There is a continued need to develop a seven-day pharmacy service to allow medicines reconciliation to be completed by a pharmacist, within 24 hours of admission to hospital, for all adult patients
Claire M Irwin MSc
Michael G Scott PhD
Dianne Gill MSc
Glenda F Fleming PhD
Pharmacy and Medicines Management Centre, Northern Health and Social Care Trust, Antrim Area Hospital, Bush Road, Antrim
Medication errors commonly occur at transition points in patient care, particularly on admission to hospital, with an estimated variation between medication that patients are taking before admission and those prescribed in hospital being 30–70%.1 Medicines reconciliation has been defined by the Institute of Healthcare Improvement as being the process of identifying the most accurate list of a patient’s current medicines (prescription and non-prescription drugs) – including the name, dosage, frequency and route- and comparing them to what is currently prescribed.2 The National Prescribing Centre advises that the process of medicines reconciliation should involve communicating and documenting any changes that have been made to the patient’s prescription.3
The absence of medicines reconciliation at transition points in care may be responsible for up to 50% of medication errors and up to 20% of adverse drug reactions (ADRs) in hospital.4 Pharmacists’ involvement in medication reconciliation significantly reduces the number of unreconciled medications, improving patient safety and reducing the costs of medication errors and the occurrence of ADRs.5
For these reasons it is imperative that medicines reconciliation occurs for all patients admitted to hospital. An erroneous medication history may result in failure to detect drug-related problems as the cause of hospital admission or lead to interrupted or inappropriate drug therapy during hospitalisation. Following hospital discharge, the continuation of these errors may result in drug interactions, therapeutic duplication, other unintended adverse events, and additional costs.6 Over recent years, strategic plans for healthcare have increasingly taken into account the valuable role that pharmacists can bring to patient care in the hospital setting. In 2001, Antrim Area Hospital introduced and showed the benefits of an integrated medicines management (IMM) service at each stage of the patients’ hospital journey, from admission through to discharge in a group of patients. Those who received an IMM service benefited from a reduced length of hospital stay (two day reduction), a reduced rate of readmission over a 12-month follow-up period and an increased time to readmission.7
A major part of the IMM service was based on clinical pharmacists obtaining an accurate medication history for those patients admitted to hospital using two sources of information and involved, where possible, speaking to the patient or carer. A total of 5531 medicine discrepancies were recorded over the study period. This pilot was used as a template to support the expansion of a comprehensive one-stop pharmacy service that can now be seen on all adult medical wards in the hospital. Since this initial IMM project, work has been ongoing to expand the role of the clinical pharmacist further and to provide an extended pharmacy service to both hospital staff and patients.
The increasing recognition across the UK of the value of a hospital pharmacy team has led to both increased expectation and targets being set out for the pharmacy team. In December 2007, the National Institute for Health and Care Excellence (NICE), in collaboration with the National Patient Safety Agency (NPSA), issued guidance to the National Health Service on how to improve the process of medicines reconciliation.8,9 The guidance advised that all healthcare organisations should put in place policies for medicines reconciliation. This process should involve a pharmacist and should be completed within 24 hours of admission. These targets were originally suggested by the World Health Organization (WHO) in May 2007 and they recommended using at least two sources of information.
A patient’s hospital journey usually begins in the Emergency Department (ED) where a decision is taken to admit or discharge the patient. For those patients who require admission to hospital, a bed must become available on a ward to facilitate their transfer out ED. For those patients admitted medically many are moved to the admission wards and then onto a speciality ward. Research carried out at the hospital,10 showed that most presentations in the ED occur between 8am to midnight with the busiest period being from 11am to 8.30pm with Mondays having the most presentations. For those patients in ED who have been admitted medically but await a bed on a ward for a number of hours, the opportunity for their medicines to be reconciled within 24 hours is greatly reduced in the absence of an ED pharmacist. Given the usual working hours of the pharmacy team, patients admitted to a ward later in the day will often not be seen by a pharmacist until the following working day thus again reducing early interventions with all the subsequent attendant problems.
Aim of the study
The aim of the current study was to evaluate the benefits of the introduction of a pharmacist into the ED at a large district general teaching hospital in Northern Ireland. In particular the study wished to evaluate if the introduction of an ED pharmacist would improve medicines reconciliation rates for adult medical patients.
The objectives were:
- To set standards for the medication reconciliation process
- To collect and analyse data on the number of patients having their medications reconciled within 24 hours on the two admission wards in the hospital.
- To analyse whether the introduction of an ED pharmacist working 12-hour days, improved the set standards
- To establish if the presence of an ED pharmacist would improve the number of patients having their medicines reconciled within 24 hours of admission.
The study was based in two admission wards (study ward 1 and 2) in a 426-bed district general teaching hospital in Northern Ireland (Antrim Area Hospital).
Sampling and duration of study
All patients on the study wards at 8.30am on the days of the audit were included with those admitted after this time being excluded. Such patients were identified from the Patient Administration System (PAS) which provided details of the total number of patients on the wards, the date they were admitted and indicated the newly admitted patients each day.
Baseline information regarding medication reconciliation was collected on the study wards over a three-month period prior to the introduction of a pharmacist into the ED (March–June 2012). Data collection was repeated following the introduction of the ED pharmacist for the three-month period from July 2012 to September 2012. Data was collected for a total of 16 days in each period from Monday to Friday. It was ensured that each weekday was represented equally in each period.
Data collection and analysis
A medical admission commences when the ED team hand the care of the patient over to the medical team with the aim that these patients have their medicines reconciled within 24 hours of this occurring. Bespoke data collection forms were used to record the number of patients on the admission wards requiring their medication reconciled on the day of audit and their date of admission to hospital. The medication reconciliation process was counted as being complete when a medication history had been confirmed using two sources, all medicines had been reconciled and the pharmacy paperwork had been completed and filed in the patients’ notes.
For each day of the study, it was then possible to calculate the number of patients admitted via the ED to the admission wards, who had their medicines reconciled within 24 hours to hospital and to see if this figure improved and to what degree with the introduction of an ED pharmacist. Staffing numbers available on the admission wards were also recorded. The data was collated onto a Microsoft Excel spreadsheet and Chi-square analysis and odds-ratio analysis were used for data comparison using 0.05 and a 95% confidence interval for the statistical analysis. A target was set that ideally 100% of patients admitted via the study wards would have their medications reconciled within 24 hours of admission.
Information on a total of 834 patients admitted to the study wards was collected with regard to medication reconciliation (427 patients in the first audit and 407 patients in the second audit). To account for any potential variables that may affect the results, other factors were measured on each day of the audit as shown in Table 1. A mean value was calculated for each audit cycle and there was no significant difference detected.
The percentage of patients with their medicines reconciled by a pharmacist within 24 hours of admission increased from 44% to 85% (Table 2 and Figure 1). The target of 100% of patients having medication reconciliation complete within 24 hours of admission was not met during either audit cycle however the increase from audit cycle 1 to audit cycle 2 was significant (p<0.001).
There was a significant reduction in the percentage of patients without their medication reconciled by 5pm on the admission wards each day from audit cycle 1 to audit cycle 2 (p<0.001). There was no significant difference (p=0.492) between the two wards during the audit and both had similar performances during both cycles (p=0.782) indicating the ED pharmacist impacted on both wards equally and wards had a constant level of performance throughout the whole audit.
A pharmacist was introduced into the ED at a large district general teaching hospital, Northern Ireland, in July 2012, with a view to assessing if medicines reconciliation could be improved. A key role of the pharmacist was to identify those patients who required admission to hospital and to reconcile their medication prior to their arrival at a ward. This role was identified in order to assist the Trust to meet the targets set by NICE that 100% of adult patients should have their medicines reconciled within 24 hours of admission.
Previous studies have shown the importance and economic benefit of early medication reconciliation. A study involving 1016 hospitals and reported a pharmacy service completing accurate medication histories made a saving of seven million dollars per hospital per year and decreased mortality rates.11,12 There is also overwhelming evidence to suggest that medication reconciliation performed by a pharmacist tends to be more accurate than that of a doctor,13 therefore the aim of this study was not to prove the benefits of early medication reconciliation but to examine if the introduction of an ED pharmacist could help to reduce the time a patient waits for their medicines to be reconciled. Historically, patients requiring medication reconciliation were identified on the admission wards each morning and any patients admitted after this time were not seen by a pharmacist until the next working day. This in theory could mean that if a decision is taken in the ED to admit a patient in the morning, the patient may have to wait a number of hours for a medical bed (depending on the bed status of the hospital) and once admitted to a ward, will be seen by a pharmacist the following day, at the earliest. This gives a small window of opportunity for their medicines to be reconciled within 24 hours of medical admission. The advantage of having a pharmacist in the ED means that as soon as the decision is made to admit a patient, the medication history can be requested and completed before the patient leaves the ED. Extending the working hours to 8.30pm also means that patients admitted in the afternoon are more likely to seen that day by a pharmacist than having to wait until the following day. Having a pharmacist work until 8.30pm also provided a service to the ED during its busiest period from 11am to 8.30pm.
This study did not collect data on Saturdays or Sundays as at the time of the study a full pharmacy service was not provided at the weekend. Lack of weekend cover results in a large amount of patients requiring medicines reconciliation on Mondays and thus affects overall weekly figures for the number of patients having their medicines reconciled within 24 hours. It was recognised that in the absence of a full pharmacy service at the weekend, the hospital would always fail to reach NICE targets. There is currently ongoing work in the hospital to facilitate a full pharmacy weekend service to include patient medicine reconciliation, inpatient monitoring and pharmacist-prepared discharge prescriptions. These future developments should allow for all adult medical patients to have their medicines reconciled within 24 hours of admission.
Future developments of the role of the pharmacist in the ED
Following the success of the pilot in 2012, Antrim Area Hospital now has two full-time independent prescribing pharmacists working in the ED covering Monday to Friday 8am–8.30pm. The role of the ED pharmacist remains primarily to reconcile medicines for those patients being admitted, however the role has developed further to include more varied tasks and responsibilities. The ED pharmacists provide a one-stop service to implement the NICE guidelines on venous thromboprophylaxis for those patients with a lower limb cast. They have been involved in the safe introduction of the use of non-vitamin K oral anticoagulants (NOACs) in the ED and were involved in the introduction of over labelled pre-packed medication in response to the Guidelines and Audit Implementation Network (GAIN) guidelines for the supply of take home medications from the ED.14 There is now a pharmacist present in the monthly ED Governance meetings and there is work ongoing to look at the role of a pharmacy technician in the ED. A further initiative has been introduced to improve both the use of patients’ own drugs in the ED and the subsequent safe storage and transport to admitting wards.
In conclusion, there is a significant role for an ED pharmacist working longer hours within a large hospital. It is recognised that the ED can benefit from the presence of a pharmacist in areas other than medication reconciliation and this role is continuing to expand and evolve. There is a continued need to develop a seven-day pharmacy service to allow medicines reconciliation to be completed by a pharmacist, within 24 hours of admission to hospital, for all adult patients.
- Medicines reconciliation should be completed within 24 hours of admission and should involve a pharmacist.
- Pharmacists working in the emergency department (ED) are able to commence medicines reconciliation as soon as a decision is made to admit the patient to hospital.
- The busiest period for the ED was shown to be 11am to 8.30pm.
- Extending the pharmacist working hours Monday to Friday in the ED to 8.30pm significantly increased the number of medicines reconciliation completed within 24 hours.
- Lack of pharmacist cover in the ED on Saturday and Sunday is an area that must be addressed.
- Campbell C et al. Systematic review of the effectiveness of interventions aimed at preventing medication error (medicines reconciliation) at hospital admission. www.nice.org.uk/guidance/psg001/documents/systematic-review-for-clinical-and-cost-effectiveness-of-interventions-in-medicines-reconciliation-at-the-point-of-admission2 (accessed 10 August 2015).
- The Institute of Healthcare Improvement. Innovation at its best; Medication Reconciliation. Cambridge, UK.
- National Prescribing Centre. Medicines reconciliation: a guide to implementation. www.nicpld.org/courses/hospVoc/assets/MM/NPCMedicinesRecGuideImplementation.pdf (accessed 10 August 2015).
- The Institute for Healthcare Improvement. How-to Guide: Prevent adverse drug events by implementing medication reconciliation. www.ihi.org/resources/pages/tools/howtoguidepreventadversedrugevents.aspx (accessed 10 August 2015).
- Strunk LB et al. Impact of a pharmacist on medication reconciliation on patient admission to a Veterans Affairs Medical centre. Hosp Pharm 2008;43(8)643–9.
- Nester TM, Hale LS. Effectiveness of a pharmacist acquired medication history in promoting patient safety. Am J Health Syst Pharm 2002;59:2221–5.
- Scullin C et al. An innovative approach to integrated medicines management. J Eval Clin Pract 2007;13(5):781–8.
- National Institute for Health and Care Excellence.Technical patient safety solutions for medicines reconciliation on admission of adults to hospital. www.nice.org.uk/guidance/psg001 (accessed 10 August 2015).
- National Patient Safety Agency. Medicines reconciliation in adults. www.nrls.npsa.nhs.uk/resources/?EntryId45=59878 (accessed 10 August 2015).
- Tribal Report. Northern Health and Social Care Trust (2010) Review of Emergency Care & Medical Specialities – Phase 1 A&E and MAU, Antrim, Northern Ireland.
- Bond CA, Raehl CL, Franke T. Clinical pharmacy services and hospital mortality rates. Pharmacotherapy 1999;19(5):556–64.
- Bond CA, Raehl CL, Franke T. Clinical pharmacy services, pharmacy staffing and the total cost of care in United States hospitals. Pharmacotherapy 2000;20(6):609–21.
- Gleason KM et al. Reconciliation of discrepancies in medication histories and admission orders of newly hospitalised patients. Am J Health-Sys Pharm 2004;61:1689–95.
- Guidelines and Audit Implementation Network Regional Guidelines for the Supply of “Take Home Medication” from Northern Ireland Emergency Departments; 2014.