Identifying opportunities to improve medication management in transitions of care.

PURPOSE: The types and causes of medication discrepancies during the transition from inpatient to ambulatory care were investigated. METHODS: A descriptive study was conducted at an academic outpatient group practice affiliated with a private nonacademic hospital to (1) describe discrepancies between inpatient discharge summaries and patient-reported medication lists, (2) identify patient and system factors related to breakdowns in medication documentation, and (3) determine reasons for medication discrepancies. During a four-month period, 17 patients at high risk for medication misadventures while transitioning from hospital care to outpatient follow-up were contacted by telephone soon after discharge and asked to provide information on all medications they were taking. Patient-reported medication lists were compared with the corresponding discharge summaries, and medication discrepancies were categorized by patient- and system-level factors using a validated instrument. RESULTS: Of the total of 96 discrepancies identified, more than two thirds (n = 67, 68%) involved the omission of a prescribed medication from either the patient-reported list or the discharge summary. Cardiovascular medications, including antihypertensives, antilipemics, diuretics, and antiarrhythmics, accounted for almost one quarter of all medication discrepancies. About 15% (n = 14) and 16% (n = 15) of identified discrepancies related to medication dose and frequency, respectively. CONCLUSION: Among 17 patients transitioning from inpatient to outpatient care, nearly 100 discrepancies between patient-reported medication lists and discharge summaries were identified. Most discrepancies were attributed to nonintentional nonadherence and resumption of home medications without instructions to do so. All 17 patients had at least 1 medication discrepancy categorized as involving a system-level factor.

Comparison of gentamicin and mupirocin in the prevention of exit-site infection and peritonitis in peritoneal dialysis.

Exit-site infection (ESI) and peritonitis are the most frequent reasons for catheter removal and patient drop-out from peritoneal dialysis (PD). After a randomized double-blind study showed gentamicin to be superior to mupirocin for exit-site prophylaxis, several dialysis centers including ours switched from topical mupirocin to gentamicin. Our study examined whether the change from mupirocin to gentamicin affected ESI and peritonitis rates. We retrospectively reviewed consecutive charts of patients seen at our PD clinic between January 2003 and December 2007. We noted the rates of ESI and peritonitis in patients who met the study entry criteria. Chart data for the 100 patients that met study entry criteria were evaluated in depth. The ESI rate was 0.002 episodes/patient-month in the gentamicin group and 0.004 episodes/patient-month in the mupirocin group (p = 0.45). The peritonitis rate was 0.06 episodes/patient-month in the gentamicin group and 0.02 episodes/patient-month in the mupirocin group (p = 0.07). The rate of gram-positive peritonitis was 0.05 episodes/ patient-month in the gentamicin group and 0.01 episodes/patient-month in the mupirocin group (p = 0.08). The rate of gram-negative peritonitis was 0.009 episodes/patient-month in the gentamicin group and 0.008 episodes/patient-month in the mupirocin group (p = 0.83). We observed no statistically significant difference in the rates of ESI between patients using mupirocin and those using gentamicin for exit-site prophylaxis. Both groups had a very low ESI rate. A trend toward higher peritonitis rates was noted in the gentamicin group, largely as a result of gram-positive bacteria (p value nonsignificant).

Treatment of primary headache in the emergency department.

BACKGROUND: Each year many patients present to an emergency department for treatment of acute primary headache. We investigated the diagnosis and clinical outcome of patients treated for primary headache in the emergency department. METHODS: Patients treated for acute primary headache in the emergency department completed a questionnaire related to their headache symptoms, response to treatment, and ability to return to normal function. These responses were compared to the treating physicians' observations of the patient's condition at the time of discharge from the emergency department. RESULTS: Based on the questionnaire, 95% of the 57 respondents met International Headache Society diagnostic criteria for migraine. Emergency department physicians, however, diagnosed only 32% of the respondents with migraine, while 59% were diagnosed as having "cephalgia" or "headache NOS" (not otherwise specified). All patients previously had taken nonprescription medication, and 49% had never taken a triptan. In the emergency department, only 7% of the patients received a drug "specific" for migraine (ie, a triptan or dihydroergotamine). Sixty-five percent of the patients were treated with a "migraine cocktail" comprised of a variable mixture of a nonsteroidal anti-inflammatory agent, a dopamine antagonist, and/or an antihistamine; 24% were treated with opioids. All 57 patients reported that after discharge they had to rest or sleep and were unable to return to normal function. Sixty percent of patients still had headache 24 hours after discharge from the emergency department. CONCLUSION: The overwhelming majority of patients who present to an emergency department with acute primary headache have migraine, but the majority of patients receive a less specific diagnosis and a treatment that is correspondingly nonspecific.