Classifying and predicting errors of inpatient medication reconciliation.

BACKGROUND: Failure to reconcile medications across transitions in care is an important source of potential harm to patients. Little is known about the predictors of unintentional medication discrepancies and how, when, and where they occur. OBJECTIVE: To determine the reasons, timing, and predictors of potentially harmful medication discrepancies. DESIGN: Prospective observational study. PATIENTS: Admitted general medical patients. MEASUREMENTS: Study pharmacists took gold-standard medication histories and compared them with medical teams' medication histories, admission and discharge orders. Blinded teams of physicians adjudicated all unexplained discrepancies using a modification of an existing typology. The main outcome was the number of potentially harmful unintentional medication discrepancies per patient (potential adverse drug events or PADEs). RESULTS: Among 180 patients, 2066 medication discrepancies were identified, and 257 (12%) were unintentional and had potential for harm (1.4 per patient). Of these, 186 (72%) were due to errors taking the preadmission medication history, while 68 (26%) were due to errors reconciling the medication history with discharge orders. Most PADEs occurred at discharge (75%). In multivariable analyses, low patient understanding of preadmission medications, number of medication changes from preadmission to discharge, and medication history taken by an intern were associated with PADEs. CONCLUSIONS: Unintentional medication discrepancies are common and more often due to errors taking an accurate medication history than errors reconciling this history with patient orders. Focusing on accurate medication histories, on potential medication errors at discharge, and on identifying high-risk patients for more intensive interventions may improve medication safety during and after hospitalization.

Association between language proficiency and the quality of primary care among a national sample of insured Latinos.

BACKGROUND: Latinos experience substantial barriers to primary care. Limited English language proficiency may be a mechanism for these deficiencies, even for Latinos with health coverage. OBJECTIVE: To determine the relationship between English language proficiency and the experience of primary care reported by insured Latinos. DESIGN, SETTING, PARTICIPANTS: Analysis of the National Latino and Asian American Study, a nationally representative household survey, 2002-2003. This analysis was restricted to Latinos who reported current health insurance (n= 1792), and included information on ethnic subgroups. MAIN OUTCOME MEASURES: Four outcomes addressed different aspects of the quality of primary care: (1) not having a regular source of care or lacking continuity of care, (2) difficulty getting an appointment over the phone, (3) long waits in the waiting room, and (4) difficulty getting information or advice by phone. RESULTS: English language proficiency was associated with the experience of primary care for 3 of the 4 outcomes. Insured Latinos with poor/fair English language proficiency were more likely than those with good/excellent proficiency to report not having a regular source of care or lacking continuity [odds ratio (OR) 2.20, 95% confidence interval (CI) 1.60-3.02], long waits (OR, 1.88; CI, 1.34-2.64), and difficulty getting information/advice by phone (OR, 1.76; 95% CI, 1.25-2.46). CONCLUSIONS: Among insured Latinos, low English language proficiency is associated with worse reports of the quality of primary care. These results suggest that interventions to address limited English proficiency may be important to improving the quality of primary care for this rapidly growing population.

Hospital characteristics and racial disparities in hospital mortality from common medical conditions.

OBJECTIVES: Less is known about racial disparities in mortality from medical conditions than for procedures. We determined whether black-white disparities in risk-adjusted hospital mortality exist for five common conditions (myocardial infarction, congestive heart failure, cerebral vascular accident, gastrointestinal hemorrhage and pneumonia), and to determine the role of hospital characteristics. METHODS: We used the 2003 Nationwide Inpatient Sample. Where a mortality disadvantage for black patients was demonstrated, additional analyses assessed whether the degree of disparity varied by hospital characteristics. RESULTS: Mortality for black patients was equivalent to or lower than that for white patients for four of the five conditions. Black patients were more likely than white patients to die from gastrointestinal hemorrhage (1.5% vs. 1.1%, p<0.001). In multivariate analysis, hospital racial composition was the only characteristic associated with degree of disparity for gastrointestinal hemorrhage, with hospitals discharging fewer black patients demonstrating greater disparity. CONCLUSIONS: In a large, multistate sample, there was no evidence of disparities in mortality for four of five common conditions. Black-white racial disparities in mortality from gastrointestinal hemorrhage, however, may be associated with hospital racial composition.

Association of breastfeeding with maternal depressive symptoms.

PURPOSE: To identify risk factors for lack of breastfeeding initiation and duration of <1 month among a racially diverse cohort of women. In particular, our interest was to examine depressive symptoms during pregnancy as a potential risk factor for not initiating or continuing breastfeeding. METHODS: Survey and medical record data from a cohort of pregnant women from the San Francisco Bay area who delivered a singleton infant (n = 1448) were analyzed to examine lack of breastfeeding initiation and duration of <1 month. RESULTS: In this study, 5.6% of women did not initiate breastfeeding, and 11.1% of women who initiated breastfeeding had a duration of breastfeeding of <1 month. There were no racial or ethnic differences in initiation of breastfeeding after adjusting for demographic and clinical characteristics. At 1 month postpartum, African American women were more likely than white women to have a duration of breastfeeding lasting <1 month. Depressive symptoms during or prior to pregnancy had no effect on initiation of breastfeeding even when symptoms were persistent. Women with persistent depressive symptoms (symptoms at two time points, including one prior to delivery) were more likely to have breastfeeding duration of <1 month (odds ratio [OR] 1.77, 95% confidence interval [95% CI] 1.10-2.86), whereas depressive symptoms at a single time point were not associated with breastfeeding duration of <1 month. CONCLUSIONS: Addressing depressive symptoms experienced by women both during and after pregnancy may improve the duration of breastfeeding.