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Improving Medication History at Admission Utilizing Pharmacy Students and Technicians: A Pharmacy-Driven Improvement Initiative

Katerina Petrov PharmD, BCPS
Ranjani Varadarajan PhD, MS, BS, Pharm
Martha Healy PharmD, BCPS
Elmira Darvish PharmD
Cathleen Cowden PharmD

INTRODUCTION

Inpatient medication errors are associated with increased patient risks and readmission rates.1,2 Studies have shown that for 50 to 70% of admitted patients, the initial medication history contains at least one error.13 Errors in the home medication list reviewed during reconciliation upon admission lead to inpatient medication errors and can also propagate errors in the discharge medication list.

In response, hospitals have been encouraged to develop and implement adequate medication reconciliation processes.46 In addition, the World Health Organization (WHO), the Agency for Healthcare Research and Quality, and the Society of Hospital Medicine have promoted a structured method of obtaining the Best Possible Medication History (BPMH) for each patient to decrease errors and improve patient safety.79

Inova Loudoun Hospital (ILH) is a 189-bed community hospital in Northern Virginia, which admits approximately 13,000 patients per year. In 2015, a pilot medication history program conducted by the ILH pharmacy department found a high rate of discrepancies in the medication histories completed at admission. With an average of nearly four medication discrepancies per medication list, these findings prompted a concerted effort to improve the medication history process. ILH therefore developed and launched a pharmacy-driven medication history program using a structured process to obtain the BPMH for admitted patients.10

Pharmacy technicians have been shown to reduce medication list discrepancies as part of various medication reconciliation programs.1120 Pharmacy students have demonstrated similar results.2132 However, there is less reported evidence regarding the positive benefit that pharmacy students and technicians create while working together to enhance the overall outcomes and efficiency in the medication history process.33

METHODS

The ILH pharmacy-driven medication history service consisted of two full-time medication history technicians and two advanced pharmacy practice experience (APPE) medication history students rotating through the service in five-week clinical rotation blocks. The team was trained, supervised, and managed by a clinical pharmacist preceptor. Team members were required to successfully pass a performance-based competency exam (Appendix A) at the end of their training and prior to independently executing the service. In addition, staff pharmacists assisted students in reviewing and cosigning medication history chart notes.

The focus of the medication history service was on completing the BPMH for adult patients in the emergency department (ED) prior to hospital admission. Patients admitted overnight when the medication history service was not staffed were interviewed the next day whenever possible.

The team was alerted to ED patients awaiting admission through an electronic ED track board within the computer system. Upon notification, a member of the medication history team would begin the BPMH process. During this study, ED triage nurses continued to complete the medication history for all patients registered in the ED. There were no changes to this process as an initial medication history is important for patient assessment and treatment in the ED.

When there were no ED patients awaiting admission, the team members interviewed and collected the BPMH for patients admitted to inpatient units overnight. These patients were located with an electronic list of current admissions by leveraging the electronic health record (EHR) field Prior to Admission (PTA) Medication List Status. ED nurses document “In Progress” for the PTA Medication List Status field after completing an initial patient medication history review. When unit nurses review the home medications, they document “Complete.” An additional option, “Pharmacy Complete,” was added to this field so that patients interviewed by the pharmacy team could easily be identified.

The pharmacy medication history service was staffed 12 hours a day, seven days per week during the hours of greatest admission volume. Because patients could be admitted and discharged prior to pharmacy review of home medications, it was important to continue with the current process of completing the medication history for patients admitted when the service was not staffed. Therefore, nurses continued the normal medication history-review process during this period and documented the information in the PTA Medication List Status field appropriately.

Prior to each patient interview, the medication history service team members used a paper Medication History Collection Tool (Appendix B) to review and gather pertinent information from the patient’s electronic chart and evaluate the current medication list. The team assessed the current medication information for possible discrepancies such as therapeutic and exact duplications; unclear or omitted medications; incorrect medication doses, frequencies, or formulations; and unclear or incorrect free-text medication administration instructions.

The medication history service team employed a patient-centered interview method, which encouraged each patient or caregiver to provide as much information as possible about allergies, medications, and adherence without providing leading cues. During the face-to-face interview, the team member clarified and updated the patient’s allergies; the location and contact information for the community or mail-order pharmacies used by the patient; and the name, dosage form, dose, route, frequency, and last dose of all prescriptions, over-the-counter medications, and supplements. Team members attempted to clarify all possible discrepancies noted during the EHR review while at the bedside with the patient. The patient’s or caregiver’s medication knowledge was evaluated during the interview process using a locally developed and non-validated, five-point medication knowledge scale (Appendix B) to estimate the level of the patient/caregiver’s medication knowledge. Team members addressed specific barriers to medication adherence with questions relating to financial concerns, language proficiency, and logistic barriers, including memory or cognitive issues and the patient’s ability to obtain necessary medications. They also discussed and documented the currently available and utilized medication-administration memory aids. When necessary, team members communicated any information relating to medication adherence barriers to the hospital case management professionals via a medication history progress note in the EHR, to optimize transitional care services. They also used language services whenever required, including assistance from in-house Spanish interpreters or a telephonic “language-line” for other languages.

Whenever the patient’s and/or caregiver’s estimated medication knowledge score was less than four or “Knowledgeable,” the team members were required to verify the medication list with a secondary source, such as a community pharmacy, family member or caregiver, physician’s office, or another HIPPA-appropriate resource. Once the patient interview and any verification were completed, the BPMH was documented in the EHR with all medication history updates as well as additional information collected, such as specific allergic reactions or intolerances to medications and the name and address of the community and mail-order pharmacies used by the patient.

For each patient interviewed, team members documented the following data in a password-protected database: unique patient identifier, date of patient interview, patient location at time of interview (ED or inpatient unit), number of medications on the PTA medication list, type and number of discrepancies, and collecting team member designation (student or technician). Intervention-type data included removal of duplicate medication, addition of omitted medication, removal of discontinued medication, clarification of medication, medication dose, frequency, and route, and missing or incorrect allergy. Members also collected the specific information sources consulted for BPMH verification including patient, family member, pharmacy, physician, insurance company, and other facility.

Discrepancy and information source data were totaled and analyzed. Volume and types of discrepancies were reported as the average number of discrepancies per patient and the percentage of total number of discrepancies for each type, respectively. The frequency of each information source used to complete the BPMH as well as the percentage of interviews that required an external source (phone call) for secondary verification were both reported. Because there were two types of pharmacist extenders used in this service, the volume and type of discrepancies and information sources were evaluated for each group.

Finally, readmission rates were obtained through Premier Network, a quality improvement reporting network, and included all patients admitted through the ED regardless of their inpatient unit.

RESULTS

Data for the medication history service were collected for six months from July 27, 2015 to January 27, 2016. During this period, a total of 4,070 patients were interviewed (Table 1). Of these, 3,162 patients were found to have at least one medication discrepancy in their medication list, with a total of 7,284 discrepancies identified and rectified for all patients. The average number of medications and discrepancies per patient were 7.5 and 1.8, respectively (Table 1).

The most frequent discrepancies identified and rectified were Removal of Discontinued Drug (23.7%) followed by Addition of Omitted Drug (22.5%) and Clarification of Dose (20.6%) [Figure 1]. An additional source of medication information other than the patient or bedside caregiver was necessary for 62% of patients. Of those sources consulted, 68% required a phone call to the patient’s community pharmacy, off-site family or caregiver, physician’s office, or insurance company (Figure 2).

A comparison regarding the types and volumes of discrepancies documented and the information sources used by the different medication-history team members is provided in Table 2. Overall, pharmacy students documented almost 50% more medication discrepancies per patient than did pharmacy technicians (2.3 and 1.5, respectively). The types of interventions conducted by pharmacy students and pharmacy technicians were similar, with a few notable differences. Pharmacy students added an omitted drug more often than any other intervention, while pharmacy technicians removed a discontinued drug more often. Allergies were more often clarified by pharmacy students, while technicians more often clarified information about a drug and its route. Notably, the percentage of patients interviewed by pharmacy students without any medication discrepancy was much lower than that for pharmacy technicians (12.3% vs. 27.9%, respectively). Pharmacy students contacted external information sources more frequently than did pharmacy technicians and were also more likely to call a physician’s office, an insurance company, or a community pharmacy (Table 2).

The all-cause 30-day readmission rate for all hospital patients during the study period was similar to the readmission rate for all hospital patients during the same period in the previous year (10.5% and 11.2%, respectively). However, the all-cause 30-day readmission rate for patients interviewed by the medication history team using the BPMH process was lower (8.9%) (Figure 3).

DISCUSSION

The admission medication-reconciliation process is complicated and has been challenging to streamline. The foundation of this process, the collection of the home medication list, has traditionally been delegated as a nursing responsibility. However, the Joint Commission does not specify which health-care team member should provide this service. Pharmacists,3438 pharmacy technicians,1120 and pharmacy students2131 have all demonstrated improved accuracy in completing the home medication history. This study describes the outcomes of a unique, hybrid medication-history service staffed by pharmacy students who are supervised by a clinical preceptor, alongside full-time, dedicated medication history pharmacy technicians. Judging by the volume of discrepancies rectified in the vast majority of admitted patients, this service improved the accuracy of the medication history list at ILH.

This study was not designed to directly assess actual or potential adverse drug events. As a process prior to medication reconciliation, corrections to the medication history were identified and rectified prior to providers’ orders whenever possible, thus alleviating potential adverse events. The outcomes reviewed in this study address the basic question of whether a pharmacy-driven medication history service improves the quality of the medication reconciliation process as defined by the volume of interventions necessary to complete the BPMH. An additional outcome was a decrease in readmission rates, which could be related.

The medication-history service team interviewed and completed the BPMH for 4,070 patients, making it one of the largest medication reconciliation studies so far.39 This study reports a high total volume of admitted patients whose medication lists contained at least one discrepancy, as well as a high volume of discrepancies overall.

There were minor differences between pharmacy technicians and pharmacy students in the types of medication history discrepancies identified, and larger differences in the percentage of patients who did not require an intervention. The types of secondary sources used to verify information also varied. Pharmacy students identified more discrepancies per patient and more patients with at least one discrepancy than did pharmacy technicians. With a more extensive level of clinical training and knowledge, students may have stronger medication and allergy evaluation skills, thus leading to these differences. Pharmacy students may also be more comfortable communicating with and eliciting information from providers, insurers, and pharmacy personnel judging by the increased frequency of pharmacy student calls to these sources. From a logistical standpoint, pharmacy students were able to provide patient medication adherence and barrier information directly to transitional-care medical and allied health-care professionals as a result of their heightened EHR access and ability to write electronic medication history chart notes. Conversely, technicians were required to call providers to alert them to changes in the patient’s medication history list, which is an interruptive process and creates a barrier to providing highly detailed information regarding medication history changes and updates.

Overall, pharmacy technicians were more effective in executing the logistical details of the service, seeing more patients, and clarifying the drug and route as well as removing discontinued and duplicate medications from the list more often. This work complemented the work of students who were involved in more extensive patient interviews, reaching out to providers, and frequently placing phone calls for clarifications. Our medication history service also provided another touchpoint with the health-care team for patients, and provided active and meaningful direct patient-care experiences for pharmacy students and technicians.

The all-cause 30-day readmission rate for patients interviewed by the medication history service was 15% lower than the overall hospital readmission rate for the same period, and 20% lower than the readmission rate for the same period in the previous year, suggesting a positive impact of this medication history service on readmissions.

One limitation of this study was our focus on non–critical-care patients, who may generally have a lower chance of readmission due to lesser acuity. Also, while the medication service ran 12 hours a day, seven days a week, there were times when some target patients were not interviewed because of high patient volume and did not have a BPMH completed by the pharmacy team.

A limitation to the hybrid medication history team model was the increased time and energy required for training, coaching, evaluating the competency of, and supervising new students every five weeks. Even though APPE students arrived for the medication history rotation with advanced didactic clinical knowledge, there were barriers to consistency in student competency, including diversity in language abilities, as well as variability in individual skill sets and level of comfort with patient interactions. Therefore, some students required more training and supervision than others. Student medication history chart notes, while highly valued by providers and transitional care services, required a co-signature from a pharmacist and thus a hand-off for each patient.

The two medication history pharmacy technicians, while not as formally educated, were extensively trained, well acquainted with the hospital and medication history process, well known by providers and nurses, and remained consistent throughout the study. Pharmacy technicians were also crucial to sustaining the service when students were unavailable during summer and holiday breaks.

The focus of this medication history service was at the point of patient admission. For the greatest patient safety, the home medication list needs to be evaluated again at discharge to avoid confusion with medication history changes as well as follow-through with interventions identified at admission and during transition of care. Optimizing this pharmacy-driven medication history service could include extending the service window to 24 hours per day and providing additional resources to follow patients and changes in their medications from admission to discharge to ensure optimal medication reconciliation during transitions.

To improve patient safety and therapy by improving the accuracy of the medication history obtained at admission, hospitals should consider leveraging both pharmacy students and pharmacy technicians to assist in the medication history process. Our hybrid medication history service model capitalized on the various benefits of both pharmacy students and pharmacy technicians and demonstrated improved patient care.

CONCLUSION

This pharmacy-driven medication history service, which utilized pharmacy technicians and pharmacy students to provide BPMH for admitted patients, increased the accuracy of patient medication lists over a six-month period. The program demonstrated different but complementary benefits of employing both pharmacy students and pharmacy technicians as medication history team members, and may have had a positive impact on readmission rates.

Figures and Tables

Medication History Discrepancy Types

Information Sources Consulted

All-Cause 30-Day Readmissions

Medication History Overview

Study Period: July 27, 2015–January 27, 2016
Total number of patients interviewed 4,070
Total number of patients with medication discrepancies 3,162
Total number of medication discrepancies 7,284
Average number of medications per patient 7.5
Average number of discrepancies per patient 1.8

Pharmacy Students vs. Technicians Overview

Total Students Technicians
Patients interviewed (%) 4,070 (100) 1,471 (36.1) 2,599 (63.9)
Total discrepancies 7,284 3,392 3,892
Discrepancies per patient 1.8 2.3 1.5
Medication list with no discrepancy (% of patients interviewed) 907 (22.2) 182 (12.3) 725 (27.9)
Discrepancy Types (% of total discrepancies per group)
Clarification of drug 571 (7.8) 253 (7.5) 318 (8.2)
Clarification of dose 1,503 (20.6) 720 (21.2) 783 (20.1)
Clarification of frequency 1,341 (18.4) 656 (19.3) 685 (17.6)
Clarification of administration route 160 (2.2) 27 (0.8) 133 (3.4)
Clarification of text note 12 (0.2) 11 (0.3) 1 (0)
Removal of discontinued drug 1,727 (23.7) 657 (19.4) 1,070 (27.5)
Removal of duplicate drug 162 (2.2) 67 (2.0) 95 (2.4)
Addition of omitted drug 1,640 (22.5) 839 (24.7) 801 (20.6)
Allergy clarification 168 (2.3) 162 (4.8) 6 (0.2)
Verification Information Sources
Total number of sources consulted 2,524 1,252 1,272
External sources requiring a phone call (% of total sources consulted per group) 1,715 (67.9) 972 (77.6) 743 (58.4)
Information Source Consulted (% of total sources per group)
Caregiver or family 700 (27.7) 259 (20.7) 441 (34.7)
Insurance company 34 (1.3) 31 (2.5) 3 (0.2)
Community pharmacy 926 (36.7) 638 (51.0) 288 (22.6)
Physician’s office 55 (2.2) 44 (3.5) 11 (0.9)
Medication list or vials 636 (25.2) 189 (15.1) 447 (35.1)
SNF, assisted living, rehab 173 (6.9) 91 (7.3) 82 (6.5)

SNF = Skilled nursing facility

Author bio: 
Drs. Petrov and Varadarajan are Pharmacists at the Bernard J. Dunn School of Pharmacy at Shenandoah University in Fairfax, Virginia. Drs. Healy, Darvish, and Cowden are Pharmacists at the Inova Loudoun Hospital in Leesburg, Virginia.

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