Improving medication safety during hospital-based transitions of care

STEP 1: OBTAIN A COMPLETE PREADMISSION MEDICATION LIST

The “best-possible medication history” is obtained in a systematic process of interviewing the patient or caregiver plus reviewing at least one other reliable source.²³ The resulting list should include all medications the patient is taking (prescription and nonprescription), doses, directions for use, formulations if applicable, indications, start and stop dates, and medication allergies and reactions.

Review existing information. Before eliciting a history from the patient, review his or her recorded medical history and existing medication lists (eg, prior discharge summaries, records from other facilities, records from outpatient visits, pharmacy fill data). This will provide context about the regimen and help identify issues and questions that can be addressed during the history-taking.

Ask open-ended questions. Instead of just asking the patient to confirm the accuracy of the existing medication list, we recommend actively obtaining the full medication list from the patient or caregiver. The conversation should begin with an open-ended question such as, “What medications do you take at home?” This approach will also allow the clinician to gauge the patient’s level of understanding of each medication’s indication and dosing instructions. Using a series of prompts such as those recommended in Table 3 will elicit a best-possible medical history, while verifying all of the medications on the existing list.

Clarify discrepancies. Resolve differences between the existing medication lists and the patient’s or caregiver’s report during the preadmission interview. Examples include errors of omission (a medication is missing), errors of commission (an additional medication is present), and discrepancies in the strength, formulation, dosing instructions, and indications for the drugs. If necessary, other sources of information should be consulted, such as the patient’s medication bottles, pharmacy or pharmacies, primary care physician, and a family member or caregiver.

Assess adherence. The extent to which patients take their medications as directed is an important component of the history, but is often left out. Medication nonadherence rates in the United States are 40% to 70%,²⁵ contributing to poor patient outcomes and imposing extraordinary costs on the health care system.²⁶

Asking open-ended, nonjudgmental questions at the time of hospital admission will help to uncover medication-taking behaviors as well as barriers to adherence (Table 3). The patient’s responses should be taken into account when determining the treatment plan.

Document your findings. After completing the medication history and clarifying discrepancies, document the preadmission list in the medical record. All members of the health care team should have access to view and update the same list, as new information about the preadmission medications may be uncovered after the initial history.

Make clinical decisions. Complete the admission medication reconciliation by deciding whether each medication on the list should be continued, changed, held, or discontinued on the basis of the patient’s clinical condition. Well-designed information technology applications enable the provider to document each action and the rationale for it, as well as carry that information into the order-entry system. Medications marked as held or discontinued on admission should be revisited as the patient’s clinical condition changes and at discharge.

STEP 2: AVOID RECONCILIATION ERRORS

Reconciliation errors reflect discrepancies between the medication history and the medications that are ordered after admission.

Reconciliation errors are less common than medication history errors, accounting for approximately one-third of potentially harmful medication errors in hospitalized medical patients.⁹ These include errors of omission (a medication is omitted from the orders), errors of commission (a medication is prescribed with no indication for continuation), and therapeutic duplication.

Preventing errors of omission

Medications are often held at transition points for appropriate clinical reasons. Examples include holding anticoagulants and antiplatelet agents in patients who have gastrointestinal bleeding or an upcoming procedure, antihypertensives in patients with hemodynamic instability, and other chronic medications in patients with an acute illness.

Poor documentation and communication of these decisions can lead to a failure to resume the medications—an error of omission—at hospital discharge.

Hospitalized patients are at risk of unintentional discontinuation of their chronic medications, including antiplatelet drugs, anticoagulants, statins, and thyroid replacement, particularly if admitted to the intensive care unit.¹² These errors can be minimized by a standardized medication reconciliation process at each transition and clear documentation of the medication plan.

Communication among providers can be improved if the admitting clinician documents clearly whether each preadmission medication is being continued, changed, or stopped, along with the reason for doing so, and makes this information available throughout the hospital stay. Upon transfer to another unit and at discharge, the physician should review each; preadmission medication that was held and the patient’s current clinical status and, based on that information, decide whether medications that were held should be resumed. If a medication will be restarted later, specific instructions should be documented and communicated to the patient and the physicians who are taking over his or her care.

Preventing errors of commission

Failure to perform a complete reconciliation at each transition of care and match each medication with an appropriate indication can lead to errors of commission.

One study showed that 44% of patients were prescribed at least one unnecessary drug at hospital discharge, one-fourth of which were started during the hospitalization.²⁷ Commonly prescribed unnecessarily were gastrointestinal agents, central nervous system drugs, nutrients, and supplements.

It is critical to assess each medication’s ongoing need, appropriateness, and risk-benefit ratio at every transition. Medications no longer indicated should be discontinued in order to simplify the regimen, avoid unnecessary drug exposure, and prevent ADEs.

For example, proton pump inhibitors or histamine 2 receptor blockers are often started in the hospital for stress ulcer prophylaxis. One-third of patients are then discharged home on the medication, and 6 months later half of those patients are still taking the unnecessary drug.²⁸ This situation can be avoided by limiting use of these medications to appropriate circumstances, clearly marking the indication as stress ulcer prophylaxis (as opposed to an ongoing condition that will require continuing it after discharge), and discontinuing the agent when appropriate.

All drugs, even common and seemingly benign ones, carry some risk and should be discontinued when no longer needed. Thus, medications added during the hospitalization to control acute symptoms should also be reviewed at each transition to prevent inappropriate continuation when symptoms have resolved.

One study, for example, found that many patients were discharged with inappropriate prescriptions for atypical antipsychotics after receiving them in the intensive care unit, likely for delirium.²⁹ Documenting that an acute issue such as delirium has resolved should prompt the discontinuation of therapy.

Preventing therapeutic duplication

Therapeutic duplication occurs in about 8% of discharges.¹ These errors often result from formulary substitutions or altering the dosage form in the acute setting. For example, patients who receive a prescription for the substituted agent at discharge and also resume their prehospitalization medications end up with duplicate therapy.

Therapeutic substitution is common at the time of admission to the hospital as a result of formulary restrictions. Drug classes that are frequently substituted include statins, antihypertensives, urinary antispasmodics, and proton pump inhibitors. Physicians should be familiar with the preferred agents on the hospital formulary and make careful note when a substitution occurs. Furthermore, hospital systems should be developed to remind the physician to switch back to the outpatient medication at discharge.

Similar problems occur when home medications are replaced with different dosage forms with different pharmacokinetic properties. For example, a long-acting medication may be temporarily replaced with an intravenous solution or immediate-release tablet for several reasons, including nothing-by-mouth status, unstable clinical condition, need for titration, and need to crush the tablet to give the drug per tube. The differing formulations must be reconciled throughout the patient’s hospital course and at discharge to avoid therapeutic duplication and serious medication errors. Deliberate changes to the dosage form should be clearly communicated in the discharge medication list so that patients and other clinicians are aware.

Hospital systems should also have the capability to identify duplications in the medication list and to warn prescribers of these errors. The ability to group medications by drug class or sort the medication list alphabetically by generic name can help uncover duplication errors.

STEP 3: REVIEW THE LIST IN VIEW OF THE CLINICAL PICTURE

Transitions of care should prompt providers to review the medication list for possible drug-disease interactions, confirm compliance with evidence-based guidelines, and evaluate the risks and benefits of each medication in the context of the patient’s age and acute and chronic medical issues. This is also an opportunity to screen the full list for potentially inappropriate medications and high-alert drugs such as insulin or anticoagulants, which are more likely than other drugs to cause severe harm when used in error.

Acute kidney injury. New drug-disease interactions can arise during a hospitalization and can affect dosing and the choice of drug. The onset of acute kidney injury, for example, often necessitates adjusting or discontinuing nephrotoxic and renally excreted medications. ADEs or potential ADEs have been reported in 43% of hospitalized patients with acute kidney injury.³⁰

Because acute kidney injury is often transient, medications may need to be held or adjusted several times until renal function stabilizes. This can be challenging across the continuum of care and requires close monitoring of the serum creatinine level and associated drug doses and levels, if applicable. Well-designed clinical decision support tools can integrate laboratory data and alert the prescriber to a clinically important increase or decrease in serum creatinine that may warrant a change in therapy. Modifications to the regimen and a plan for timely follow-up of the serum creatinine level should be clearly documented in the discharge plan.

Liver disease. Similar attention should be given to drugs that are hepatically metabolized if a patient has acute or chronic liver impairment.

Geriatric patients, particularly those who present with altered mental status, falls, or urinary retention, should have their medication list reviewed for potentially inappropriate medications, which are drugs that pose increased risk of poor outcomes in older adults.^31,32 Patients and providers may have been willing to accept the risk of medications such as anticholinergics or sedative-hypnotics when the drugs were initiated, but circumstances can change over time, especially in this patient population. Hospitalization is a prime opportunity to screen for medications that meet the Beers criteria³¹ for agents to avoid or use with caution in older adults.

As-needed medications. Medications prescribed on an as-needed basis in the hospital should be reviewed for continuation or discontinuation at discharge. How often the medication was given can inform this decision.

For example, if as-needed opioids were used frequently, failure to develop a plan of care for pain can lead to persistent symptoms and, possibly, to readmission.^33,34 Similar scenarios occur with use of as-needed blood pressure medications, laxatives, and correction-dose insulin.

If an as-needed medication was used consistently during hospitalization, the physician should consider whether a regularly scheduled medication is needed. Conversely, if the medication was not used during the inpatient admission, it can likely be discontinued.