Optimizing Subsequent CARdiovascular Medication Reintroduction in the Intensive Care Unit.

Importance: Hospital admission for a critical illness episode creates communication breakpoints and can lead to medication discrepancies during hospital stays. Due to the patient's underlying condition and the care setting, chronic medications such as cardiovascular medication are often held, discontinued, or changed to alternative administration routes. Unfortunately, data on the optimal timing of cardiovascular drug reinitiation among intensive care unit (ICU) survivors are lacking. Objective: The primary objective of this study was to describe the prevalence of chronic cardiovascular medication taken before hospital admission and discontinued at ICU discharge and hospital discharge for critically ill patients. A secondary objective was to assess factors associated with medication discontinuation. Design setting and participants: We conducted a multicentered retrospective cohort study at 2 tertiary academic hospitals in Canada. All adult patients taking cardiovascular medication before ICU admission and surviving to hospital discharge between April 1, 2016, and April 1, 2017, were eligible. Main outcomes and measures: The main outcome of the study was the discontinuation of cardiovascular medication prescribed before ICU admission. The outcome was assessed through participants' chart review. Results: We included 352 patients with a median age of 71.0 years. A total of 155 patients (44.03%) had at least 1 cardiovascular medication discontinued during their stay. Our adjusted model uncovered 3 factors associated with cardiovascular medication discontinuation: male sex (odds ratio [OR] = 0.564, 95% confidence interval [CI] = 0.346-0.919), number of cardiovascular medications taken preadmission (OR = 1.669, 95% CI = 1.003-2.777 for 2 medications and OR = 3.170, 95% CI = 1.325-7.583), and the use of vasopressors (OR = 1.770, 95% CI = 1.045-2.997). Conclusion: Our study uncovered that cardiovascular medication discontinuation for ICU patients is frequent, especially for renin-angiotensin system (RAS) blockers. Data from our study could be used to reinforce site-specific protocols of medication reconciliation and optimization, as well as inform future protocols aimed at RAS blocker reinitiation follow-up.

Importance de cette étude: L'admission à l'hôpital pour un épisode de maladie grave crée des ruptures de communication et peut entraîner des écarts dans la médication pendant le séjour à l'hôpital. Il arrive souvent, selon l'état sous-jacent du patient et l'environnement de soins, que les médicaments destinés à traiter des maladies chroniques, comme les médicaments cardiovasculaires, soient poursuivis, cessés ou administrés par d'autres voies. On manque malheureusement de données sur le moment optimal pour la reprise du traitement cardiovasculaire chez les survivants des unités de soins intensifs (USI). Objectifs: L'objectif principal était de décrire la prévalence de l'arrêt, à la sortie de l'USI et de l'hôpital, des médicaments pris par les patients gravement malades pour traiter les maladies cardiovasculaires chroniques avant leur admission. Un objectif secondaire était d'évaluer les facteurs associés à l'arrêt du traitement. Conception sujets et cadre de l'étude: Nous avons mené une étude de cohorte rétrospective multicentrique dans deux hôpitaux universitaires tertiaires canadiens. Étaient admissibles tous les patients adultes qui prenaient des médicaments cardiovasculaires avant leur admission à l'USI entre le 1er avril 2016 et le 1er avril 2017 et qui avaient survécu jusqu'à leur sortie de l'hôpital. Mesures et principaux critères d'intérêt: Le principal critère d'intérêt était l'arrêt du traitement cardiovasculaire prescrit avant l'admission à l'USI. Ce critère a été établi par l'examen des dossiers des sujets. Résultats: Nous avons inclus 352 patients (âge médian : 71,0 ans) desquels 155 (44 %) avaient vu au moins un de leurs médicaments pour traiter une maladie cardiovasculaire cessé pendant leur séjour. Notre modèle corrigé a révélé trois facteurs associés à l'arrêt du traitement cardiovasculaire : être de sexe masculin (rapport de cotes [RC] : 0,564; IC95 % : 0,346-0,919), le nombre de médicaments cardiovasculaires pris avant l'admission (RC : 1,669; IC95 % : 1,003-2,777 pour deux médicaments, et RC : 3,170; IC95 % : 1,325-7,583) et l'utilisation de vasopresseurs (RC : 1,770; IC95 % : 1,045-2,997). Conclusion: Notre étude a révélé que l'arrêt du traitement contre les maladies cardiovasculaires chroniques, en particulier les inhibiteurs du SRA, est fréquent chez les patients hospitalisés aux soins intensifs. Les données de notre étude pourraient servir à renforcer les protocoles de bilan de médication et d'optimisation propre à chaque site de même que pour éclairer les futurs protocoles visant à assurer le suivi de la réinitiation des inhibiteurs du SRA.

Medication Reconciliation as Part of Admission Management-A Survey to Improve Drug Therapy Safety in a Urology Department.

Complete medication reconciliation during hospital admission is the rationale for further treatment decisions. A consecutive, controlled intervention study was conducted to assess discrepancies in medication reconciliation performed by nurses of the Urology Department compared to the Best Possible Medication History (BPMH) established by pharmacists. This study included pre-intervention (control group, CG), nursing training as a pharmaceutical intervention, and post-intervention (intervention group, IG) groups. The discrepancies were classified as "Missing" (not recorded but taken), "Added" (additionally recorded) "Strength" (incorrect documented dosage), "Intake" (incorrect intake time/schedule), "Double" (double prescription), and "Others" (no clear assignment). Additionally, high-risk drug subgroup discrepancies were particularly prevalent and were evaluated. Training success was compared concerning discrepancies in the CG and IG. Generally, the percentage of discrepancies per patient found was lower in the IG than in the CG (78.1% vs. 87.5%, significantly). The category most identified was "Missing" (IG, 33.3% vs. CG, 35.2%). Overall, a discrepancy of 7.4% each (discrepancies: IG, 27 vs. CG, 38) was determined for high-risk drugs while "Missing" occurred (77.8% vs. 52.6%, out of 7.4%). Despite nursing training only partially reducing discrepancies, the implementation of medication reconciliation using BPMH by pharmacists could improve the process, especially for high-risk drugs.

An international, multicenter post hoc analysis comparing in-person and virtual medication management strategies in post-ICU recovery clinics.

DISCLAIMER: In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE: To compare the incidence of ICU pharmacist interventions in intensive care unit recovery center (ICU-RC) in-person and virtual clinic visits. METHODS: This was a post hoc analysis of interventions implemented by ICU pharmacists among adult patients who were referred to 12 ICU-RCs across the United States and the United Kingdom between September 2019 and July 2021, as reported in a previously published study "An International, Multicenter Evaluation of Comprehensive Medication Management by Pharmacists in ICU Recovery Centers." That study included patients who received a comprehensive medication review by an ICU pharmacist. Medication-related interventions performed by an ICU pharmacist during ICU-RC in-person clinic visits were compared to those performed during virtual clinic visits. RESULTS: There were 507 patients referred to an ICU-RC, of whom 474 patients attended a clinic visit. Of those, 472 received a comprehensive medication review, with 313 patients attending in-person visits and 159 patients attending virtual visits. The incidence of medication-related interventions implemented was higher in the ICU-RC in-person clinic group compared to the virtual clinic group (86.5% vs 79.2%, P = 0.04). There was no difference in the median number of ICU pharmacist interventions per patient between the in-person and virtual clinic groups (2 vs 2, P = 0.13). An ICU admission diagnosis was an independent predictor of medication-related interventions among all patients. CONCLUSION: The incidence of ICU pharmacist interventions was higher at ICU-RC in-person clinic visits compared to virtual clinic visits. Pharmacists aid in meeting the complex pharmacologic challenges of post-intensive care syndrome in both settings.

Surveillance of antibiotics use in inpatients at Benjamin Mkapa Zonal Referral Hospital in Dodoma, Tanzania: a point prevalence survey.

OBJECTIVE: To assess antibiotics prescribing and use patterns for inpatients at Benjamin Mkapa Zonal Referral Hospital (BMH) using the WHO-Point Prevalence Survey (WHO-PPS). DESIGN: A cross-sectional survey. SETTING: The Benjamin Mkapa Zonal Referral Hospital, Dodoma, Tanzania. PARTICIPANTS: Inpatient prescriptions, regardless of whether antibiotics were prescribed (n=286) on the day of PPS. OUTCOME MEASURES: Our study analysed the prevalence of antibiotic use at BMH for inpatients, the type of antibiotics used, the indications for use and the proportion of oral and parenteral antibiotics. We also assessed prescription-prescribed antibiotics after a positive antimicrobial susceptibility testing (AST) result. RESULTS: A survey was conducted on 286 prescriptions, which revealed that 30.07% of them included antibiotics. On average, each prescription contained at least 1.6 antibiotics. All prescriptions that included antibiotics were written in generic names, and 77.91% (67/86) of them followed the Standard Treatment Guidelines. Of the prescriptions that included antibiotics, 58.14% (50/86) had a single antibiotic, 20.93% (18/86) had parenteral antibiotics and 79.07% (68/86) had oral antibiotics. Based on AWaRe's (Access, Watch and Reserve) categorisation of antibiotics, 50% (8/16) were in the Access group, 31.25% (5/16) were in the Watch group, 12.50% (2/16) were in the Reserve group and 6.25% (1/16) were not recommended antimicrobial combinations. Out of 86 prescriptions included antibiotics, only 4.65% showed positive culture growth. However, antibiotics were still prescribed in 29.07% of prescriptions where there was no growth of bacteria, and in 66.28% of prescriptions, antibiotics were prescribed empirically without any requesting of bacteria culture and AST. CONCLUSION: BMH has reduced inpatient Antibiotic Use by half compared with the 2019 WHO-PPS. Adherence to National Treatment Guidelines is suboptimal. Clinicians should use AST results to guide antibiotic prescribing.

Patient Perspectives on a Digital Assistant for Medication Reconciliation: An Interview Study Comparing Socioeconomic Groups.

Medication reconciliation, the process of documenting a patient's medication, is currently a time-consuming and labor-intensive process. To make medication reconciliation more efficient, digital assistants (DAs) offer a promising solution. Especially since human-like digital interfaces tend to be appreciated by more vulnerable populations such as patients in a low socioeconomic position (SEP). Despite the potential of DAs for low-SEP populations in particular, these groups are often not involved during the development and design phase of such digital health interventions. This exclusion may explain the lower adoption rates of digital interventions among low-SEP patients and exacerbate the so-called digital divide. We explored the perceptions and needs of patients across the SEP gradient using a participatory design approach. Patients of low-, middle-, and high-SEP backgrounds were asked to interact with a DA developed for this study and were interviewed afterward. A thematic analysis revealed seven themes regarding design, input method, comprehensibility, privacy concerns, benefits, the intention to use, and reassurance. Overall, patients were afraid to make mistakes in their medication entries and therefore valued feedback from the system or caregivers. Low-SEP patients specifically seemed to value more structured input methods when using the DA, while high-SEP patients emphasized the importance of a secure environment for the DA and sought clarity about its functionalities. Our study demonstrates the importance of involving patients across the socioeconomic gradient when developing a digital health tool and offers concrete recommendations for inclusive DA design for researchers and developers.

Using personal health records for medication continuity during transition of care: An observational study.

Background: National Personal Health Records (PHRs) have been proposed to improve the transfer of medication-related information during transition of care. Objective: To evaluate the concordance between the medications captured in the Australian national PHR, My Health Record (MyHR), and the pharmacist obtained best possible medication history (BPMH) for patients upon hospital admission. Method: This prospective observational study used a convenience sample of hospital patients. For newly admitted patients, the investigating pharmacist obtained a BPMH and then compared it to the medication list captured in MyHR. Upon comparison, the medications were categorised into either complete match, partial match or mismatch. Medications with a complete or partial match were grouped together. Medications with deviations were then assessed for risk based on their potential consequence, and reported descriptively. A multivariable logistic regression was conducted to assess the factors associated with a drug being mismatched. Results: A total of 82 patients were recruited, with a cumulative total of 1,207 medications documented. Of the 1,207 medications, 714 (59.2%) medications were documented as a complete/partial match. The remaining 493 (40.8%) medications were mismatched. Of the 493 mismatched medications, 442 (89.7%) were deemed low-risk deviations and 51 (10.3%) were deemed high-risk. A medication was more likely to be mismatched, rather than completely/partially matched, if it was a regular non-prescription medication, or "when-required" prescription medication, or "when required" non-prescription medication, or if it was administered parenterally. Conclusion: National PHRs may be a secondary source to either confirm a patient's medication history or be used as a starting point for a BPMH.

Factors associated with disease knowledge and attitude among ambulatory patients with type 2 diabetes - a multicenter study.

BACKGROUND: Diabetes is a multifactorial disease state that requires adequate patient monitoring for improved health outcomes. Diabetes knowledge and attitude, and associated factors such as medication adherence, medication discrepancy, health literacy, and glycemic control were evaluated in this study. The selected factors were also compared with diabetes knowledge and attitude. METHODS: A cross-sectional study was carried out among ambulatory diabetes patients in three tertiary healthcare facilities in Nigeria. An interviewer-administered semi-structured questionnaire was utilized for data collection. Data was analysed using descriptive and inferential statistics with the level of significance set at p < 0.05. RESULTS: A total of 188 diabetes patients participated in the study; 51 (27.1%) at the Federal Medical Center, Abeokuta, 69 (36.7%) at the University College Hospital, Ibadan, and 68 (36.2%) at the University of Ilorin Teaching Hospital, Ilorin. One hundred and twelve (59.6%) female patients participated in the study and patients' average age was 58.69 ± 13.68 years. Medication discrepancy was observed among 101 (53.7%) patients. One hundred and three (54.8%), 47 (25.0%) and 38 (20.2%) had high, medium, and low medication adherence, respectively. Ninety-one (48.4%) had high health literacy. Mean diabetes knowledge score was 14.64 ± 2.55 points out of a maximum obtainable score of 18 points. Mean diabetes attitude of patients was 62.50 ± 6.86 points out of a maximum obtainable score of 70 points. Significant positive association was observed between diabetes knowledge and health literacy (Beta = 0.021, p = 0.029). Diabetes knowledge was higher in patients with higher level of formal education (p = 0.046), higher diabetes attitude (p < 0.001) and high health literacy (p = 0.002). Patients' diabetes attitude was higher in individuals older than 60 years of age (p = 0.029), and those with high health literacy (p = 0.005). CONCLUSIONS: The diabetes patients displayed good disease knowledge, attitude and medication adherence. Average levels of health literacy and medication discrepancy was observed among the patients. Significant differences were observed between patients' diabetes knowledge and level of formal education, diabetes attitude, health literacy and age. Patients' health literacy was significantly associated with diabetes knowledge.

Nurse-led medication management as a critical component of transitional care for preventing drug-related problems.

Drug-related problems (DRPs) are critical medical issues during transition from hospital to home with high prevalence. The application of a variety of interventional strategies as part of the transitional care has been studied for preventing DRPs. However, it remains challenging for minimizing DRPs in patients, especially in older adults and those with high risk of medication discrepancies after hospital discharge. In this narrative review, we demonstrated that age, specific medications and polypharmacy, as well as some patient-related and system-related factors all contribute to a higher prevalence of transitional DPRs, most of which could be largely prevented by enhancing nurse-led multidisciplinary medication reconciliation. Nurses' contributions during transitional period for preventing DRPs include information collection and evaluation, communication and education, enhancement of medication adherence, as well as coordination among healthcare professionals. We concluded that nurse-led strategies for medication management can be implemented to prevent or solve DRPs during the high-risk transitional period, and subsequently improve patients' satisfaction and health-related outcomes, prevent the unnecessary loss and waste of medical expenditure and resources, and increase the efficiency of the multidisciplinary teamwork during transitional care.

Improving Self-Perceived Competencies of Second-Year Pharmacy Students Through an Introductory Medication Reconciliation Rotation.

OBJECTIVE: Medication reconciliation (MedRec) is an essential health care function that is particularly relevant to pharmacists' expertise and a learning opportunity for pharmacy students. Our objective was to assess change across clinical competence, confidence, and communication skills after the completion of a MedRec rotation by second-year pharmacy students. METHODS: A retrospective post-then-pre-survey including 29 questions was developed/delivered to students after the completion of required MedRec hours. The primary end point was the change in 3 domains via summed scores from individual questions. Cohen's difference (d) was used to determine group effect size change. The secondary end points included individual question change, perceived patient impact, and subgroup analyses. RESULTS: Of 115 second-year pharmacy students, 81.7% (n = 94) participated in the study. Students self-reported increases on the Likert scale (0-10) of 2.49 ± 1.90 in clinical competency domain, 3.57 ± 2.13 in confidence domain , and 3.12 ± 2.15 in communication skills domain, representing statistically significant and large group effect changes across all 3. A total of 21 of the 22 individual questions had large group effect changes; 1 question (nursing communications) had a moderate group effect change. Student perception of MedRec impact on patient care (Likert scale 0-10) was positive: post-rotation score 7.39 ± 1.57. CONCLUSION: To the best of our knowledge, this is the first larger-scale study that examines student-evaluated outcomes of a MedRec-based rotation. Students self-reported high levels of post-rotation competency across all domains; students from ethnic minorities and with less work/MedRec experience increased their lower pre-rotation scores to statistically similar post-rotation scores, compared with non-minority and more experienced peers. Further study of the model and outcomes is advised.

Using Kane's Validity Framework to Compare an Integrated and Single-Skill Objective Structured Clinical Examination.

OBJECTIVE: The aim of this study was to compare the validity of an integrated objective structured clinical examination (OSCE) station assessing both oral and written components with that of an OSCE station assessing 1 single skill (oral only), both targeted at assessing taking a best possible medication history. METHODS: A convergent mixed-methods design that used the 4 inferences of Kane's validity framework (scoring, generalization, extrapolation, and implications) as a scaffold to integrate qualitative data (post-OSCE reflections) and quantitative data (assessment grades and categories of medication errors) was applied. RESULTS: In 2022, 216 students completed the OSCE station with the oral component alone, while in 2023, 254 students completed the integrated (oral and written) OSCE station. Students in 2023 performed significantly better, with a median score of 88% vs 80% in 2022. There was a greater proportion of commission errors in the integrated assessment (20.4% vs 15.3%), but fewer omission errors (29.9% vs 31.8%) and patient profile errors (5.1% vs 69.4%). Student reflections revealed that conversations were rushed in the integrated assessment, with a greater focus on written formatting, but an appreciation for the authenticity and structured format of the integrated OSCE compared with the single-skill OSCE alone. CONCLUSION: Students completing the integrated OSCE (with oral and written components) had fewer patient profile and medication omission errors than students who completed the oral-only OSCE. Considering Kane's validity framework, there was a stronger argument for the more authentic integrated OSCE in terms of the inferences of extrapolation and implications.

Service development project to pilot a digital technology innovation for video direct observation of therapy in adult patients with asthma.

BACKGROUND: Adherence to pharmacotherapy and use of the correct inhaler technique are important basic principles of asthma management. Video- or remote-direct observation of therapy (v-DOT) could be a feasible approach to facilitate monitoring and supervising therapy, supporting the delivery of standard care. OBJECTIVE: To explore the utility and the feasibility of v-DOT to monitor inhaler technique and adherence to treatment in adults attending the asthma outpatient service in a tertiary hospital in Northern Ireland. METHOD: The project evaluated use of the technology with 10 asthma patients. Patient and clinician feedback was obtained, in addition to measures of patient engagement and disease-specific clinical markers to assess the feasibility and utility of v-DOT technology in this group of patients. RESULTS: The engagement rate with v-DOT for participating patients averaged 78% (actual video uploads vs expected video uploads) over a median 7 week usage period. Although 50% of patients reported a technical issue at some stage during the usage period, all patients and clinicians reported that the technology was easy to use and that they were satisfied with the outcomes. A range of positive impacts were observed, including optimised inhaler technique and an observed improvement in lung function. An increase in asthma control test scores aligned with clinical aims to promote adherence and alleviate symptoms. CONCLUSION: The v-DOT technology was shown to be a feasible method of assessing inhaler technique and monitoring adherence in this small group of adult asthma patients. A range of positive impacts for participating patients and clinicians were observed. Not all patients invited to join the project agreed to participate or engage with using the technology, highlighting that in this setting, digital modes of delivering care provide only one of the approaches in the necessary "tool kit" for clinicians and patients.

A national survey on assessment of knowledge, perceptions, practice, and barriers among hospital pharmacists towards medication reconciliation in United Arab Emirates.

Medication reconciliation (MedRec) helps prevent medication errors. This cross-sectional, nationwide study assessed the knowledge, perceptions, practice, and barriers toward MedRec amongst hospital pharmacy practitioners in the United Arab Emirates. A total of 342 conveniently chosen stratified hospital pharmacists responded to the online survey (88.6% response rate). Mann-Whitney U test and Kruskal-Wallis test were applied at alpha = 0.05 and post hoc analysis was performed using Bonferroni test. The overall median knowledge score was 9/12 with IQR (9-11) with higher levels among clinical pharmacists (p < 0.001) and previously trained pharmacists (p < 0.001). Of the respondents, 35.09% (n = 120) practiced MedRec for fewer than five patients per week despite having a strong perception of their role in this process. The overall median perception score was 32.5/35 IQR (28-35) with higher scores among clinical pharmacists (p < 0.001) and those who attended previous training or workshops (p < 0.001). The median barrier score was 24/30 with an IQR (21-25), where lack of training and knowledge were the most common barriers. Results showed that pharmacists who did not attend previous training or workshops on MedRec had higher barrier levels than those who attended (p = 0.012). This study emphasizes the significance of tackling knowledge gaps, aligning perceptions with practice, and suggesting educational interventions.

Effectiveness of Clinical Pharmacists-Led Medication Reconciliation to Prevent Medication Discrepancies in Hospitalized Patients: A Non-Randomized Controlled Trial.

Aim: Medication discrepancies are a major safety concern for hospitalized patients and healthcare professionals. Medication Reconciliation (MR) is a widely used tool in different practice settings to ensure the proper use of medications. Objective: This study aimed to assess the effectiveness of the clinical pharmacists-led MR process in identifying, preventing, and resolving medication discrepancies among hospitalized patients. Patients and Methods: This was a prospective study with an observational and interventional part, conducted at the Internal Medicine Department of a tertiary Hospital in Sudan from January to September 2023. The enrolled patients were divided into two groups, the observation group, in which the routine MR process was performed by doctors (usual care), and the intervention group, in which clinical pharmacists led the MR process. Results: Compared to the usual care, the clinical pharmacists were more efficient in identifying and preventing medication discrepancies (P=0.001). From a total of 1012 medications, clinical pharmacists' interventions contributed to the detection of (39%) equivalent to 2.2 discrepancies per patient, resolving 325 (83%) and preventing (55%) clinically significant discrepancies. Dose discrepancy (43%) was the most common type of identified discrepancies. These interventions were accepted by (98%) of doctors and implemented in (86%) of the total cases. The main predictors of medication discrepancies (P ≤0.05) for patients were the length of hospital stay, patient-hospital transfer, high number of medication histories, and increased number of medications used during hospitalization. Conclusion: Through the implementation of the MR process, the clinical pharmacist's interventions substantially contributed to the detection and resolution of medication discrepancies among hospitalized patients. It is recommended that this intervention be disseminated in more hospitals in Sudan to encourage the implementation of appropriate practices.

The Impact of Real-Time Documentation of In-Hospital Medication Changes on Preventing Undocumented Discrepancies at Discharge and Improving Physician-Pharmacist Communication: A Retrospective Cohort Study and Survey.

Background: Transitional medication safety is crucial, as miscommunication about medication changes can lead to significant risks. Unclear or incomplete documentation during care transitions can result in outdated or incorrect medication lists at discharge, potentially causing medication errors, adverse drug events, and inadequate patient education. These issues are exacerbated by extended hospital stays and multiple care events, making accurate medication recall challenging at discharge. Objective: Thus, we aimed to investigate how real-time documentation of in-hospital medication changes prevents undocumented medication changes at discharge and improves physician-pharmacist communication. Methods: We conducted a retrospective cohort study in a tertiary hospital. Two pharmacists reviewed medical records of patients admitted to the acute medical unit from April to June 2020. In-hospital medication discrepancies were determined by comparing preadmission and hospitalization medication lists and it was verified whether the physician's intent of medication changes was clarified by documentation. By a documentation rate of medication changes of 100% and <100%, respectively, fully documented (FD) and partially documented (PD) groups were defined. Any undocumented medication changes at discharge were considered a "documentation error at discharge". Pharmacists' survey was conducted to assess the impact of appropriate documentation on the pharmacists. Results: After reviewing 400 medication records, patients were categorized into FD (61.3%) and PD (38.8%) groups. Documentation errors at discharge were significantly higher in the PD than in the FD group. Factors associated with documentation errors at discharge included belonging to the PD group, discharge from a non-hospitalist-managed ward, and having three or more intentional discrepancies. Pharmacists showed favorable attitudes towards physician's documentation. Conclusion: Appropriate documentation of in-hospital medication changes, facilitated by free-text communication, significantly decreased documentation errors at discharge. This analysis underlines the importance of communication between pharmacists and hospitalists in improving patient safety during transitions of care.

During transitions of care, communication failures among healthcare professionals can lead to medication errors. Therefore, effective sharing of information is essential, especially when intentional changes in prescription orders are made. Documenting medication changes facilitates real-time communication, potentially improving medication reconciliation and reducing discrepancies. However, inadequate documentation of medication changes is common in clinical practice. This retrospective cohort study underlines the importance of real-time documentation of in-hospital medication changes. There was a significant reduction in documentation errors at discharge in fully documented group, where real-time documentation of medication changes was more prevalent. Pharmacists showed favorable attitudes toward the physician's real-time documenting of medication changes because it provided valuable information on understanding the physician's intent and improving communication and also saved time for pharmacists. This study concludes that physicians' documentation on medication changes may reduce documentation errors at discharge, meaning that proper documentation of medication changes could enhance patient safety through effective communication.

Medication Reconciliation Errors on Discharge for Epilepsy Monitoring Unit Patients.

Background and Purpose: Medication errors are common in the inpatient setting. Epilepsy patients who miss doses of their antiseizure medications are at risk for breakthrough seizures and subsequent complications. The purpose of this study was to quantify and characterize anti-seizure medications reconciliation errors on discharge from the epilepsy monitoring unit (EMU). Methods: Consecutive admissions to an academic medical center EMU were retrospectively reviewed. Medication reconciliation errors on discharge, including drug errors, dosing errors, and dose timing errors, were recorded. Associations between medication errors and clinical and demographic variables were analyzed using binary logistic regression for continuous variables and Fisher exact tests for categorical variables. Results: One hundred and eleven admissions between January 1, 2021 and December 31, 2021 were identified. Fourteen anti-seizure medication reconciliation errors were recorded during 11 unique admissions (9.9% of admissions). The most common error type was dosing error (10/14 errors; 71.4%). Number of antiseizure medications on admission (p=0.004), total number of medications on admission (p=0.013), number of medication changes during admission (p=0.0007), and length of stay (p=0.0001) were associated with increased likelihood of errors. Conclusions: Medication reconciliation errors upon discharge from the EMU occur during approximately 10% of admissions. A higher number of preadmission antiseizure medications, higher total number of preadmission medications, higher number of medication changes during admission, and longer length of stay are associated with increased risk of discharge medication reconciliation errors. Careful attention should be paid to patients with these risk factors.

Rapid response systems, antibiotic stewardship and medication reconciliation: a scoping review on implementation factors, activities and outcomes.

INTRODUCTION: Many patient safety practices are only partly established in routine clinical care, despite extensive quality improvement efforts. Implementation science can offer insights into how patient safety practices can be successfully adopted. OBJECTIVE: The objective was to examine the literature on implementation of three internationally used safety practices: medication reconciliation, antibiotic stewardship programmes and rapid response systems. We sought to identify the implementation activities, factors and outcomes reported; the combinations of factors and activities supporting successful implementation; and the implications of the current evidence base for future implementation and research. METHODS: We searched Medline, Embase, Web of Science, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and Education Resources Information Center from January 2011 to March 2023. We included original peer-reviewed research studies or quality improvement reports. We used an iterative, inductive approach to thematically categorise data. Descriptive statistics and hierarchical cluster analyses were performed. RESULTS: From the 159 included studies, eight categories of implementation activities were identified: education; planning and preparation; method-based approach; audit and feedback; motivate and remind; resource allocation; simulation and training; and patient involvement. Most studies reported activities from multiple categories. Implementation factors included: clinical competence and collaboration; resources; readiness and engagement; external influence; organisational involvement; QI competence; and feasibility of innovation. Factors were often suggested post hoc and seldom used to guide the selection of implementation strategies. Implementation outcomes were reported as: fidelity or compliance; proxy indicator for fidelity; sustainability; acceptability; and spread. Most studies reported implementation improvement, hindering discrimination between more or less important factors and activities. CONCLUSIONS: The multiple activities employed to implement patient safety practices reflect mainly method-based improvement science, and to a lesser degree determinant frameworks from implementation science. There seems to be an unexploited potential for continuous adaptation of implementation activities to address changing contexts. Research-informed guidance on how to make such adaptations could advance implementation in practice.