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Background
Medical records that do not accurately reflect the patient’s current medication list are an open invitation to errors and may compromise patient safety.
Methods
This cross-sectional study compares primary care provider (PCP) medication lists and pharmacy claims for 100 patients seen in 8 primary care practices and examines the associati...
Citations
... General character 4 1 a included in the 38 agreements important risk factors for insufficient medication safety among the investigated units and most likely also for Swedish primary care in general. Updating the medication list in the medical record is often done deficiently, which has been noted previously [20,21]. Medical records that do not accurately reflect the patient's current medication list are open invitations to possible significant medical errors. ...
Background
There is an urgent need to improve patient safety in the area of medication treatment among the elderly. The aim of this study was to explore which improvement needs and strengths, relating to medication safety, arise from a multi-professional intervention in primary care and further to describe and follow up on the agreements for change that were established within the intervention.
Methods
The SÄKLÄK project was a multi-professional intervention in primary care consisting of self-assessment, peer-review, feedback and written agreements for change. Data were obtained from five primary care units randomised to the intervention group. Reviewer feedback reports and agreements for change were analysed using content analysis.
Results
Strengths that were identified included a committed leadership, work methods to enhance medication safety and access to consultants. Methods for securing an accurate medication list, knowledge and methods of working of the prescriber and patient’s ability to contribute to medication safety were areas that gave rise to three predesigned categories for improvement needs on a local level. Another category became apparent during the analysis; namely learning from mistakes and from results. In all categories, apparent shortcomings were identified. These included inaccurate medication lists, lack of medication reconciliation, lack of time for follow-up of elderly patients, need for further education in geriatrics and pharmacotherapy and lack of information on indication and maximum dosage. An increased number of medication reviews were among the most common agreements for change seen.
Conclusions
This study identified substantial shortcomings, like poorly updated medication lists, which affected medication safety in the participating Swedish primary care units. Similar shortcomings are most likely present in other primary care units in the country. Working together multi-professionally, including performing medication reviews, could be one way of improving medication safety. On the other hand, the individual physician must possess enough pharmaceutical knowledge and the working conditions must allow time for follow-up of prescriptions. Strengths of the primary care unit, such as successful methods of working, must be taken advantage of. The culture in primary care may affect the ability to successfully implement routines that improve patient safety and reduce risk of medication errors.
... Die Anzahl der Abweichungen wurden getrennt nach Rx und OTC erfasst. Abweichungen vom ursprünglichen Plan waren definiert als: Arzneimittel auf dem Plan, aber nicht eingenommen; Arzneimittel eingenommen, aber nicht auf dem Plan; Dosisabweichungen und Abweichungen von Fertigarzneimittelnamen [9,10]. Pro Arzneimittel konnten maximal drei Fehler auftreten (Arzneimittel fehlt/zusätzlich; Dosis zu hoch/zu niedrig; Namensabweichung). ...
... However, an overview of actual medication use is essential for medication reviews. It is known that GPs' and pharmacists' medication records and actual intake often mismatch [24,25]. Results from an Australian study showed that medication use obtained by means of a telephone interview had good agreement with those obtained by means of an interview [26]. ...
Background:
Information on medication use and drug-related problems is important in the preparation of clinical medication reviews. Critical information can only be provided by patients themselves, but interviewing patients is time-consuming. Alternatively, patient information could be obtained with a questionnaire.
Objective:
In this study the agreement between patient information on medication use and drug-related problems in older patients obtained with a questionnaire was compared with information obtained during an interview.
Setting:
General practice in The Netherlands.
Method:
A questionnaire was developed to obtain information on actual medication use and drug-related problems. Two patient groups ≥65 years were selected based on general practitioner electronic medical records in nine practices; I. polypharmacy and II. ≥1 predefined general geriatric problems. Eligible patients were asked to complete the questionnaire and were interviewed afterwards.
Main outcome measure:
Agreement on information on medication use and drug-related problems collected with the questionnaire and interview was calculated.
Results:
Ninety-seven patients participated. Of all medications used, 87.6 % (95 % CI 84.7-90.5) was reported identically in the questionnaire and interview. Agreement for the complete medication list was found for 45.4 % (95 % CI 35.8-55.3) of the patients. On drug-related problem level, agreement between questionnaire and interview was 75 %. Agreement tended to be lower in vulnerable patients characterized by ≥4 chronic diseases, ≥10 medications used and low health literacy.
Conclusion:
Information from a questionnaire showed reasonable agreement compared with interviewing. The patients reported more medications and drug-related problems in the interview than the questionnaire. Taking the limitations into account, a questionnaire seems a suitable tool for medication reviews that may replace an interview for most patients.
... [1][2][3][4][5][6][7][8] This national injury phenomenon has been shown to be even more severe for vulnerable lower income consumers often lacking resources, support, or health literacy to help them avoid such adverse medication-related encounters. [9][10][11][12] An external cause of injury, or E-code diagnosis code, is a supplemental code assigned by servicing providers to standard condition code(s) during typical care provision to elaborate on the additional reason(s) for required health care treatments. 13 E-code events have been systematically defined as a key injury measure by the World Health Organization as conditions documented as due to a drug, medicinal, or biologic substance. ...
To inform Medicaid medication management and public health policymaking, the authors analyzed the major predictive factors influencing program-approved therapeutic use or poisoning E-coded encounters leading to emergency department visits and hospital admission for the totality of Michigan Medicaid beneficiaries during a 12-month 2010–2011 period. The analytic cohort was composed of 26,134 approved E-code encounters submitted for 19,865 discrete Michigan Medicaid beneficiaries.
More than 1% of all beneficiaries experienced at least one adverse medication/agent-related E-code encounter during the period. More such encounters and costlier approved encounters were recorded female subjects, African Americans, dually eligible adults, urban elderly, those with fee-for-service Medicaid coverage, and those residing in urban-density counties.
Especially notably for patient safety policymakers, more than 9% of total E-coded encounters for children and adults were primarily attributed by providers to likely preventable poisoning causes such as exposure to household cleaning agents/gases, cosmetic products, illicit drug/alcohol, or secondary tobacco smoke. Encounter costs for the total sample totaled $37 million but ranged considerably up to more than a quarter million dollars.
In view of the future expanding Medicaid-covered beneficiary cohorts, the authors propose several key patient safety/public health policy implications for researchers and policymakers striving to serve lower-income health care consumer groups.
... Ordered medication exposures are a very-frequently used element of EHR-based research, and present a unique set of challenges. The documentation of medication use within an electronic health record is not well standardized [18]. Documentation of prescription medications within a patient's medical record may be stored in either structured or unstructured clinical fields and often there is necessary information in both types of fields [18,19]. ...
... The documentation of medication use within an electronic health record is not well standardized [18]. Documentation of prescription medications within a patient's medical record may be stored in either structured or unstructured clinical fields and often there is necessary information in both types of fields [18,19]. Frequently, multiple sources of medication documentation must be interrogated and combined in order to obtain a complete and accurate description of a patient's medication history. ...
We aim to quantify HMG-CoA reductase inhibitor (statin) prescriber-intended exposure-time using a generalizable algorithm that interrogates data stored in the electronic health record (EHR).
This study was conducted using the Marshfield Clinic (MC) Personalized Medicine Research Project (PMRP) a central Wisconsin-based population and biobank with, on average, 30 years of electronic health data available in the independently-developed MC Cattails MD EHR. Individuals with evidence of statin exposure were identified from the electronic records, and manual chart abstraction of all mentions of prescribed statins was completed. We then performed electronic chart abstraction of prescriber-intended exposure time for statins, using previously identified logic to capture pill-splitting events, normalizing dosages to atorvastatin-equivalent dose. Four models using iterative training sets were tested to capture statin end-dates. Calculated cumulative provider-intended exposures were compared to manually abstracted gold-standard measures of ordered statin prescriptions, and aggregate model results (totals) for training and validation populations were compared. The most successful model was the one with the smallest discordance between modeled and manually abstracted Atorvastatin 10mg/year Equivalents (AEs).
Of the approximately 20,000 patients enrolled in the PMRP, 6,243 were identified with statin exposure during the study period (1997-2011), 59.8% of whom had been prescribed multiple statins over an average of approximately 11 years. When the best-fit algorithm was implemented and validated by manual chart review for the statin-ordered population, it was found to capture 95.9% of the correlation between calculated and expected statin provider-intended exposure time for a random validation set, and the best-fit model was able to predict intended statin exposure to within a standard deviation of 2.6 AEs, with a standard error of +0.23 AEs.
We demonstrate that normalized provider-intended statin exposure time can be estimated using a combination of structured clinical data sources, including a medications ordering system and a clinical appointment coordination system, supplemented with text data from clinical notes.
... Een recente Amerikaanse studie liet zien dat de overeenstemming tussen huisartsen en apothekers over medicatie die aan patiënten is voorgeschreven, beperkt is. 2 Ook zijn er veel verschillen tussen de medicatiegegevens van de ziekenhuisspecialist vergeleken met de medicatielijsten van huisartsen en apothekers. 3 Bovendien kunnen door de specialist voorgeschreven medicamenten bij de patiënt bekend zijn, maar nog niet in de huisartsenpraktijk. ...
BACKGROUND: Polypharmacy in older people should be addressed by an annual review of the chronic medication. In the PIL-study this was done by an integrated approach by GP, practice nurse, pharmacist, specialist and patient. All patients were first visited at home by the practice nurse. RESEARCH QUESTIONS: What 'over the counter' (OTC) medications do polypharmacy patients use? Do they know the indications of the prescribed medication? Does medication use according to the patient match with medication use according to the records of GP and pharmacist? METHOD: Inclusion criteria were: age 60 years or older, daily use of five or more chronic medications, mental competence, and adequate command of the Dutch language. All patients were visited at home by the practice nurse, who made an inventory of the actual drug use. RESULTS: Five hundred fifty patients used a total of 5576 drugs, including 527 (9.4%) OTC medication. Patients knew the indication of 64% of the prescribed medication. The number of prescribed drugs that a patient actually used did not match the numbers known to GP and pharmacist. In 60.4% of all medication prescriptions there was complete agreement between GP, pharmacist and patient. On a patient level agreement was 18.7%. CONCLUSIONS: Home visits by the nurse practitioner to make an inventory of the medication as reported by the patient seem to have an added value.
Medication reconciliation in ambulatory care settings helps prevent adverse drug events. Patient involvement in the process is crucial, as clinicians must verify the reported medication history with other sources such as home medication lists or brown-bagged home medications provided by patients. However, only 47.8% of brain injury and stroke adult outpatients at Toronto Rehabilitation Institute, an academic rehabilitation hospital, bring their medications/medication lists to clinic visits. In turn, missing medication information impacts the clinic by causing delays in treatment and interrupted clinic flow. This project aimed to increase the percentage of patients who bring their medications/medication lists to 80% and decrease the impact on clinic visits caused by missing medication information to 10%. This was a controlled before-after study, with the outpatient rehabilitation assessment (OPRA) clinic as the intervention and the spasticity clinic as the control. The model for improvement was used as the project framework. Process mapping, Ishikawa diagrams, driver diagrams and patient surveys generated the change ideas. Verbal reminders during confirmation phone calls, written reminders and medication list templates were implemented. Data were collected on a biweekly basis and analysed using statistical control charts. After six Plan-Do-Study-Act cycles conducted over 49 weeks, both project aims were achieved. The percentage of OPRA clinic patients who brought medications/medication lists was 81.8% and the impact on clinic visits caused by missing medication information was 9.1% of clinic visits. Special cause variation was detected on the statistical control charts. Conversely, there was no special cause variation for the spasticity clinic (the control) for either aim. Lessons learnt include the importance of prolonged data collection when implementing interventions with long lag time, and that verbal reminders may not be effective for patients with cognitive impairments. Future efforts may focus on implementing the bundle of project interventions for the spasticity clinic.
There is a shift by payers and health plans away from volume-based payments toward value-based payments that are linked to clinical quality, clinical practice improvement activities, and certified electronic health records technology. These alternative payment programs include fee-for-service with performance-based incentives, advanced payments for care management, shared savings, and population-based payments.
Alternative payment programs that focus on clinical quality and practice improvements are founded on patient-centered care principles and based on team-based care delivery. There will be opportunities to expand primary care teams to address chronic care management, care transitions, and high-risk populations – all of which present medication optimization and management challenges that can be delegated to pharmacists working closely with primary care clinicians.
This commentary will discuss implementation considerations for pharmacist services, standardized documentation of medication-related problems, and “upstream” pharmacist interventions (closest to the point of care) that align with alternative payment models.
Lack of concordance between medications listed in the medical record and taken by the patient contributes to poor outcomes. We sought to determine whether patients who received health coaching by medical assistants improved their medication concordance and adherence.
This was a nonblinded, randomized, controlled, pragmatic intervention trial. English- or Spanish-speaking patients, age 18 to 75 years, with poorly controlled type 2 diabetes, hypertension, and/or hyperlipidemia were enrolled from 2 urban safety net clinics and randomized to receive 12 months of health coaching versus usual care.
Outcomes included concordance between medications documented in the medical record and those reported by the patient and adherence based on the patient-reported number of days (of the last 7) on which patient took all prescribed medications. The proportion of medications completely concordant increased in the coached group versus the usual care group (difference in change, 10%; P = .05). The proportion of medications listed in the chart but not taken significantly decreased in the coached group compared with the usual care group (difference in change, 17%; P = .013). The mean number of adherent days increased in the coached but not in the usual care group (difference in change, 1.08; P < .001).
Health coaching by medical assistants significantly increases medication concordance and adherence.
© Copyright 2015 by the American Board of Family Medicine.
Background
Polypharmacy in older people should be addressed by an annual review of the chronic medication. In the PIL-study this was done by an integrated approach by GP, practice nurse, pharmacist, specialist and patient. All patients were first visited at home by the practice nurse.
Research questions
What ‘over the counter’ (OTC) medications do polypharmacy patients use? Do they know the indications of the prescribed medication? Does medication use according to the patient match with medication use according to the records of GP and pharmacist?
Method
Inclusion criteria were: age 60 years or older, daily use of five or more chronic medications, mental competence, and adequate command of the Dutch language. All patients were visited at home by the practice nurse, who made an inventory of the actual drug use.
Results
Five hundred fifty patients used a total of 5576 drugs, including 527 (9.4%) OTC medication. Patients knew the indication of 64% of the prescribed medication. The number of prescribed drugs that a patient actually used did not match the numbers known to GP and pharmacist. In 60.4% of all medication prescriptions there was complete agreement between GP, pharmacist and patient. On a patient level agreement was 18.7%.
Conclusions
Home visits by the nurse practitioner to make an inventory of the medication as reported by the patient seem to have an added value.
