Steady Drop in Medication Mix-ups With New Approach

Marcia Frellick

March 26, 2019

NATIONAL HARBOR, Maryland — Hospitals that used a reconciliation toolkit were able to cut the number of medication discrepancies from an average of three per person to just one during an 18-month study period.

The toolkit is leading to dramatic improvements in one of the biggest problem areas in hospitals, said lead investigator Jeffrey Schnipper, MD, from Brigham and Women's Hospital in Boston.

The three errors per patient is for prescription medications only, he told Medscape Medical News. "What else in healthcare has a 300% error rate?"

What else in healthcare has a 300% error rate?

Schnipper and his colleagues refined the toolkit used in the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) trial (NCT01337063) trial, which involved five hospitals, and expanded the scope of their MARQUIS 2 study to 18 hospitals.

Findings from 1229 patients assessed before the toolkit implementation and 3718 after implementation at the 18 geographically diverse, small and large, and academic and community hospitals were presented here at the Society of Hospital Medicine 2019 Annual Meeting.

An interrupted time series analysis revealed a 5% relative decrease in discrepancies per month at the sites over baseline trends (adjusted incidence rate ratio [IRR], 0.95; 95% confidence interval [CI], 0.93 - 0.97; < .001).

Participating hospitals could choose which of the 17 toolkit components to implement.

Three components appear to have had the most impact: taking a full medication history in the emergency department before a patient is admitted to the hospital; doing medication reconciliation at discharge for high-risk patients; and hiring a pharmacy technician to do just medication reconciliations.

Connecting With Patients

Patients who received at least one patient-level intervention had 53% fewer inconsistencies than those who received no interventions (adjusted IRR, 0.47; 95% CI, 0.45 - 0.49; < .001).

The next step is to analyze the data to determine which parts of the toolkit are most crucial for success, said Schnipper.

The proper management of medication is a constant source of frustration for hospitals, said Benji Mathews, MD, from the University of Minnesota in Minneapolis.

Medications can be added, deleted, or changed by multiple providers, which can lead to confusion on the part of patients and inaccuracies in their medication lists, he pointed out.

Individual hospitals have tried to fix their own systems, but this package of interventions works across multiple levels of hospitals and has received "a lot of street cred," which elevated it to one of three research papers selected for the research plenary, Mathews told Medscape Medical News.

It probably takes about 25 minutes to take a good medication history, and the average provider probably gives it about 4 minutes. You get what you pay for.

Of the 72 hospitals that applied to be a MARQUIS 2 study site, the 18 selected were chosen because they demonstrated an outstanding commitment to improve medication reconciliation and a willingness to provide resources to facilitate it, Schnipper explained.

That could lead some to claim that the sites were cherry-picked, potentially stacking the deck toward success, he acknowledged.

But, he added, "Why would you spend all this time, money, and effort to try to improve med rec in a site that isn't ready to change?"

Medication reconciliation has historically been under-resourced, and pharmacy techs are a low-cost but efficient way to improve the process.

"It probably takes about 25 minutes to take a good medication history, and the average provider probably gives it about 4 minutes. You get what you pay for," Schnipper said.

Now that the toolkit has shown definitive results, the team will move from research to helping more sites implement it, he reported.

Already, the Leapfrog Group — a nonprofit organization that measures quality improvement for hospitals — has added the MARQUIS metric for medication reconciliation to its portfolio, so "hundreds of hospitals are measuring discrepancy rates the same way we are," Schnipper said.

Schnipper has received investigator-initiated grants from Mallinckrodt Pharmaceuticals to evaluate opioid-related adverse drug events in surgical patients and from Portola Pharmaceuticals to assess inpatients who decline doses of subcutaneous venous thromboembolism prophylaxis. Mathews has disclosed no relevant financial relationships.

Society of Hospital Medicine (HM) 2019 Annual Meeting: Abstract 597725. Presented March 26, 2019.

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