Medication Reconciliation Performed by Pharmacy Technicians at the Time of Preoperative Screening
Medication Reconciliation Performed by Pharmacy Technicians at the Time of Preoperative Screening
Background: Medication errors occur regularly in surgical patients, especially due to transfer problems at the time of hospital admission. A method for decreasing the error rate is medication reconciliation by hospital pharmacists as part of a preoperative clinic. The role of pharmacy technicians in this process has not been studied.
Objective: To study the use of pharmacy technicians in medication reconciliation by measuring the effect of early reconciliation in the preoperative clinic on medication and allergy discrepancies and on inadvertent continuation of antithrombotics. A secondary objective was to study the effect of community pharmacist follow-up on recommendations to discontinue antithrombotic therapy.
Methods: During the preintervention measurement period, patients received usual care by anesthesiologists, who recorded the medication and documented allergies of the patient. The intervention consisted of the addition of a pharmacy technician to the preoperative screening clinic to perform the same tasks as anesthesiologists as related to medication reconciliation. If necessary, the patient was advised on stopping the antithrombotic. On the day that the patient was supposed to stop the antithrombotic, that person's community pharmacist contacted the patient to determine whether this had been done. The main outcome measures were the proportions of patients with one or more medication discrepancy, one or more allergy discrepancy, and one or more antithrombotic error.
Results: In the preintervention period, 204 patients were evaluated; 93 were included in the postintervention analysis. The proportion of patients with one or more medication discrepancy (RR 0.29; 95% CI 0.12 to 0.71) was statistically significantly reduced in the postintervention group. The proportions of patients with one or more allergy discrepancy (RR 0.76; 95% CI 0.35 to 1.64) and one or more antithrombotic errors (RR 0.18; 95% CI 0.02 to 1.33) were reduced, but not significantly. Follow-up by the community pharmacist did not identify any patients who had not followed the preoperative clinic's advice on temporarily withholding their antithrombotics.
Conclusions: The results of this study show that pharmacy technicians can be successfully assigned to a preoperative clinic, resulting in a statistically significant decrease in medication discrepancies.
Medication errors occur regularly in hospitalized patients, with reported frequencies of up to 59%. A substantial number of errors occurs when drugs are prescribed. Prescriptions by surgeons and continuation of preadmission medicines are potential risk factors for prescribing errors.
In general, up to 27% of prescribing errors in hospital are caused by incomplete medication records at the time of admission, and approximately 54% of patients are reported to have at least one unintended discrepancy in their admission medication record. Prescribing is not a routine task of surgeons and is generally limited to a few analgesics, antibiotics, antithrombotics, and sedatives. This limited experience may explain the increased risk for prescription errors among surgical specialties.
In elective surgery, preoperative screening can be carried out by anesthesiologists and surgeons; often, they prepare their own preoperative medication history of the patient. These separate histories should, of course, be identical, but one study showed that 73% of patient records contained at least one discrepancy. The authors suggested that medication reconciliation by a pharmacist could be a solution to this problem. Indeed, several studies have shown the benefit of pharmacist medication reconciliation in preadmission clinics. These studies were performed in countries in which the number of hospital pharmacists is generally higher than it is in the Netherlands. In Dutch hospitals, it is common for pharmacists to delegate tasks to pharmacy technicians because of their high-quality education and additional in-hospital training courses. The supervision of these delegated tasks remains the responsibility of hospital pharmacists. Medication reconciliation is perceived to be a task that could be performed by pharmacy technicians, but evidence in international literature is limited. Within the Netherlands, there is evidence from projects of medication reconciliation by pharmacy technicians indicating that technicians may have the capacity to reduce unintended medication discrepancies at the time of hospital admission as effectively as other healthcare professionals. Because surgeons are more likely to commit prescribing errors, these projects are mostly performed in surgical wards. A problem often encountered in these projects is the fact that antithrombotic therapy must be withheld for a few days preceding surgery; however, many patients have continued their antithrombotics. This may lead to postponement of surgery or a higher risk of bleeding. By means of earlier medication reconciliation, namely, at the time of preoperative screening, this problem could be solved. Improved communication of these instructions to the patient by skilled pharmacy technicians and follow-up by the patient's community pharmacist may increase the proportion of patients who correctly withhold their antithrombotic drugs preceding elective surgery.
Therefore, we set up an interventional study aimed at determining the frequency of medication and allergy discrepancies before and after implementation of medication reconciliation by pharmacy technicians at the time of preoperative screening. This medication reconciliation also involved communication to the patient of instructions on temporarily withholding antithrombotics, as well as follow-up by the community pharmacist.
Abstract and Introduction
Abstract
Background: Medication errors occur regularly in surgical patients, especially due to transfer problems at the time of hospital admission. A method for decreasing the error rate is medication reconciliation by hospital pharmacists as part of a preoperative clinic. The role of pharmacy technicians in this process has not been studied.
Objective: To study the use of pharmacy technicians in medication reconciliation by measuring the effect of early reconciliation in the preoperative clinic on medication and allergy discrepancies and on inadvertent continuation of antithrombotics. A secondary objective was to study the effect of community pharmacist follow-up on recommendations to discontinue antithrombotic therapy.
Methods: During the preintervention measurement period, patients received usual care by anesthesiologists, who recorded the medication and documented allergies of the patient. The intervention consisted of the addition of a pharmacy technician to the preoperative screening clinic to perform the same tasks as anesthesiologists as related to medication reconciliation. If necessary, the patient was advised on stopping the antithrombotic. On the day that the patient was supposed to stop the antithrombotic, that person's community pharmacist contacted the patient to determine whether this had been done. The main outcome measures were the proportions of patients with one or more medication discrepancy, one or more allergy discrepancy, and one or more antithrombotic error.
Results: In the preintervention period, 204 patients were evaluated; 93 were included in the postintervention analysis. The proportion of patients with one or more medication discrepancy (RR 0.29; 95% CI 0.12 to 0.71) was statistically significantly reduced in the postintervention group. The proportions of patients with one or more allergy discrepancy (RR 0.76; 95% CI 0.35 to 1.64) and one or more antithrombotic errors (RR 0.18; 95% CI 0.02 to 1.33) were reduced, but not significantly. Follow-up by the community pharmacist did not identify any patients who had not followed the preoperative clinic's advice on temporarily withholding their antithrombotics.
Conclusions: The results of this study show that pharmacy technicians can be successfully assigned to a preoperative clinic, resulting in a statistically significant decrease in medication discrepancies.
Introduction
Medication errors occur regularly in hospitalized patients, with reported frequencies of up to 59%. A substantial number of errors occurs when drugs are prescribed. Prescriptions by surgeons and continuation of preadmission medicines are potential risk factors for prescribing errors.
In general, up to 27% of prescribing errors in hospital are caused by incomplete medication records at the time of admission, and approximately 54% of patients are reported to have at least one unintended discrepancy in their admission medication record. Prescribing is not a routine task of surgeons and is generally limited to a few analgesics, antibiotics, antithrombotics, and sedatives. This limited experience may explain the increased risk for prescription errors among surgical specialties.
In elective surgery, preoperative screening can be carried out by anesthesiologists and surgeons; often, they prepare their own preoperative medication history of the patient. These separate histories should, of course, be identical, but one study showed that 73% of patient records contained at least one discrepancy. The authors suggested that medication reconciliation by a pharmacist could be a solution to this problem. Indeed, several studies have shown the benefit of pharmacist medication reconciliation in preadmission clinics. These studies were performed in countries in which the number of hospital pharmacists is generally higher than it is in the Netherlands. In Dutch hospitals, it is common for pharmacists to delegate tasks to pharmacy technicians because of their high-quality education and additional in-hospital training courses. The supervision of these delegated tasks remains the responsibility of hospital pharmacists. Medication reconciliation is perceived to be a task that could be performed by pharmacy technicians, but evidence in international literature is limited. Within the Netherlands, there is evidence from projects of medication reconciliation by pharmacy technicians indicating that technicians may have the capacity to reduce unintended medication discrepancies at the time of hospital admission as effectively as other healthcare professionals. Because surgeons are more likely to commit prescribing errors, these projects are mostly performed in surgical wards. A problem often encountered in these projects is the fact that antithrombotic therapy must be withheld for a few days preceding surgery; however, many patients have continued their antithrombotics. This may lead to postponement of surgery or a higher risk of bleeding. By means of earlier medication reconciliation, namely, at the time of preoperative screening, this problem could be solved. Improved communication of these instructions to the patient by skilled pharmacy technicians and follow-up by the patient's community pharmacist may increase the proportion of patients who correctly withhold their antithrombotic drugs preceding elective surgery.
Therefore, we set up an interventional study aimed at determining the frequency of medication and allergy discrepancies before and after implementation of medication reconciliation by pharmacy technicians at the time of preoperative screening. This medication reconciliation also involved communication to the patient of instructions on temporarily withholding antithrombotics, as well as follow-up by the community pharmacist.
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