EXECUTIVE SUMMARY

To reduce the high number of medication errors observed in the medication lists of medically complex patients who are admitted to the hospital from the ED, Cedars-Sinai Medical Center in Los Angeles developed an intervention whereby pharmacists or trained pharmacy technicians review and prepare medication histories rather than rely on usual care for this task.

  • In a three-arm, randomized trial involving 306 medically complex patients destined for admission from the ED, investigators found that mistakes in medical histories as well as drug orders could be reduced by more than 80% if either pharmacists or trained pharmacy technicians compiled medication histories compared to usual care.
  • The study results have prompted Cedars-Sinai to implement the intervention routinely in the ED, and the targeted population is expanding gradually to include more patients.
  • Investigators note other hospitals have demonstrated that rather than nurses spending more than 40 minutes preparing medication histories, it is more cost-effective to use a trained pharmacy technician who is under the supervision of a pharmacist.

Medication errors are one of the most commonly cited reasons for adverse events and it is easy to see why, particularly in the case of patients with complex conditions who are taking multiple drugs.

“Patients have medications generated at a variety of different encounters, and when people go to see their physicians, generally it is a medical assistant who will enter that information into the electronic medical record [EMR], but at every encounter someone else is actually entering that information,” explains Rita Shane, PharmD, FASHP, FCSHP, the chief pharmacy officer at Cedars-Sinai Medical Center in Los Angeles.

Frequently, patients do not recall all the medications they are taking, let alone what dosages they are prescribed, and medical assistants may not be able to understand all the elements of a medication order, so it is not unusual to see incomplete or incorrect entries in the EMR, Shane observes. This presents problems when a patient arrives at the ED, and then is determined to require inpatient care.

“When patients are admitted to the hospital, those [medication] lists are the basis for the inpatient orders as well as the discharge orders, and our study shows that frequently — an upsetting percentage of the time — these lists have errors,” Shane notes. “The study demonstrated [an average of] eight errors for a high-risk patient, and even in quality improvement studies that I have been doing since 2011, that number shows up all the time. It is either seven or eight errors for high-risk patients.” These errors can lead physicians to order the wrong medications or incorrect dosages, Shane adds.

Recognizing that more time and expertise must be employed to ensure medication lists for these patients are accurate prior to admission from the ED, Cedars-Sinai developed an intervention whereby either pharmacists or trained pharmacy technicians who are supervised by pharmacists would take over the task of compiling accurate medication histories. In a three-arm, randomized trial involving 306 medically complex patients, investigators compared the results of directing pharmacists or pharmacy technicians to compile medication histories with usual care, in which this task typically was handled by a nurse.

The results were dramatic: Investigators found that mistakes in medical histories as well as drug orders could be reduced by more than 80% if either pharmacists or trained pharmacy technicians compiled the medication histories.1

Start With High-risk Patients

In the study, investigators focused only on patients who were taking 10 or more medications routinely, patients with a history of acute myocardial infarction or congestive heart failure (CHF) on their problem list, patients with transplants, and patients admitted from a skilled nursing facility (SNF). Additionally, patients taking an active blood thinner, insulin, or another drug known to have a narrow therapeutic index were included in the target group.

The strong results prompted the hospital to implement the intervention routinely, but Shane notes that she is enlarging the targeted group gradually.

“Our goal right now is to see if we can actually go beyond the high-risk patients and get to all of the patients that are being admitted from the ED,” she says. “We have been targeting anyone over 65 who is on greater than seven medications that they take routinely, so we have been trying to incrementally increase the population we reach to try to ensure their medication lists are accurate.”

The study demonstrated that both pharmacists and trained pharmacy technicians were able to obtain the medication lists safely and more accurately than usual care. Shane notes that this makes sense given the fact that clinicians are tasked with many other responsibilities in the ED.

“Nurses and physicians are focused on stabilizing the patient. The pharmacists and the pharmacy technicians are focused on the medications. That is our area,” she says. “We say that to be able to take care of patients [requires] a three-legged stool: the physician, the pharmacist, and the nurse. You need all three to make sure that patients receive the care they need.”

Shane stresses that the pharmacy technicians are trained and proctored to take on the role of preparing medication histories. The task can involve studying claims data as well as consulting with family members, other providers, and pharmacies that have filled prescriptions for the patient. The pharmacy technicians also will examine what over-the-counter (OTC) medications a patient takes.

“We really try to get as accurate a list as possible,” she explains. “And we check with the patients to make sure they are indeed taking the medications that the prescription claims reflect.”

It’s a time-consuming task, and Shane notes that other hospitals have demonstrated that rather than asking nurses to spend more than 40 minutes preparing medication histories, it is more cost-effective to use a trained pharmacy technician.

“A number of hospitals have actually added pharmacy technicians for this expressed purpose because the way the EMR works, the errors just get promulgated through the inpatient course,” Shane explains. “Pharmacists do catch a lot of the egregious errors, but there is a potential that these errors could continue if an order and a dose don’t look unusual, and a thorough history is not taken. Then, [the error] can become the basis of a discharge prescription and subsequent orders when the patients go to see their various doctors.”

Complete Task Before Admission

At Cedars-Sinai, the pharmacy technicians are made aware of patients who require medication histories through a tracking board on the ED’s EMR, Shane notes.

“[Technicians] know who is being admitted, and they will focus on patients who are high risk,” she explains. By looking through the claims information, technicians can discern which patients meet the criteria. “We want to get as many histories as possible,” Shane adds. “If the patient doesn’t speak English, we will get a translator who is certified to translate in the patient’s native language.” Once a pharmacy tech has consulted with the patient and completed work on the medication history, he or she transcribes any changes to the medication list into the EMR and marks the list as updated and reviewed.

“The goal is to get as many [medication histories] done as possible while the patients remain in the ED because physicians then order off that medication list,” Shane notes. “Physicians will sometimes tell us that they are waiting for us to finish the history before writing their orders.”

While there have been cases in which the medication history has not been completed before the patient is admitted, the pharmacy technician will aim to complete the process within 24 hours of admission, Shane observes. For instance, this could occur when a patient arrives in the ED in the middle of the night, a time when resources are limited.

The intervention has uncovered several significant medication errors embedded in patient EMRs, Shane says. These range from doses of insulin that a patient may have required at one time, but that are no longer correct, to faulty information regarding prescriptions for blood thinners.

“Roughly 39% of medication history errors have the potential to cause moderate to severe harm,” she says. “Blood thinners are notorious for causing problems with dosing, and with CHF and diabetic patients, it is really important to get their medications right.”

Integrate Process Into Workflow

Hospitals interested in employing this type of intervention must first define their own high-risk population to determine what resources to put in place, Shane observes. She adds that it critical to determine where the intervention can be implemented most effectively into the ED workflow.

“Timing is everything. Patients may be going for different imaging tests or different evaluations, so one of the lessons [we] learned is to try to make sure we were not interfering with other things going on with the patient,” Shane explains. “Also, make sure that the other providers know that you are doing this work so that the patient isn’t being asked the same questions by multiple different clinicians.”

Further, if a patient brings in a medication list, make sure that it is either scanned or maintained so that the information is not lost, and that it is directed into the correct EMR, Shane advises. “The logistics and the workflows need to be worked out very collaboratively with the other clinicians who work in the ED,” she adds.

Joshua Pevnick, MD, MSHS, the lead author of the study who serves as an assistant professor of medicine in the department of general internal medicine and as associate director of the division of informatics at Cedars-Sinai, notes that while the intervention has worked well at Cedars-Sinai, he advises other organizations to evaluate their goals, resources, and patient population first to see if the intervention is a good fit for their work setting.

“Smaller organizations may not have enough patient volume in the ED, especially of these older and sicker patients, to justify stationing pharmacy personnel in the ED all the time unless [these personnel] are also contributing in other ways,” he explains. “One resource that can help hospitals do this type of initial assessment is the MARQUIS [Multi-Center Medication Reconciliation Quality Improvement Study] toolkit, which is available for free online from the Society of Hospital Medicine.”2

Maintain Quality Control

Every discipline is likely to welcome pharmacy assistance with the compiling of medication histories, Shane says.

“For busy clinicians, this task is something that adds to their work, and they would rather have someone do it who is most knowledgeable about the medications,” she says. “The physicians have said they are grateful that we do this, and the nurses are as well. I recently surveyed the nurses, and they indicated they would be very happy if we could do all [the medication histories].”

Shane observes that there is a grammar to medication orders that other healthcare workers don’t always understand.

“There is the drug, the dose, the route, the frequency, the duration, and the dosage form,” Shane notes. Also, there are indications for drugs that are directed to be used on an “as-needed” basis. “Knowing what a complete medication order sentence is may not be something that busy clinicians are aware of,” Shane explains. “These days, there are so many unusual dosage forms with sustained release and immediate release drugs, and getting those mixed up can actually cause harm.”

While pharmacy technicians complete training modules to expertly prepare the medication histories, Cedars-Sinai also leverages first-year pharmacy students to perform this task.

“That is one of the first things pharmacy students learn when they get to pharmacy school is how to take a medication history,” Shane notes. “We try to leverage different individuals to do this, but all the individuals have the training to do it.”

Throughout the study period, investigators used reference standard admission medication histories to assess the quality of the admission medication histories used clinically, Pevnick says. However, he notes that the National Quality Forum recently endorsed a quality measure that assesses admission medication history quality in the same way for a small number of randomly selected patients each month.

“We believe this to be a practical way of ensuring continued success with this and other medication reconciliation interventions,” he says. (See Measure 2456 under “Find Measures” at: http://bit.ly/2C5X0hA.)

Pevnick adds that Cedars-Sinai plans to study a more refined intervention that investigators hope will be able to streamline the gains documented in their initial study. At the same time, Shane plans to apply the intervention to more patient populations beyond the ED. In fact, given the high rate of medication errors and their associated risks, Shane makes the case that “universal precautions” should be developed and applied to EMR-based medication histories or lists in much the same way that they have been developed to deal with infections from blood-borne pathogens.3

“If the information [on the medication histories] is inaccurate, everything is inaccurate,” Shane observes. “This is something we should look at to keep our patients safe, especially when they are in hospitals and are so vulnerable.”

REFERENCES

  1. Pevnick JM, Nguyen C, Jackevicius CA, et al. Improving admission medication reconciliation with pharmacists or pharmacy technicians in the emergency department: A randomised controlled trial. BMJ Qual Saf 2017 Oct 6. pii: bmjqs-2017-006761. doi: 10.1136/bmjqs-2017-006761. [Epub ahead of print].
  2. Agency for Healthcare Quality and Research. Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) Toolkit. Available at: http://bit.ly/2lflMkG. Accessed Dec. 28, 2017.
  3. Shane R. Why “universal precautions” are needed for medication lists. BMJ Qual Saf 2016;25:731-732.

SOURCES

  • Joshua Pevnick, MD, MSHS, Assistant Professor of Medicine, Department of General Internal Medicine; Associate Director, Division of Informatics, Cedars-Sinai Medical Center, Los Angeles. Email: Joshua.Pevnick@cshs.org.
  • Rita Shane, PharmD, FASHP, FCSHP, Chief Pharmacy Officer, Cedars-Sinai Medical Center, Los Angeles. Email: Shane@cshs.org.