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American Journal of Transplantation 2013; 13: 796–801 Wiley Periodicals Inc.

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Copyright 2013 The American Society of Transplantation and the American Society of Transplant Surgeons doi: 10.1111/ajt.12070

Brief Communication

Improving Transplant Patient Safety Through Pharmacist Discharge Medication Reconciliation C. R. Musgravea, ∗ , N. A. Pilcha , D. J. Taberb , H. B. Meadowsa , J. W. McGillicuddyb , K. D. Chavinb and P. K. Baligab a Department of Pharmacy Services, Medical University of South Carolina, Charleston, SC b Department of Transplant Surgery, Medical University of South Carolina, Charleston, SC ∗ Corresponding author: Caitlin R. Musgrave, [email protected]

Greater than 50% of medication errors are estimated to occur during transitions of care, and solid-organ transplant recipients are at an increased risk for errors due to significant changes in their medication regimen following transplantation. This prospective, observational study with a historical control group was conducted to evaluate the discharge process for transplant recipients and determine if transplant pharmacist involvement would improve safety. During the prospective period, a total of 191 errors were made on discharge medication reconciliations (n = 64, mean rate 3.0 per patient); however, pharmacists prevented 119 of these errors (1.9 errors per patient). In the retrospective period, none of the 430 errors identified were prevented at the time of discharge (n = 128, p < 0.0001). The 72 errors not prevented at the time of discharge in the prospective cohort were identified by the pharmacist at the patient’s first clinic visit (1.1 errors per patient). In the historical cohort, all 430 errors made at discharge persisted until at least the time of the first clinic visit (3.4 errors per patient, p < 0.0001). This study demonstrates that transplant recipients are at a high risk for medication errors and that transplant pharmacist involvement leads to improved safety through the significant reduction of medication errors. Key words: Adverse effect, medications, pharmacy, safety Abbreviations: ASHP, American Society of HealthSystem Pharmacists; CMV, cytomegalovirus; FTE, fulltime equivalent; H2-antagonist, histamine-2 receptor antagonist; MAR, medication administration record; PharmD, Doctor of pharmacy; PJP, Pneumocystis jiroveci pneumonia; PPI, proton pump inhibitor; PPMI, pharmacy practice model initiative; SD, standard deviation. Received 10 October 2012, revised 12 November 2012 and accepted for publication 13 November 2012

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Background Transitions of care within the health care continuum, particularly when patients move from the outpatient to the inpatient setting and back, are often associated with a significant risk for medication-related errors (1). In accordance with Joint Commission standards, medical centers have instituted requirements for medication reconciliation, the process of obtaining a complete and accurate list of home medications from a patient upon admission to the hospital and subsequently utilizing that list upon admission and discharge to ensure continuity of care (2). Unfortunately, there are numerous barriers to the medication reconciliation process: patients may be unable to produce an accurate history due to their current illness or a lack of familiarity with their medications, the admission process may be rushed and not allow time for a detailed exploration of home medications, or there may be a generalized lack of attention to detail during the admission or discharge process. The hospitalization may then be associated with the unintentional continuation or discontinuation of treatments for chronic conditions in addition to the initiation of new medications, which can lead to patient confusion and the potential for adverse drug events (3). Though all patient populations are at risk for medication errors during transitions of care, patients whose home medication regimen will undergo significant changes during the hospitalization may be at increased risk. During their short hospital stay, solid-organ transplant recipients may be initiated on nine or more new medications for the purposes of immunosuppression, prophylaxis against bacterial, viral and fungal infections, and gastrointestinal, bowel and pain management. An estimated 20–50% of kidney transplant recipients and 9–21% of liver transplant recipients also develop new-onset diabetes after transplant and will therefore be initiated on insulin therapy with frequent blood glucose monitoring (4). In addition, the patient’s home medications taken prior to surgery may or may not be necessary after transplantation. The process of discharge medication reconciliation is of the utmost importance in this patient population due to the risk for rejection and other complications in the posttransplant period. There have been multiple reports in the literature discussing the positive impact that pharmacists can have on the medication reconciliation process; however, no studies have assessed the effect of pharmacist involvement on

Improving Transplant Patient Safety

medication reconciliation in solid-organ transplant recipients (5)– (7). At our institution, we previously reported a reduction in delayed discharges and 7-day readmission rates secondary to multidisciplinary clinical initiatives aimed at the discharge process; these initiatives were recognized by the American Society of Health-System Pharmacists (ASHP) Foundation with the 2010 Award for Excellence in Medication-Use Safety (8). The aim of this study was to critically evaluate the discharge process for solid-organ transplant recipients in order to determine if a transplant pharmacists’ formalized involvement with the discharge medication reconciliation process would improve medication safety by decreasing the rate and severity of medication errors.

Methods A prospective, observational, single-center study with a historical matched control group was conducted to evaluate the effect of transplant pharmacist formalized involvement in the discharge process for solid-organ transplant recipients following approval of the local Institutional Review Board (protocol number 00012941). Prospective data collection was performed on an observational basis from September to November 2011; all patients discharged from the abdominal transplant surgery service were eligible for enrollment. Our institution’s current multidisciplinary care model is structured such that surgical residents and mid-level providers complete medication reconciliation forms at both admission and discharge. The discharge forms are expected to include all newly initiated posttransplant medications as well as any home medications that have been restarted or new medications for the management of chronic conditions that are to be continued at the time of discharge. After the medication reconciliation is complete, a transplant pharmacist then verifies the form to ensure all appropriate medications are included with the correct doses and schedules. If any discrepancies are found, these are corrected prior to discharge. Pharmacists also verify that the patient’s medications have been ordered from the outpatient pharmacy and delivered for the patient to take with them at the time of discharge, a practice that was instituted in February 2010 as a component of a multistep initiative to decrease length of stay, preventable readmissions and adverse drug events in transplant patients. At the patient’s first clinic visit following discharge, a second transplant pharmacist meets with the patient to review their medication card, comparing it with the patient’s discharge medication list in the medical record and medication bottles. During the study period, any medication errors that were corrected by transplant pharmacists at the time of discharge or during the first clinic visit were recorded on two separate data collection forms (Supporting Figures S1 and S2). The retrospective group was randomly selected (every third patient) from a consecutive list of patients who received an abdominal transplant between January 2006 and December 2008, prior to implementation of the current level of pharmacy services. Retrospective patients were matched 2:1 based on organ type to the prospective cohort. In order to determine the medication discrepancies at the time of discharge in this patient population, the patient’s medication administration record (MAR) was utilized to determine all active medications at time of discharge. This was compared to the patient’s discharge medication lists. These discharge medications were then compared to the medication list from the patient’s first clinic visit, and clinic visit notes were assessed to determine if any medication changes were necessary in clinic due to errors at the time of discharge.

American Journal of Transplantation 2013; 13: 796–801

All errors identified during the retrospective and prospective periods were classified based on the type of medication implicated in the error. A severity score was applied based on the “Instrument for characterizing pharmacists” clinical activities’ which was created and validated by Overhage et al. Errors could be classified as serious, significant, minor, or “no error” based on the rating scale (Supporting Table S1) (9). Between-group differences in means were compared using an unpaired t-test while frequencies were compared using two-by-two contingency tables utilizing a two-tailed Fisher’s exact test.

Results From September 1 to November 16, 2011, a total of 73 abdominal solid-organ transplants were performed at our institution; 64 (88%) were included in the prospective cohort, while nine were not analyzed due to incomplete data regarding medication plans and documented medication errors at the time of discharge. These 64 patients were matched to a total of 128 retrospective patients. The patient characteristics, which are summarized in Table 1, as well as immunosuppressant and prophylaxis strategies, summarized in Supporting Table S2, were consistent with the overall transplant population at our institution. During the prospective period, pharmacists spent a median time of 15 min per patient (range 5–30 min) verifying medication reconciliations at the time of discharge and 20 min per patient (range 0–90 min) reviewing medications during the first clinic visit on the next business day following discharge. At the time of discharge, the pharmacists identified 119 errors on completed discharge medication reconciliations (1.9 errors per patient); all of these errors were prevented from reaching the patient and are considered “near-misses”. At the first clinic visit, pharmacists identified an additional 72 medication errors that occurred at the time of discharge (1.1 errors per patient) and again intervened to correct these errors. Therefore, a total of 191 medication errors were made at the time of discharge

Table 1: Patient characteristics Prospective No. of patients, n Organ transplanted, n (%) Kidney Kidney/pancreas Liver Liver/kidney Pancreas Male, n (%) Age, median (range) Race, n (%) Caucasian African American Other Donor, n (%) Deceased Living

64

Retrospective p-Value 128

N/A

41 (64.1) 82 (64.1) 3 (4.7) 6 (4.7) 15 (23.4) 30 (23.4) 4 (6.3) 8 (6.3) 1 (1.6) 2 (1.6) 44 (68.8) 84 (65.6) 54 (22 to 72) 51.5 (1 to 78)

1.0 1.0 1.0 1.0 1.0 1.0 1.0

37 (57.8) 27 (42.2) –

68 (53.1) 59 (46.1) 1 (0.8)

0.65 0.65 1.0

63 (98.4) 1 (1.6)

113 (88.3) 15 (11.7)

0.02 0.02

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Musgrave et al. Table 2: Summary of discharge medication errors: avoided and persistent

Discharge medication errors avoided through pharmacist 1 intervention, n (mean ± SD ) Discharge medication errors persisting until the first clinic 1 visit, n (mean ± SD ) Discharges with no medication errors, n (%) 1 SD-standard

Prospective (n = 64)

Retrospective (n = 182)

119 (1.9 ± 1.7) 72 (1.1± 1.4) 16 (25)

0 (0) 430 (3.4 ± 1.9) 5 (3.9)