Deficits in discharge documentation in patients transferred to rehabilitation facilities on anticoagulation: results of a systemwide evaluation.

BACKGROUND: Anticoagulation is a commonly prescribed and effective therapy for several medical conditions but requires detailed communication among clinicians to avoid adverse patient outcomes following hospital discharge. METHODS: Discharge documentation packets of a sample of patients discharged from all five acute care hospitals of the Partners Healthcare System to 30 subacute facilities in Boston and prescribed anticoagulation for treatment or prophylaxis of thromboembolic disease were evaluated. Required data elements included information on anticoagulation indication, duration, dosing, monitoring, and follow-up. Discharge documentation packets were randomly selected for reviewers at acute sites, whereas reviewers at subacute sites selected which packets to review. RESULTS: Of 757 patients prescribed anticoagulation at discharge from March 2005 through June 2007, duration of therapy (for unfractionated or low-molecular-weight heparin [UFH/LMWH]) and recent dosing and monitoring information (for warfarin) were the areas with the biggest deficits. Of the patients prescribed UFH/LMWH or warfarin, 45.4% and 16.4%, respectively, had all the required information in the discharge summary. Patients discharged from community hospitals were more likely to be discharged with all the information needed for the use of warfarin (Odds Ratio [OR], 2.56; 95% confidence interval [CI], 1.20-5.46) or UFH/LMWH (OR, 2.97; 95% CI, 1.98-4.44) than patients discharged from academic medical centers. DISCUSSION: Important information to safely prescribe anticoagulation after discharge was often missing from the discharge summaries of patients transferred from acute hospitals to subacute facilities. Future research should focus on developing, implementing, and evaluating quality improvement interventions to address this gap.

Sterile product compounding using an i.v. compounding workflow management system at a pediatric hospital.

PURPOSE: Patient safety enhancements achieved through the use of an automated i.v. compounding workflow management system are reported. SUMMARY: Automated systems integrating barcode verification of ingredients and the capture of serial images of all steps of the admixture process have the potential to improve the accuracy of parenteral i.v. medication dose preparation. About 18 months after the implementation of such a system at a large pediatric hospital, a retrospective analysis of dose preparation outcomes was conducted to evaluate the effectiveness of the i.v. workflow manager in detecting compounding errors and to categorize detected errors. In verifying the accuracy of 425,683 medication doses prepared during the approximately 13-month evaluation period, dispensing pharmacists detected preparation or documentation errors affecting 2,900 doses (0.68%); 1,223 of those doses (0.29%) required reworking, and 1,677 (0.4%) were rejected and destroyed. Roughly 23% of the detected errors were classified as undetectable via the pharmacy's previous verification practices, with 167 errors judged to pose the potential for adverse drug events resulting in moderate (n=146) or severe (n=21) harm. Among the reworked and rejected doses, 43.8% and 31.3%, respectively, were due to newly emergent problems not seen with traditional paper-based verification systems; however, most of these errors involved blurry or missing images and were not judged to be clinically significant. CONCLUSION: Implementation of an i.v. workflow management system that integrates barcode verification, automated calculations, and image-capture capabilities led to increased detection of errors in the sterile product compounding process.

Addition of electronic prescription transmission to computerized prescriber order entry: Effect on dispensing errors in community pharmacies.

PURPOSE: The addition of electronic prescription transmission to computerized prescriber order entry (CPOE) and its effect on dispensing errors in community pharmacies were evaluated. METHODS: A controlled, before-and-after trial to measure the effect of electronic prescribing on dispensing errors in two control clinics and one e-prescribing clinic already using CPOE was conducted between January and November 2006. Prescriptions documented within the CPOE system were reconciled with dispensed prescription information from participating pharmacy chains via a national pharmacy information exchange network. Dispensing errors were defined as discrepancies between the prescriber's written orders and the dispensed prescription information. Prescriptions filled at nonparticipating pharmacies were not analyzed. RESULTS: A total of 11,447 prescriptions were written in the control clinics, and 29,575 were written in the e-prescribing clinic. During the intervention period, 2,179 (22%) of 9,905 intervention clinic prescriptions were electronically transmitted, including 621 (28%) available for analysis. There was no significant difference in the dispensing-error rates between the baseline and intervention periods for the control clinics. Similarly, the dispensing-error rates did not differ significantly for the e-prescribing clinic between the baseline and intervention periods for prescriptions that were not electronically transmitted. The e-prescribing clinic's dispensing-error rate for electronically transmitted prescriptions during the intervention was significantly lower than its baseline dispensing-error rate (p = 0.03). CONCLUSION: Electronic transmission of prescription data from physicians' offices to a pharmacy nearly halved the risk of dispensing errors compared with generating the prescription with outpatient CPOE and printing it and giving it to the patient.

Improving adherence to treatment guidelines: a blueprint.

Patients with chronic diseases often require complex medication regimens to meet evidence-based treatment guidelines. However, translating evidence-based recommendations into clinical care has proven to be difficult. Several factors-patient adherence, disease complexity, competing medical issues, guideline dissemination, and clinical inertia-are thought to contribute to this problem. In this manuscript, we describe a multidisciplinary ambulatory approach to improve the care of patients with chronic conditions. Our goal was to design an intervention that focused on improving the prescription rates of medications known to reduce cardiovascular-related events and hospital admissions for patients with diabetes mellitus, coronary artery disease, heart failure, chronic kidney disease, or stroke. We also describe the critical lessons we have learned in implementing our intervention, including the successes and barriers we encountered during the project.