton-pump inhibitor upon completion of the Capecitabine protocol concurrent with radiotherapy, to confer gastro-protection against the antidepressant medication, as per the START criteria. Upon discharge from medical oncology, neither of the changes had been adopted by the patient's general practitioner. This highlights one of the challenges facing clinical pharmacists in an outpatient setting, where evidence-based recommendations are not always implemented as care transitions from tertiary to primary care. CONCLUSION: Comprehensive Geriatric Assessment is a process that identifies potential issues in older adults with cancer that aren't identified with standard medication review. This is also evident for medication reviews as part of a Comprehensive Geriatric Assessment, and where resources allow, and recommendations are likely to be accepted, it should be offered to all older adults with cancer. Pharmacists are still faced with challenges in implementing recommendations from medication reviews, particularly in healthcare systems where pharmacist prescribing has yet to be introduced.

Identifying older inpatients at high risk of unintentional medication discrepancies: a classification tree analysis.

Unintentional medication discrepancies at admission are differences between the best possible medication history and the prescribed treatment at admission, and are associated with adverse outcomes, particularly in older people. This study aimed to identify the clinical profiles of geriatric inpatients with unintentional medication discrepancies at hospital admission. A classification tree Chi-square Automatic Interaction Detector (CHAID) analysis was conducted to assess those patients' profiles and characteristics that were associated with a higher risk of unintentional medication discrepancies. One-hundred and thirty consecutive older patients admitted to acute care (87 ± 5 years old; 61.8% women) were assessed. The CHAID analysis retrieved 5 clinical profiles of older inpatients with a risk of up to 94.4% for unintentional medication discrepancies. These profiles were determined based on combinations of three characteristics: use of eye drops, frequent falls (≥ 1/year), and admission due to urgent hospitalization. These easily measurable clinical characteristics may be helpful as a supportive measure to improve pharmacological care.

Effect of educational intervention on medication reconciliation practice of hospital pharmacists in a developing country - A non-randomised controlled trial.

BACKGROUND: Medication reconciliation is an evidence-based practice that reduces medication-related harm to patients. This study evaluated the effect of educational intervention on medication reconciliation practice of pharmacists among ambulatory diabetes and hypertensive patients. METHODS: A non-randomized clinical trial on medication reconciliation practice was carried out among 85 and 61 pharmacists at the intervention site and control site, respectively. Medication reconciliation was carried out among 334 (intervention-183; control-151) diabetes and/or hypertensive patients by the principal investigator to indirectly evaluate pharmacists' baseline medication reconciliation practice at both sites. A general educational intervention was carried out among intervention pharmacists. Medication reconciliation was carried out by the principal investigator among another cohort of 96 (intervention-46; control-50) and 90 (intervention-44; control-46) patients at three and six months postintervention, respectively, to indirectly assess pharmacists' postintervention medication reconciliation practice. Thereafter, a focused educational intervention was carried out among 15 of the intervention pharmacists. Three experts in clinical pharmacy analysed the medication reconciliation form filled by the 15 pharmacists after carrying out medication reconciliation on another cohort of 140 patients, after the focused intervention. Data was summarized with descriptive (frequency, percentage, mean ± standard deviation) and inferential (Pearson product-moment correlations analysis, independent-samples t-test and one-way ANOVA) statistics with level of significance set at p<0.05. KEY FINDINGS: Baseline medication reconciliation practice was poor at both sites. Post-general educational intervention, medication discrepancy was significantly reduced by 42.8% at the intervention site (p<0.001). At the intervention site, a significant increase of 54.3% was observed in patients bringing their medication packs for clinic appointments making medication reconciliation easier (p=0.003), at 6-months postintervention. Thirty-five, 66 and 48 drug therapy problems were detected by 31 (43.1%), 33 (66.0%) and 32 (71.1%) intervention pharmacists at 1-, 3- and 6-month post-general educational intervention, respectively. Post-focused educational intervention, out of a total of 695 medications prescribed, 75 (10.8%) medication discrepancies were detected and resolved among 42 (30%) patients by the 15 pharmacists. CONCLUSIONS: The educational interventions improved pharmacists' medication reconciliation practice at the intervention site. It is expected that this research would help create awareness on medication reconciliation among pharmacists in developing countries, with a view to reducing medication-related patient harm.

Electronic Medication Reconciliation Tools Aimed at Healthcare Professionals to Support Medication Reconciliation: a Systematic Review.

The development of health information technology available and accessible to professionals is increasing in the last few years. However, a low number of electronic health tools included some kind of information about medication reconciliation. To identify all the electronic medication reconciliation tools aimed at healthcare professionals and summarize their main features, availability, and clinical impact on patient safety. A systematic review of studies that included a description of an electronic medication reconciliation tool (web-based or mobile app) aimed at healthcare professionals was conducted. The review protocol was registered with PROSPERO: registration number CRD42022366662, and followed PRISMA guidelines. The literature search was performed using four healthcare databases: PubMed, EMBASE, Cochrane Library, and Scopus with no language or publication date restrictions. We identified a total of 1227 articles, of which only 12 met the inclusion criteria.Through these articles,12 electronic tools were detected. Viewing and comparing different medication lists and grouping medications into multiple categories were some of the more recurring features of the tools. With respect to the clinical impact on patient safety, a reduction in adverse drug events or medication discrepancies was detected in up to four tools, but no significant differences in emergency room visits or hospital readmissions were found. 12 e-MedRec tools aimed at health professionals have been developed to date but none was designed as a mobile app. The main features that healthcare professionals requested to be included in e-MedRec tools were interoperability, "user-friendly" information, and integration with the ordering process.

Medication Discussions With Patients With Cardiovascular Disease in the Emergency Department: An Opportunity for Emergency Nurses to Engage Patients to Support Medication Reconciliation.

INTRODUCTION: This study aimed to investigate the level of patient involvement in medication reconciliation processes and factors associated with that involvement in patients with cardiovascular disease presenting to the emergency department. METHODS: An observational and cross-sectional design was used. Patients with cardiovascular disease presenting to the adult emergency department of an academic medical center completed a structured survey inclusive of patient demographics and measures related to the study concepts. Data abstracted from the electronic health record included the patient's medical history and emergency department visit data. Our multivariable model adjusted for age, gender, education, difficulty paying bills, health status, numeracy, health literacy, and medication knowledge and evaluated patient involvement in medication discussions as an outcome. RESULTS: Participants' (N = 93) median age was 59 years (interquartile range 51-67), 80.6% were white, 96.8% were not Hispanic, and 49.5% were married or living with a partner. Approximately 41% reported being employed and 36.9% reported an annual household income of <$25,000. Almost half (n = 44, 47.3%) reported difficulty paying monthly bills. Patients reported moderate medication knowledge (median 3.8, interquartile range 3.4-4.2) and perceived involvement in their care (41.8 [SD = 9.1]). After controlling for patient characteristics, only difficulty paying monthly bills (b = 0.36, P = .005) and medication knowledge (b = 0.30, P = .009) were associated with involvement in medication discussions. DISCUSSION: Some patients presenting to the emergency department demonstrated moderate medication knowledge and involvement in medication discussions, but more work is needed to engage patients.

Strategies for Avoiding Typical Drug-Drug Interactions and Drug-Related Problems in Patients with Vascular Diseases.

Background and objectives: Drug-drug interactions and drug-related problems in patients with vascular diseases are common. To date, very few studies have focused on these important problems. The aim of the present study is to investigate the most common drug-drug interactions and DRPs in patients with vascular diseases. Materials and Methods: The medications of 1322 patients were reviewed manually in the time period from 11/2017 to 11/2018; the medications of 96 patients were entered into a clinical decision support system. Potential drug problems were identified, and a read-through consensus was reached between a clinical pharmacist and a vascular surgeon during the clinical curve visits; possible modifications were implemented. The focus was on additional dose adjustment and drug antagonization on drug interactions. Interactions were classified as contraindicated/high-risk combination (drugs must not be combined), clinically serious (interaction can be potentially life-threatening or have serious, possibly irreversible consequences), or potentially clinically relevant and moderate (interaction can lead to therapeutically relevant consequences). Results: A total of 111 interactions were observed. Of these, 6 contraindicated/high-risk combinations, 81 clinically serious interactions, and 24 potentially clinically relevant and moderate interactions were identified. Furthermore, 114 interventions were recorded and categorized. Discontinued use of the drug (36.0%) and drug dose adjustment (35.1%) were the most common interventions. Mostly, antibiotic therapy was continued unnecessarily (10/96; 10.4%), and the adjustment of the dosage to kidney function was overlooked in 40/96; 41.7% of the cases. In the most common cases, a dose reduction was not considered necessary. Here, unadjusted doses of antibiotics were found in 9/96, 9.3% of the cases. Notes for medical professionals summarized information that did not require direct intervention but rather increased attention on the part of the ward doctor. It was usually necessary to monitor laboratory parameters (49/96, 51.0%) or the patients for side effects (17/96, 17.7%), which were expected with the combinations used. Conclusions: This study could help identify problematic drug groups and develop prevention strategies for drug-related problems in patients with vascular diseases. A multidisciplinary collaboration between the different professional groups (clinical pharmacists and surgeons) might optimize the medication process. Collaborative care could have a positive impact on therapeutic outcomes and make drug therapy safer for patients with vascular diseases.

[Targeting anticoagulated patients for medication reconciliation at discharge in orthopaedic surgery]. / Conciliation médicamenteuse de sortie ciblée en chirurgie orthopédique : focus sur les anticoagulants.

In orthopedic surgery, the well-known iatrogenic risk of oral anticoagulants is particularly increased due to surgical management (suspension and resumption of treatment). In order to prevent avoidable iatrogenic events linked to incomplete discharge documents, targeted medical reconciliation (MR) has been deployed. This is a single-center prospective study conducted in orthopaedic surgery for six months including any patient treated upon admission with an oral anticoagulant. The analysis of the compliance of discharge documents (hospitalization report and prescriptions) was carried out before and after pharmaceutical interventions. The criteria analysed included the mention of the oral treatment, its dosage as well as the supervision of the switch from heparin therapy to the usual oral treatment. The documents were compliant if the mention of oral anticoagulant treatment and the date of the shift were correctly documented. Thirty-seven patients were included. The compliance rate of discharge documents was significantly improved by MR, going from 13.5 % to 78.4 % (P <0.05). The non-compliances before the intervention concerned the absence of mention of: the usual treatment (64.9 %), its dosage (81.1 %) or the switch's securing (75.7 %). Discharge from surgery of the patient on anticoagulants is a stage presenting a real risk which can be managed by the intervention of pharmacists. Improving the compliance of discharge documents is a first step towards better securing drug management.

[Medication reconciliation on admission: One year of practice in health care institutions during the COVID-19 pandemic]. / Conciliation médicamenteuse à l'admission : bilan d'une année d'activité en établissement de santé durant la crise COVID-19.

OBJECTIVES: Medication reconciliation is a key point of the v2020 certification. The main objective of this study was to evaluate this activity over one year, including the first epidemic wave at COVID-19. The secondary objectives were to identify the obstacles and levers and to evaluate doctor satisfaction. METHODS: This was a retrospective study of drug reconciliations performed on admission during 12 months of the emergence of COVID-19. Patients aged 65 years and older from orthopedic and visceral surgery, acute hospitalization and conventional medicine units were included. Unintentional discrepancies were analyzed. The obstacles and levers were identified by means of a focus group. Doctors' satisfaction was collected using online quiz. RESULTS: A total of 760 patients were conciliated, of which 27% (n=208) by hospital pharmacy technicians. A decrease in activity was observed during the first epidemic wave. An unintentional discrepancy was found in 77% of patients, and only 48% were corrected by the prescriber. These results were impacted by the pandemic. The pharmaceutical team was mobilized in the logistical management of the crisis, but it was able to adapt in order to perpetuate the activity. Doctors are satisfied with the process. CONCLUSIONS: Medication reconciliation on admission is essential for the prevention of iatrogeny, particularly with the impact of the COVID-19 pandemic in healthcare institutions.