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Application of the structured history taking of medication use tool to optimise prescribing for older patients and reduce adverse events

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Abstract

Background Older patients, due to polypharmacy, co-morbidities and often multiple prescribing doctors are particularly susceptible to medication history errors, leading to adverse drug events, patient harm and increased costs. Medication reconciliation at the point of admission to hospital can reduce medication discrepancies and adverse events. The Structured HIstory taking of Medication use (SHiM) tool was developed to provide a structure to the medication reconciliation process. There has been very little research with regards to SHiM, it’s application to older patients and it’s potential to reduce adverse events. Objective To determine whether application of SHiM could optimise older patients’ prescriptions on admission to hospital, and in-turn reduce adverse events, compared to standard care. Setting A sub-study of a large clinical trial involving hospital inpatients over the age of 65 in five hospitals across Europe. Method A modified version of SHiM was used to obtain accurate drug histories for patients after the attending physician had obtained a medication list via standard methods. Discrepancies between the two lists were recorded and classified, and the clinical relevance of the discrepancies was determined. Whether discrepancies in patients’ medication histories, as revealed by SHiM, resulted in actual clinical consequences was then investigated. As this study was carried out during the observation phase of the clinical trial, results were not communicated to the medical teams. Main outcome measure Discrepancies between medication lists and whether these resulted in clinical consequences. Results SHiM was applied to 123 patients. The mean age of the participants was 78 (±6). 200 discrepancies were identified. 90 patients (73 %) had at least one discrepancy with a median of 1.0 discrepancies per patient (IQR 0.00–2.25). 53 (26.5 %) were classified as ‘unlikely to cause patient discomfort or clinical deterioration’, 145 (72.5 %) as ‘having potential to cause moderate discomfort or clinical deterioration’, and 2 (1 %) as ‘having potential to cause severe discomfort or clinical deterioration’. Of the 200 discrepancies identified, 2(1 %) resulted in adverse events. Conclusion The results suggest SHiM is an effective medications reconciliation tool and does identify discrepancies with potential for patient harm. However, it’s the capacity to prevent actual adverse events is less convincing.

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References

  1. Andersen SE, Pedersen AB, Bach KF. Medication history on internal medicine wards: assessment of extra information collected from second drug interviews and GP lists. Pharmacoepidemiol Drug Saf. 2003;12(6):491–8.

    Article  CAS  PubMed  Google Scholar 

  2. Atkin PA, Stringer RS, Duffy JB, Elion C, Ferraris CS, Misrachi SR, et al. The influence of information provided by patients on the accuracy of medication records. Med J Aust. 1998;169(2):85–8.

    CAS  PubMed  Google Scholar 

  3. Institute of Medicine Committee on Quality of Health Care in America. Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. Washington: National Academies Press. Copyright 2000 by the National Academy of Sciences. ISBN: 0-309-06837-1. All rights reserved; 2000.

  4. O’Sullivan D. Pharmacotherapy optimization in older patients by a structured clinical pharmacist assessment and interventions. PhD Thesis, University College Cork; 2013.

  5. 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: Can Med Assoc J. 2005;173(5):510–5.

    Article  Google Scholar 

  6. Bates DW, Spell N, Cullen DJ, Burdick E, Laird N, Petersen LA, et al. The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. J Am Med Assoc. 1997;277(4):307–11.

    Article  CAS  Google Scholar 

  7. Cornish PL, Knowles SR, Marchesano R, Tam V, Shadowitz S, Juurlink DN, et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005;165(4):424–9.

    Article  PubMed  Google Scholar 

  8. Gleason KM, Groszek JM, Sullivan C, Rooney D, Barnard C, Noskin GA. Reconciliation of discrepancies in medication histories and admission orders of newly hospitalized patients. Am J Health Syst Pharm. 2004;61(16):1689–95.

    PubMed  Google Scholar 

  9. Drenth-van Maanen AC, Spee J, van Hensbergen L, Jansen PA, Egberts TC, van Marum RJ. Structured history taking of medication use reveals iatrogenic harm due to discrepancies in medication histories in hospital and pharmacy records. J Am Geriatr Soc. 2011;59(10):1976–7.

    Article  PubMed  Google Scholar 

  10. Lau HS, Florax C, Porsius AJ, De Boer A. The completeness of medication histories in hospital medical records of patients admitted to general internal medicine wards. Br J Clin Pharmacol. 2000;49(6):597–603.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Unroe KT, Pfeiffenberger T, Riegelhaupt S, Jastrzembski J, Lokhnygina Y, Colon-Emeric C. Inpatient medication reconciliation at admission and discharge: a retrospective cohort study of age and other risk factors for medication discrepancies. Am J Geriatr Pharmacother. 2010;8(2):115–26.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Steurbaut S, Leemans L, Leysen T, De Baere E, Cornu P, Mets T, et al. Medication history reconciliation by clinical pharmacists in elderly inpatients admitted from home or a nursing home. Ann Pharmacother. 2010;44(10):1596–603.

    Article  PubMed  Google Scholar 

  13. Rozich JD, Howard RJ, Justeson JM, Macken PD, Lindsay ME, Resar RK. Standardization as a mechanism to improve safety in health care. Jt Comm J Qual Saf. 2004;30(1):5–14.

    PubMed  Google Scholar 

  14. Michels RD, Meisel SB. Program using pharmacy technicians to obtain medication histories. Am J Health Syst Pharm. 2003;60(19):1982–6.

    PubMed  Google Scholar 

  15. Rodehaver C, Fearing D. Medication reconciliation in acute care: ensuring an accurate drug regimen on admission and discharge. Jt Comm J Qual Saf. 2005;31(7):406–13.

    Google Scholar 

  16. Vira T, Colquhoun M, Etchells E. Reconcilable differences: correcting medication errors at hospital admission and discharge. Qual Saf Health Care. 2006;15(2):122–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Boockvar KS, Blum S, Kugler A, Livote E, Mergenhagen KA, Nebeker JR, et al. Effect of admission medication reconciliation on adverse drug events from admission medication changes. Arch Intern Med. 2011;171(9):860–1.

    Article  PubMed  Google Scholar 

  18. 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.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Galvin M, Jago-Byrne MC, Fitzsimons M, Grimes T. Clinical pharmacist’s contribution to medication reconciliation on admission to hospital in Ireland. Int J Clin Pharm. 2013;35(1):14–21.

    Article  PubMed  Google Scholar 

  20. Hellstrom LM, Bondesson A, Hoglund P, Eriksson T. Errors in medication history at hospital admission: prevalence and predicting factors. BMC Clin Pharmacol. 2012;12:9.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Organisation WH. Assuring medication accuracy at transitions in care. Geneva: World Health Organisation (WHO); 2007.

    Google Scholar 

  22. Fitzgerald RJ. Medication errors: the importance of an accurate drug history. Br J Clin Pharmacol. 2009;67(6):671–5.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Warholak TL, McCulloch M, Baumgart A, Smith M, Fink W, Fritz W. An exploratory comparison of medication lists at hospital admission with administrative database records. J Manag Care Pharm. 2009;15(9):751–8.

    PubMed  Google Scholar 

  24. Reeder TA, Mutnick A. Pharmacist-versus physician-obtained medication histories. Am J Health Syst Pharm. 2008;65(9):857–60.

    Article  PubMed  Google Scholar 

  25. Hartwig SC, Siegel J, Schneider PJ. Preventability and severity assessment in reporting adverse drug reactions. Am J Hosp Pharm. 1992;49(9):2229–32.

    CAS  PubMed  Google Scholar 

  26. Henneman EA, Tessier EG, Nathanson BH, Plotkin K. An evaluation of a collaborative, safety focused, nurse-pharmacist intervention for improving the accuracy of the medication history. J Pt Saf. 2014;10(2):88–94.

    Article  Google Scholar 

  27. Prins MC, Drenth-van Maanen AC, Kok RM, Jansen PA. Use of a structured medication history to establish medication use at admission to an old age psychiatric clinic: a prospective observational study. CNS Drugs. 2013;27(11):963–9.

    Article  PubMed  Google Scholar 

  28. De Winter S, Spriet I, Indevuyst C, Vanbrabant P, Desruelles D, Sabbe M, et al. Pharmacist-versus physician-acquired medication history: a prospective study at the emergency department. Qual Saf Health Care. 2010;19(5):371–5.

    PubMed  Google Scholar 

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Acknowledgments

The authors would like to thank all researchers involved in the Senator project for their assistance with data collection for this study.

Funding

This study was funded by an EU FP7 Grant (No. 305930).

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Correspondence to Shane Cullinan.

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Cullinan, S., O’Mahony, D. & Byrne, S. Application of the structured history taking of medication use tool to optimise prescribing for older patients and reduce adverse events. Int J Clin Pharm 38, 374–379 (2016). https://doi.org/10.1007/s11096-016-0254-0

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  • DOI: https://doi.org/10.1007/s11096-016-0254-0

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