Over 500 Reports Show Breakdowns in Patients' Medication Reconciliation Processes

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Pennsylvania Patient Safety Authority

Dec 17, 2013, 10:00 ET

Of the reported medication events 337 reached the patient but most did not result in patient harm, however three percent or 18 patients were harmed

HARRISBURG, Pa., Dec. 17, 2013 /PRNewswire-USNewswire/ -- Pennsylvania Patient Safety Authority analysts identified 501 reports involving breakdowns in the medication reconciliation process with a majority of the events occurring during admission medication reconciliation, according to an article in the December Pennsylvania Patient Safety Advisory released today.

"Medication reconciliation is the process of comparing the list of medications a patient is taking while at home with newly ordered medications in the hospital to identify and resolve any differences in the medications," Mike Gaunt, PharmD, patient safety analyst for the Pennsylvania Patient Safety Authority said. "The analysis showed that while most patients were not harmed, these events should be looked at to make necessary improvements to the medication reconciliation process to avoid harm."

The 501 reports were from event dates between November 1, 2011, and November 31, 2012. The majority of events occurred during admission medication reconciliation (69%, n=347). Events most often originated during prescribing (40%, n=202) and transcribing (27%, n=135).

"Drug omissions, for example, missing a drug or dose, was the most frequently reported event type overall, with one hundred and thirty-four reports" Gaunt said. "Other top event types reported included patients receiving the wrong dose or additional drug or dose."

Gaunt added that of the 501 events 337 reached the patient; 87 of the events reached the patient and required monitoring to confirm it resulted in no harm to the patient and/or required intervention to preclude harm and 18 of the events resulted in patient harm.

"Most events [40%] occurred during the prescribing phase of the medication reconciliation process," Gaunt said. "The care areas in which they occurred varied from the emergency department to pharmacy, with a majority of the patients involved in the events sixty-five or older."

Gaunt added some risk reduction strategies include standardizing the process for obtaining and communicating complete and accurate medication histories, defining roles and responsibilities for all staff, addressing the design of electronic health record systems, encouraging patient and caregiver involvement and periodic measurement of the medication reconciliation process.

"While some of these tasks to reduce the risk can take some time, it's worth the effort to minimize the risk of a medication error reaching a patient," Gaunt said. "The importance of the patient or caregiver's role in giving an accurate medication history cannot be stressed enough.

"Patients should keep an accurate list of their medications with them at all times and ask the healthcare provider to repeat their medications and doses to them," Gaunt added.

Consumer tips are also available on the Authority's website on how to minimize your risk of a medication error.

For more information about the breakdowns in medication reconciliation, go to the December Pennsylvania Patient Safety Advisory article "Breakdowns in the Medication Reconciliation Process" on the Authority's website at www.patientsafetyauthority.org. A self-assessment test for clinicians is also available with this article.

The Authority's 2013 December Advisory contains other clinical articles with toolkits for the healthcare provider to improve patient safety. Highlights include:

Falls Prevention: Pennsylvania Hospitals Implementing Best Practices: The Authority provided 83 hospitals participating in the Pennsylvania Hospital Engagement Network (HEN) Falls Reduction and Prevention Collaboration with two tools to evaluate their falls prevention programs: a self-assessment survey and a process measures audit. The tools helped facilities determine its strengths and weaknesses with their falls programs. This article discusses the tools in detail, falls prevention best practices and program elements associated with lower rates of falls with injury.
Update: Are Influenza, Pneumonia and Vaccination Rates Improving in Nursing Home Residents?: Since 2006, pneumonia and influenza combined have remained the seventh leading cause of death in people over 65 years of age in the United States. Lower respiratory tract infections (LRTIs), including pneumonia and influenza-like illness, are the second most common healthcare-associated infections (HAIs) in Pennsylvania nursing homes. This article discusses how overall national healthcare worker influenza vaccination rates have steadily increased over the last decade, including in Pennsylvania. This article discusses the gains made in vaccinating healthcare workers for influenza and pneumonia, but also points to research that shows how much more Pennsylvania needs to do to reach target goals. Consumer tips on flu, pneumonia and LRTIs are also available on the Authority's website.
Data Snapshot: Pediatric Laboratory Events: Specimen collection problems are costly in terms of the time required to secure a new specimen, trauma inflicted on the patient, potential delay in diagnosis and treatment, and financial costs of additional resources used. The pediatric population has a heightened vulnerability to and fear of specimen collection. This snapshot discusses laboratory-related events that occurred between January 2010 and December 2012 concerning pediatric patients in children's hospitals, acute care hospitals, community hospitals, rehabilitation hospitals, ambulatory surgical facilities and birthing centers.
Wrong-Site Surgery Update: Ten wrong-site procedures were reported in Pennsylvania operating suites this past quarter, the lowest yet recorded for the first quarter of an academic year since reporting began. Another two were reported belatedly for the last quarter, raising the total for the last academic year to 48, which still represents the lowest total for any academic year. This wrong-site surgery update details the most recent events and provides major areas of focus for prevention. A toolkit and wrong-site surgery consumer tips are also available on the Authority's website.