Patient Harm Resulting From Medication Reconciliation Process Failures: A Study of Serious Events Reported by Pennsylvania Hospitals

Authors

  • Amy Harper, PhD, RN Patient Safety Authority https://orcid.org/0000-0002-7416-5022
  • Elizabeth Kukielka, PharmD, MA, RPH Patient Safety Authority
  • Rebecca Jones, MBA, RN Patient Safety Authority

DOI:

https://doi.org/10.33940/data/2021.3.1

Keywords:

medication reconciliation, home medication, medication errors, transitions of care, patient safety, anticonvulsant

Abstract

Medication reconciliation broadly defined includes both formal and informal processes that involve the comprehensive evaluation of a patient’s medications during each transition of care and change in therapy. The medication reconciliation process is complex, and studies have shown that up to 91% of medication reconciliation errors are clinically significant and 1–2% are serious or potentially life-threatening. We queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) and identified 93 serious events related to the medication reconciliation process reported between January 2015 and August 2020. Serious events related to medication reconciliation were most common among patients 65 years or older (55.9%; 52 of 93). The majority of events (58.1%; 54 of 93) contributed to or resulted in temporary harm and required treatment or intervention. Permanent harm or death occurred as a result of 3.3% (3 of 93) of the events. Admission/triage was the most frequent transition of care associated with events (69.9%; 65 of 93). The most common stage of the medication reconciliation process at which failures most directly contributed to patient harm was order entry/transcription (41.9%; 39 of 93) and resulted most frequently in wrong dose (n=21) or dose omission (n=13). Most events were discovered after the patient had a change in condition (76.3%; 71 of 93), and patients most often required readmission, hospitalization, emergency care, intensive care, or transfer to a higher level of care (58.0%; 54 of 93). Among 128 medications identified across all events, neurologic or psychiatric medications were the most common (39.1%; 50 of 128), and anticonvulsants were the most common pharmacologic class among neurologic or psychiatric medications (42.0%; 21 of 50). Based on our findings, risk reduction strategies that may improve patient safety related to the medication reconciliation process include defined clinician roles for medication reconciliation, listing the indication for each medication prescribed, and for facilities to consider adding anticonvulsants to their processes for medications with a high risk for harm.

Author Biographies

Amy Harper, PhD, RN, Patient Safety Authority

Amy Harper (amharper@pa.gov) is an infection prevention analyst for the Patient Safety Authority. She has more than 25 years of combined microbiology/nursing experience, including roles in infection prevention, medical-surgical and critical care nursing, teaching, and virology research. She is board certified in medical-surgical nursing (CMSRN) and in infection control and epidemiology (CIC), and is a member of the Academy of Medical-Surgical Nurses (AMSN), The Society for Healthcare Epidemiology of America (SHEA), and the Association for Professionals in Infection Control and Epidemiology (APIC).

Elizabeth Kukielka, PharmD, MA, RPH, Patient Safety Authority

Elizabeth Kukielka is a patient safety analyst on the Data Science and Research team at the Patient Safety Authority. Before joining the PSA, she was a promotional medical writer for numerous publications, including Pharmacy Times and The American Journal of Managed Care. Kukielka also worked for a decade as a community pharmacist and pharmacy manager, with expertise in immunization delivery, diabetes management, medication therapy management, and pharmacy compounding.

Rebecca Jones, MBA, RN, Patient Safety Authority

Rebecca Jones is director of Data Science and Research at the Patient Safety Authority, where she also founded and serves as director of the Center of Excellence for Improving Diagnosis. Her previous roles at the PSA include director of Innovation and Strategic Partnerships and regional patient safety liaison. Before joining the PSA, Jones served in various roles leading patient safety efforts and proactively managing risk in healthcare organizations. She currently is chair of the Practice Committee of the Society to Improve Diagnosis in Medicine and serves on the Advisory Committee of the Coalition to Improve Diagnosis.

References

National Safety Goals Effective July 2020 for the Hospital Program [Online]. Oakbrook Terrace, IL: The Joint Commission; 2020 [cited 2020 October 18, 2020]. Available from: https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2020/npsg_chapter_hap_jul2020.pdf.

Steeb D, L; W. Improving Care Transitions: Optimizing Medication Reconciliation. USA: American Pharmacists Association and American Society of Health-System Pharmacists; 2012. p. 1-15.

Reconcile Medications at All Transition Points [Online]. Boston, MA: Institute for Healthcare Improvement; [cited 2020 October 18]. Available from: http://www.ihi.org/resources/Pages/Changes/ReconcileMedicationsatAllTransitionPoints.aspx.

Reconcile Medications in Outpatient Settings [Online]. Boston, MA: Institute for Healthcare Improvement; [updated 2020; cited 2020 October 18]. Available from: http://www.ihi.org/resources/Pages/Changes/ReconcileMedicationsinOutpatientSettings.aspx.

Mueller SK, Sponsler KC, Kripalani S, Schnipper JL. Hospital-Based Medication Reconciliation Practices: A Systematic Review. Arch Intern Med. 2012;172(14):1057-69. doi: 10.1001/archinternmed.2012.2246.

Midlöv P, Bahrani L, Seyfali M, Höglund P, Rickhag E, Eriksson T. The Effect of Medication Reconciliation in Elderly Patients at Hospital Discharge. Int J Clin Pharm. 2012;34(1):113-9. doi: 10.1007/s11096-011-9599-6.

Barnsteiner J. Medication Reconciliation. In: Hughes R, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality 2008.

Munck LK, Hansen KR, Mølbak AG, Balle H, Kongsgren S. The Use of Shared Medication Record as Part of Medication Reconciliation at Hospital Admission is Feasible. Dan Med J. 2014;61(5).

Medication Reconciliation [Online]. Rockville, MD: Agency for Healthcare Research and Quality; [cited 2020 October 19]. Available from: https://digital.ahrq.gov/ahrq-funded-projects/emerging-lessons/medication-reconciliation.

Advancing Successful Care Transitions to Improve Outcomes [Online]. Philadelphia, PA: Society of Hospital Medicine; [cited 2020 October 19]. Available from: https://www.hospitalmedicine.org/clinical-topics/care-transitions/.

Williams M, Budnitz T, Coleman E, Forth V, Greenwald J, Halasyamani L, et al. Boost: Better Outcomes for Older Adults Through Safe Transitions [Online]. Philadelphia, PA: Society of Hospital Medicine; 2010 [cited 2020 October 19]. Available from: http://tools.hospitalmedicine.org/Implementation/Workbook_for_Improvement.pdf.

Nassaralla CL, Naessens JM, Chaudhry R, Hansen MA, Scheitel SM. Implementation of a Medication Reconciliation Process in an Ambulatory Internal Medicine Clinic. Qual Saf Health Care. 2007;16(2):90-4. doi: 10.1136/qshc.2006.021113.

McShane M, Stark R. Medication Reconciliation in the Hospital: An Interactive Case-Based Session for Internal Medicine Residents. MedEdPORTAL. 2018;14:10770. Epub 2019/02/26. doi: 10.15766/mep_2374-8265.10770. PubMed PMID: 30800970; PubMed Central PMCID: PMCPMC6342339.

Holt K, Thompson A. Implementation of a Medication Reconciliation Process in an Internal Medicine Clinic at an Academic Medical Center. Pharmacy. 2018;6(2):26. doi: 10.3390/pharmacy6020026.

Berthe A, Fronteau C, Le Fur É, Morin C, Huon JF, Rouiller-Furic I, et al. Medication Reconciliation: A Tool to Prevent Adverse Drug Events in Geriatrics Medicine. Geriatr Psychol Neuropsychiatr Vieil. 2017;15(1):19-24. Epub 2017/01/26. doi: 10.1684/pnv.2016.0642. PubMed PMID: 28120773.

Mills PR, McGuffie AC. Formal Medicine Reconciliation Within the Emergency Department Reduces the Medication Error Rates for Emergency Admissions. Emerg Med J. 2010;27(12):911-5. doi: 10.1136/emj.2009.082255.

Karaoui LR, Chamoun N, Fakhir J, Abi Ghanem W, Droubi S, Diab Marzouk AR, et al. Impact of Pharmacy-Led Medication Reconciliation on Admission to Internal Medicine Service: Experience in Two Tertiary Care Teaching Hospitals. BMC Health Serv Res. 2019;19(1). doi: 10.1186/s12913-019-4323-7.

Mekonnen AB, McLachlan AJ, Brien J-AE. Pharmacy-Led Medication Reconciliation Programmes at Hospital Transitions: A Systematic Review and Meta-Analysis. J Clin Pharm Ther. 2016;41(2):128-44. doi: 10.1111/jcpt.12364.

Tam VC, Knowles SR, Cornish PL, Fine N, Marchesano R, Etchells EE. Frequency, Type and Clinical Importance of Medication History Errors at Admission to Hospital: A Systematic Review. CMAJ. 2005;173(5):510-5. Epub 2005/09/01. doi: 10.1503/cmaj.045311. PubMed PMID: 16129874; PubMed Central PMCID: PMCPMC1188190.

Cornu P, Steurbaut S, Leysen T, De Baere E, Ligneel C, Mets T, et al. Effect of Medication Reconciliation at Hospital Admission on Medication Discrepancies During Hospitalization and at Discharge for Geriatric Patients. Ann Pharmacother. 2012;46(4):484-94. Epub 2012/03/15. doi: 10.1345/aph.1Q594. PubMed PMID: 22414793.

da Silva BA, Krishnamurthy M. The Alarming Reality of Medication Error: A Patient Case and Review of Pennsylvania and National Data. J Community Hosp Intern Med Perspect. 2016;6(4):31758-. doi: 10.3402/jchimp.v6.31758. PubMed PMID: 27609720.

Pippins JR, Gandhi TK, Hamann C, Ndumele CD, Labonville SA, Diedrichsen EK, et al. Classifying and Predicting Errors of Inpatient Medication Reconciliation. J Gen Intern Med. 2008;23(9):1414-22. Epub 2008/06/20. doi: 10.1007/s11606-008-0687-9. PubMed PMID: 18563493; PubMed Central PMCID: PMCPMC2518028.

Allaudeen N, Vidyarthi A, Maselli J, Auerbach A. Redefining Readmission Risk Factors for General Medicine Patients. J Hosp Med. 2011;6(2):54-60. doi: 10.1002/jhm.805.

High-Alert Medications Require Heightened Vigilance [Internet]. Boston, MA: Institue for Heatlhcare Improvement; 2020 [updated 2020; cited 2020 November 28th]. Available from: http://www.ihi.org/resources/Pages/ImprovementStories/HighAlertMedsHeightenedVigilance.aspx#:~:text=The%20most%20common%20types%20of,a%20dangerously%20slow%20heart%20rate).

ISMP List of High-Alert Medications in Acute Care Settings [Internet]. Horsham, PA: Institute for Safe Medication Practices; [cited 2020 Nov 9]. Available from: https://forms.ismp.org/Tools/institutionalhighAlert.asp.

Institute of Medicine Committee on Quality of Health Care in A. To Err is Human: Building a Safer Health System. Kohn LT, Corrigan JM, Donaldson MS, editors. Washington (DC): National Academies Press (US) Copyright 2000 by the National Academy of Sciences. All rights reserved.; 2000.

Khansa SA, Mukhtar A, Abduljawad M, Aseeri M. Impact of Medication Reconciliation Upon Discharge on Reducing Medication Errors. J Pharmacovigil. 2016;04(06). doi: 10.4172/2329-6887.1000222.

Medical Care Availability and Reduction of Error (MCARE) Act, pub. L. No. 154 stat. 13 (2002).

Gao T, Gaunt MJ. Breakdowns in the Medication Reconciliation Process. Pa Patient Saf Advis. 2013;10(4):125-36.

Gillespie U, Alassaad A, Henrohn D, Garmo H, Hammarlund-Udenaes M, Toss H, et al. A Comprehensive Pharmacist Intervention to Reduce Morbidity in Patients 80 Years or Older. Arch Intern Med. 2009;169(9):894. doi: 10.1001/archinternmed.2009.71.

Hammad EA, Bale A, Wright DJ, Bhattacharya D. Pharmacy Led Medicine Reconciliation at Hospital: A Systematic Review of Effects and Costs. Res Social Adm Pharm. 2017;13(2):300-12. doi: 10.1016/j.sapharm.2016.04.007.

Hammour KA, Farha RA, Basheti I. Hospital Pharmacy Medication Reconciliation Practice in Jordan: Perceptions and Barriers. J Eval Clin Pract. 2016;22(6):936-41. doi: 10.1111/jep.12565.

Joint Commission: Performance Measurement FAQs: Continuing Care Plan-Discharge Medications Indications for Use [Internet]. Oakbrook Terrace, IL: The Joint Commission; 2020 [cited 2020 Dec 9]. Available from: https://manual.jointcommission.org/Manual/Questions/UserQuestionId03Hbips100019.

CRH N, Delgado J, HF G. Calcium and Beta Receptor Antagonist Overdose: A Review and Update of Pharmacological Principles and Management. Semin Respir Crit Care Med. 2002;23(1):20-5.

Cousins D, Rosario C, Scarpello J. Insulin, Hospitals and Harm: A Review of Patient Safety Incidents Reported to the National Patient Safety Agency. Clin Med. 2011;11(1):28-30. doi: 10.7861/clinmedicine.11-1-28.

Mc Donnell C. Opioid Medication Errors in Pediatric Practice: Four Years’ Experience of Voluntary Safety Reporting. Pain Res Manag. 2011;16(2):93-8. doi: 10.1155/2011/739359.

Valentine D, Gaunt M, Grissinger M. Identifying Patient Harm From Direct Oral Anticoagulants. Pa Patient Saf Advis. 2018;15(2).

Jones C, Kaffka J, Missanelli M, Dure L, Ness J, Funkhouser E, et al. Seizure Occurrence Following Nonopitmal Anticonvulsant Medication Management During the Transition Into the Hospital. J Child Neurol. 2012;28(10):1250-8.

Jones C, Missanelli M, Dure L, Funkhouser E, Kaffka J, Kilgore M, et al. Anticonvulsant Medication Errors in Children With Epilepsy During the Home-to-Hospital Transition. J Child Neurol. 2012;28(3):314-20.

Dendere R, Slade C, Burton-Jones A, Sullivan C, Staib A, Janda M. Patient Portals Facilitating Engagement With Inpatient Electronic Medical Records: A Systematic Review. J Med Internet Res. 2019;21(4):e12779. doi: 10.2196/12779.

Fitzgerald RJ. Medication Errors: The Importance of an Accurate Drug History. Br J Clin Pharmacol. 2009;67(6):671-5. doi: 10.1111/j.1365-2125.2009.03424.x. PubMed PMID: 19594536.

Your High-Alert Medication List—Relatively Useless Without Associated Risk-Reduction Strategies [Online]. Horsham, PA: ISMP (Institute for Safe Medication Practices); [cited 2020 27 Jan]. Available from: https://www.ismp.org/resources/your-high-alert-medication-list-relatively-useless-without-associated-risk-reduction.

Doctors hand with magnifying glass over bottle of pills

Published

2021-03-17

How to Cite

Harper, A., Kukielka, E., & Jones, R. (2021). Patient Harm Resulting From Medication Reconciliation Process Failures: A Study of Serious Events Reported by Pennsylvania Hospitals. Patient Safety, 3(1), 10–22. https://doi.org/10.33940/data/2021.3.1

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Section

Original Research and Articles
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