Impact of findings on practice
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The studied clinical pharmacist discharge service reduces the percentage of heart failure patients with one or more discrepancies or prescription errors by almost a half (68% vs. 39%).
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The information about medication at discharge for heart failure patients needs to be optimized for community pharmacists, for general practitioners, and for the patients.
Introduction
Aim of the study
Method
Design
Setting and study population
Regular care
Intervention
Data collection
Question | Scorea
|
---|---|
Did patient fail to list the prescribed drugs in the initial (spontaneous) report? | Yes = 1; no = 0 |
Did patient stop or interrupt therapy due to late refill or other reason? | Yes = 1; no = 0 |
Did patient report any missed days or doses? | Yes = 1; no = 0 |
Did patient reduce or cut down the prescribed amount per dose? | Yes = 1; no = 0 |
Did patient take any extra doses or more medication than prescribed? | Yes = 1; no = 0 |
Did patient report “do not know” in response to any questions? | Yes = 1; no = 0 |
Did patient refuse to answer any questions? | Yes = 1; no = 0 |
End points
Data analysis
Results
Class | Content |
---|---|
A | Circumstances or events that have the capacity to cause error |
B | An error occurred but the error did not reach the patient |
C | An error occurred that reached the patient but did not cause patient harm |
D | An error occurred that reached the patient and required monitoring to confirm that it resulted in no harm to the patient and/or required intervention to preclude harm |
E | An error occurred that may have contributed to or resulted in temporary harm to the patient and required intervention |
F | An error occurred that may have contributed to or resulted in temporary harm to the patient and required initial or prolonged hospitalization |
G | An error occurred that may have contributed to or resulted in permanent harm |
H | An error occurred that required intervention necessary to sustain life |
I | An error occurred that may have contributed to or resulted in the patient’s death |
Control (n = 44) | Intervention (n = 41) | P value | |
---|---|---|---|
Age (years ± sd) | 72 ± 10 | 74 ± 12 | >0.05a
|
Sex (% male) | 75 | 59 | >0.05b
|
Time to follow-up (days ± sd (range)) | 23 ± 10 (6–40) | 24 ± 12 (7–48) | >0.05a
|
Education (% primary school only) | 39 | 42 | >0.05b
|
Single or cohabitating (% single) | 41 | 46 | >0.05b
|
Chronic co-morbidity (CDS ± sd) | 8 ± 3 | 8 ± 3 | >0.05a
|
Treatment at the heart failure clinic before admission (% no) | 75 | 78 | >0.05b
|
Length of admission (days ± sd) | 12 ± 8 | 13 ± 7 | >0.05a
|
Medication at moment discharge (number ± sd) | 9 ± 3 | 10 ± 4 | >0.05a
|
Living conditions after discharge | |||
At home (%) | 66 | 66 | >0.05b
|
At home with additional care (%) | 14 | 22 | |
Residential home for elderly people (%) | 20 | 12 | |
Patient control over medication (% yes) | 82 | 81 | >0.05b
|
NYHA class at discharge | |||
I/II (%) | 52 | 56 | >0.05b
|
III (%) | 48 | 39 | |
IV (%) | 0 | 5 |
Intervention | Control | Total | |
---|---|---|---|
Number of patients with a discrepancy/prescription error | 16 | 30 | 46 |
Number of patients without a discrepancy/prescription error | 25 | 14 | 39 |
Total | 41 | 44 | 85 |
Relative risk (95% CI) | 0.57 (0.37–0.88) | ||
Number of medications with a discrepancy/prescription error | 25 | 62 | 87 |
Number of medications without a discrepancy/prescription error | 382 | 363 | 745 |
Total | 407 | 425 | 832 |
Relative risk (95% CI) | 0.42 (0.27–0.66) |
Example | Control, no (%) | Intervention, no (%) | |
---|---|---|---|
Re-start of discontinued medication | Before hospitalization a patient was prescribed verapamil. During hospitalization this was stopped. After discharge he was still taking verapamil because “nobody told me to stop”C
| 9 (15) | 2 (8) |
Discontinuation of prescribed medication | Not filling a prescription for a loop diuretic, because “I already use a diuretic (hydrochlorothiazide)”. Readmission within 2 weeksC
| 6 (10) | 6 (24) |
Use of higher dose of medication | Discharge prescription and written information for patient: bumetanide 1 mg tablet, once a day 2 mg | 7 (11) | 2 (8) |
The pharmacy delivered tablets of 2 mg. The patient took 2 tablets of 2 mg instead of oneC
| |||
Use of lower dose of medication | Discharge prescription: paracetamol 1,000 mg four times a day. Patient used 500 mg four times a dayI
| 1 (2) | 4 (16) |
Use more frequent | Discharge prescription: lactulose if necessary; the label of the pharmacy prescribed twice a dayC
| 2 (3) | – |
Use less frequent | Discharge prescription: lactulose once a day; the patient took it if necessaryI
| 6 (10) | 2 (8) |
Incorrect time of taking | Discharge prescription: calcium at bedtime due to interaction with ferrofumarate. Patient took both tablets at the same timeI
| 1 (2) | 2 (8) |
Prescription error—dosage error | Discharge prescription: acenocoumarol 1 mg once a day. This should be: according to schemeC, I
| 30 (48) | 7 (28) |
Prescription error—dosage form error | Discharge prescription: thiamine injections. This should be tabletsC
| ||
Total | 62 (100) | 25 (100) |
NCC MERP index | Example | Control, no (%) | Intervention, no (%) |
---|---|---|---|
A | Discharge prescription: zopiclon at bedtime. On advise of the pharmacy this prescription stoppedI
| – | 1 (4) |
B | Discharge prescription: acenocoumarol 1 mg once a day. This should be: according to schemeC, I
| 33 (53) | 9 (36) |
C | Before hospitalization a patient was prescribed nitroglycerin patch. During hospitalization this was stopped. After discharge she was still using nitroglycerinC
| 9 (15) | 7 (28) |
D | Discharge prescription: amiodaron 200 mg three times a day. This should be reduced to 200 mg once a day after a weekC
| 2 (3) | – |
E | Before hospitalization, a patient was prescribed lisinopril/hydrochlorothiazide. During hospitalization hydrochlorothiazide was stopped. After discharge the patient still used the combination tabletC, I
| 15 (24) | 7 (28) |
F | Not filling a prescription for a loop diuretic, because “I already use a diuretic (hydrochlorothiazide)”. ReadmissionC
| 3 (5) | 1 (4) |
G | – | – | |
H | – | – | |
Total | 62 (100) | 25 (100) |