Up to 7% of admissions to acute care hospitals are related to adverse drug events (ADEs) [
1]. ADEs are the sixth leading cause of death [
2] at a cost over $5.6 million (USD) per hospital per year [
3]. An estimated 19% to 23% of inpatients will have an adverse event within 30 days of hospital discharge [
4,
5], 14.3% will be readmitted [
6], and 70% of these events will be related to prescription medication [
4,
5]. Fortunately, at least 58% of these ADEs are preventable, resulting from incomplete drug information, prescribing or dispensing errors, and overuse or underuse of medications [
7,
8]. Reconciliation of changes to medications that occur during hospitalization with community-based prescriptions is believed to be important to reduce the risk of preventable ADEs during transitions in care. Indeed, one recent study suggests that inadvertent discrepancies in community and hospital medications may increase the risk of adverse events [
9]. Hospitals in Canada and the United States now require implementation of medication reconciliation for accreditation [
10‐
13]. Discharge reconciliation has been given the highest priority because it is expected to reduce the risk of adverse events caused by failures to reconcile the community drug regimen with changes made in drugs and doses during the hospital stay. It will also communicate information about medication changes to the responsible community-based pharmacists and physicians at discharge. Despite its importance, there are considerable challenges to widespread implementation [
14‐
31].
Challenge 1. Obtaining an accurate community-based medication list
Difficulty in obtaining accurate information about the community-based drug list is one of the greatest challenges in medication reconciliation [
32]. In a recent survey of hospital staff, respondents estimated that 87% of admitted patients did not know which medications they took, 80% of the time medication information was not available from alternate sources such as relatives or community-based care providers, and in 63% of admissions, hospital staff were unable to access community-based records [
32]. As a result, 46% to 67% of unintended discrepancies in medication reconciliation are omitted medications, that is medications that were taken in the community but were neither prescribed at admission nor reconciled at discharge [
16,
28,
29,
33‐
36]. The most commonly omitted medications are cardiovascular drugs, pain medications, anti-infectious medications, and central nervous system medications such as antidepressants and sleeping pills [
37]. Overall, 23% to 37% of unintended discrepancies between community and hospital medication are considered clinically significant, meaning that there is substantial potential to cause harm [
16,
28,
29,
33‐
36].
An increasing number of hospitals are employing pharmacists in the emergency department and inpatient units to obtain a complete history of community-based medications [
10‐
12,
16‐
18,
20,
38‐
44]. Pharmacists have been shown to be more effective than nurses or medical staff in obtaining an accurate medication history, reducing errors from 323 to 86 per 1,000 prescription orders, compared with nurse-taken histories where errors were reduced to only 157 per 1,000 [
37]. The superiority of pharmacists in medication history-taking may be related to two aspects of care. First, pharmacists spend an average of 12.9 minutes per patient to take a community-based medication history, two to three times longer than medical or nursing staff [
45]. Second, pharmacists dispense medication and in general are much more knowledgeable about medication characteristics. This expertise may be particularly useful when patients are attempting to recall their medication, as most patients remember their medications by the colour, shape and general purpose of the pill [
27,
46]. Pharmacists may be more likely to identify these medications than medical and nursing staff, who know the name but not usually the colour and shape of the pill. Indeed, a recent pilot study performed in a US Veterans Affairs hospital found that the integration of pill image files with medication lists was a useful approach to verify current use with patients [
27].
Although pharmacist deployment in clinical care areas is considered a cost-effective investment in preventing medication errors [
47], pharmacists are conventionally not available on weekends, evenings and nights, nor are community-based pharmacies or office-based practices usually open to transmit information about community-based medications by fax or telephone. As such, recent research has shown that unintended errors in reconciling community and admission medications at discharge are more likely to occur on night-time admission, particularly for elderly patients and those using more than four medications [
26].
New initiatives have been undertaken to use electronic medical records to access information about the community drug profile [
29‐
31,
48]. Brigham and Women’s Hospital in Boston has shown that retrieval from electronic medical records can identify 65% of current medications [
30]. The major limitations of using medication lists in electronic medical records is that many of the listed medications (up to 70%) are no longer being used by the patient as medication lists become out-of-date, and 15.5% of current medications are not listed in the electronic medical record [
48]. In contrast, almost all pharmacies have been computerized so that they can manage the online adjudication processes of public and private drug insurance programs [
49]. Prior research has shown that records of dispensed prescriptions can be used to accurately measure medication adherence [
50‐
52]. A recent study from the Netherlands also suggests that community pharmacy records can identify up to 97.6% of community-based medications accurately [
29]. Although it represents a promising approach, the utility of community-based pharmacy records for medication reconciliation at hospital discharge has not been formally assessed.
Challenge 2. Ensuring medication reconciliation is conducted for all patients at risk
In compliance with accreditation standards, most hospitals have instituted a paper-based medication reconciliation process. However, adherence is poor, with medication reconciliation generally conducted in less than 20% of patients at risk [
10‐
12,
16‐
18,
20,
38‐
44]. This low rate of utilization persists even when staff workload is reduced by an electronic ‘copy and paste’ process that eliminates the need to first document the community-based medication list and then re-transcribe the list for the hospital medication order [
26,
53]. One of the main barriers is the time and resources required for data collection (community drug list determination), particularly in emergency departments (ED), where most patients are admitted. For a typical ED with 50,000 visits per year, it is estimated that an additional 2,900 hours of nursing time and 8,750 hours of pharmacist time would be required (an added cost of $349,500 at $30/hour) to complete the admission medication reconciliation for the 35% of patient visits where it is required [
54]. Moreover, 20% of patients die or are discharged before complete information can be obtained about the community drug list [
54].
Overcoming inefficiencies in obtaining the community drug list appears to be essential to improve adherence. For example, when Brigham and Women’s Hospital established a prototype medication reconciliation module that integrated data from the ambulatory electronic medical record and discharge medication orders, they improved adherence to 68.7%, as the majority of physicians could reduce the time to complete the process by 10 minutes. Even higher rates of adherence - from 20% to 90% at admission and 95% at discharge - were achieved at Bellevue Hospital in New York, when admission and discharge orders were blocked until the medication reconciliation module was completed [
53]. However, this option is only possible in hospitals that have successfully implemented computerized prescriber order entry, which represents less than 20% of hospitals in the United States and even fewer in Canada [
55‐
57].
Challenge 3. Communicating drug or dose changes at discharge to community-based prescribing physicians and dispensing pharmacists
A substantial proportion of ADEs occur in hospitalized patients shortly after discharge [
4,
5]. It is estimated that 72% of medication reconciliation errors at discharge are due to an incomplete preadmission community drug list, while 26% are due to failures in reconciling the medication history or changes made during the hospital stay with discharge orders [
36]. During hospitalization, 31% of patients will have changes made in the dose and frequency of medication, 9% will have a medication added or substituted and 4.1% to 8% will have a medication stopped [
36,
58]. At the present time, there is no timely and effective mechanism of communicating these changes in medication to the community-based prescribing physician(s) and dispensing pharmacist(s). Most patients fill their discharge medication prescription within the first few days after hospital discharge [
59], long before the discharge summary that summarizes the reasons for hospitalization and changes in medical management has been dictated or transmitted. Indeed, in the majority of admissions, the community-based care team does not receive critical information on the patient’s health status and modified treatment plan post-discharge [
60]. As a result, the patient’s community-based pharmacist needs to determine whether remaining refills on community-based drugs are to be added to the discharge prescription or stopped; and whether the dose prescribed on a discharge medication is to be added or replace the existing preadmission medication dose. As the community-based profile is typically incomplete, these issues are usually not addressed in the discharge prescription. To add to the challenges of discharge reconciliation, 70% of elderly patients who use many medications are under the care of a number of prescribing physicians and over 40% of patients will use more than one dispensing pharmacy [
61,
62]. For all of these reasons, it is not surprising that 17% to 21% of patients will experience ADEs post-discharge, and that the majority of discrepancies in community and hospital medication reconciliation are related to therapeutic duplication (more than one drug from the same class), dose errors, and omitted medication [
7,
36,
63,
64].
In summary, effective implementation of medication reconciliation is essential to reduce preventable ADEs occurring at the transitions between community and hospital care. More efficient methods of obtaining the community drug list, an automated order entry process that facilitates re-ordering of hospital- and community-based medications at discharge, and more efficient means of transmitting discontinuation and change orders to community-based pharmacists and physicians are needed.
Pilot study results
To determine if the electronic retrieval of the community drug list would add value to the usual care process, we conducted a pilot study at the McGill University Health Centre. We used an integrated drug management system (MOXXI) developed previously by our research group to provide online access to the Quebec government prescription database, which includes all medications prescribed by community pharmacies [
57,
62,
65‐
69]. The MOXXI system provides near real-time information (within 24 hours) on dispensed prescriptions from the 1,800 community pharmacies in Quebec, through a secure virtual private network. This network is linked to the prescription claims system of the government insurer (RAMQ). In this pilot study, we assessed whether the community drug profile was able to identify missing medication at admission; the perceived value of electronic retrieval for the treatment team; and the number of community providers who would be affected by a discharge reconciliation and communication intervention. In 91 consecutive patients admitted in 2008 , we showed that electronically retrieved community pharmacy records identified, on average, three additional drugs per patient. For 21% of patients, five or more drugs were identified. Over 90% of physicians and nurses who accessed real-time community pharmacy records believed this information improved the quality and continuity of care. Overall, 72.7% were confident in their ability to use a computer to gain access (even though 29% had limited or no prior computer experience). Access to the community drug profile reduced medication history-taking by 2.5 minutes per patient. Moreover, the challenges for staff in accessing treatment information for traditional medication reconciliation were substantial: 31% of patients had more than one dispensing pharmacy, most had multiple prescribing physicians, and 14.3% had more than eight (Table
1).
Table 1
The number of prescribing physicians and dispensing pharmacies for 91 consecutive patients admitted to the McGill University Health Centre (April-May, 2008)
One | 6 (6.6%) | One | 60 (69.0%) |
Two to four | 34 (37.4%) | Two | 18 (20.7%) |
Five to eight | 38 (41.8%) | Three or more | 9 (10.4%) |
Nine or more | 13 (14.3%) | | |