Effectiveness of a pharmacist-led quality improvement program to reduce medication errors during hospital discharge

Main Article Content


Patient Discharge, Medication Reconciliation, Medication Errors, Prescriptions, Pharmacy Service, Hospital, Pharmacists, Quality Assurance, Health Care, Malaysia


Background: Patients requiring medications during discharge are at risk of discharge medication errors that potentially cause readmission due to medication-related events.

Objective: The objective of this study was to develop interventions to reduce percentage of patients with one or more medication errors during discharge.

Methods: A pharmacist-led quality improvement (QI) program over 6 months was conducted in medical wards at a tertiary public hospital. Percentage of patients discharge with one or more medication errors was reviewed in the pre-intervention and four main improvements were developed: increase the ratio of pharmacist to patient, prioritize discharge prescription order within office hours, complete discharge medication reconciliation by ward pharmacist, set up a Centralized Discharge Medication Pre-packing Unit. Percentage of patients with one or more medication errors in both pre- and post-intervention phase were monitored using process control chart.

Results: With the implementation of the QI program, the percentage of patients with one or more medication errors during discharge that were corrected by pharmacists significantly increased from 77.6% to 95.9% (p<0.001). Percentage of patients with one or more clinically significant error was similar in both pre and post-QI with an average of 24.8%.

Conclusions: Increasing ratio of pharmacist to patient to complete discharge medication reconciliation during discharge significantly recorded a reduction in the percentage of patients with one or more medication errors.

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1. Jeff A. Medication reconciliation. BMJ 2017;356:i5336. https://doi.org/10.1136/bmj.i5336
2. American Society of Health-System Pharmacists. ASHP statement on the pharmacist’s role in medication reconciliation. Am J Health Syst Pharm. 2013;70(5):453-456. https://doi.org/10.2146/sp120009
3. Wong E, Wilson M. Should the pharmacy profession lead the medication reconciliation process? Can J Hosp Pharm. 2011;64(5):373-374.
4. Michaelsen M, McCague P, Bradley C, Sahm L. Medication Reconciliation at Discharge from Hospital: A Systematic Review of the Quantitative Literature. Pharmacy (Basel). 2015;3(2):53-71. https://doi.org/10.3390/pharmacy3020053
5. Pippins JR, Gandhi TK, Hamann C, Ndumele CD, Labonville SA, Diedrichsen EK, Carty MG, Karson AS, Bhan I, Coley CM, Liang CL, Turchin A, McCarthy PC, Schnipper JL. Classifying and predicting errors of inpatient medication reconciliation. J Gen Intern Med. 2008;23(9):1414-1422. https://doi.org/10.1007/s11606-008-0687-9
6. Shiu JR, Fradette M, Padwal RS, Majumdar SR, Youngson E, Bakal JA, McAlister FA. Medication discrepancies associated with a medication reconciliation program and clinical outcomes after hospital discharge. Pharmacotherapy. 2016;36(4):415-421. https://doi.org/10.1002/phar.1734
7. Belda-Rustarazo S, Cantero-Hinojosa J, Salmeron-García A, González-García L, Cabeza-Barrera J, Galvez J. Medication reconciliation at admission and discharge: An analysis of prevalence and associated risk factors. Int J Clin Pract. 2015;69(11):1268-1274. https://doi.org/10.1111/ijcp.12701
8. Akram F, Huggan PJ, Lim V, Huang Y, Siddiqui FJ, Assam PN, Merchant RA. Medication discrepancies and associated risk factors identified among elderly patients discharged from a tertiary hospital in Singapore. Singapore Med J. 2015;56(7):379-384. https://doi.org/10.11622/smedj.2015108
9. Salanitro AH, Osborn CY, Schnipper JL, Roumie CL, Labonville S, Johnson DC, Neal E, Cawthon C, Businger A, Dalal AK, Kripalani S. Effect of patient- and medication-related factors on inpatient medication reconciliation errors. J Gen Intern Med. 2012;27(8):924-932. https://doi.org/10.1007/s11606-012-2003-y
10. Herrero-Herrero J, García-Aparicio J. Medication discrepancies at discharge from an internal medicine service. Eur J Intern Med. 2011;22(1):43-48. https://doi.org/10.1016/j.ejim.2010.10.003
11. Perren A, Previsdomini M, Cerutti B, Soldini D, Donghi D, Marone C. Omitted and unjustified medications in the discharge summary. Qual Saf Health Care. 2009;18(3):205-208. https://doi.org/10.1136/qshc.2007.024588
12. Wong JD, Bajcar JM, Wong GG, Alibhai SM, Huh JH, Cesta A, Pond GR, Fernandes OA. Medication reconciliation at hospital discharge: Evaluating discrepancies. Ann Pharmacother. 2008;42(10):1373-1379. https://doi.org/10.1345/aph.1L190
13. Grimes TC, Deasy E, Allen A, O’Byrne J, Delaney T, Barragry J, Breslin N, Moloney E, Wall C. Collaborative pharmaceutical care in an Irish hospital: Uncontrolled before-after study. BMJ Qual Saf. 2014;23(7):574-583. https://doi.org/10.1136/bmjqs-2013-002188
14. Vira T, Colquhoun M, Etchells E. Reconcilable differences: Correcting medication errors at hospital admission and discharge. Qual Saf Health Care. 2006 pr;15(2):122-126. https://doi.org/10.1136/qshc.2005.015347
15. Cheen MHH, Goon CP, Ong WC, Lim PS, Wan CN, Leong MY, Khee GY. Evaluation of a care transition program with pharmacist-provided home-based medication review for elderly Singaporeans at high risk of readmissions. Int J Qual Health Care. 2017;29(2):200-205. https://doi.org/10.1093/intqhc/mzw150
16. Ravn-Nielsen LV, Duckert ML, Lund ML, Henriksen JP, Nielsen ML, Eriksen CS, Buck TC, Pottegård A, Hansen MR, Hallas J. Effect of an in-hospital multifaceted clinical pharmacist intervention on the risk of readmission a randomized clinical trial. JAMA Intern Med. 2018;178(3):375-382. https://doi.org/10.1001/jamainternmed.2017.8274
17. Kilcup M, Schultz D, Carlson J, Wilson B. Postdischarge pharmacist medication reconciliation: Impact on readmission rates and financial savings. J Am Pharm Assoc (2003). 2013;53(1):78-84. https://doi.org/10.1331/JAPhA.2013.11250
18. Leonard MS. Patient Safety and Quality Improvement: Medical Errors and Adverse Events. Pediatr Rev. 2010;31(4):151-158. https://doi.org/10.1542/pir.31-4-151
19. Hartwig S, Denger S, Schneider PJ. Severity-indexed, incident report-based medication error-reporting program. Am J Hosp Pharm. 1991;48(12):2611-2616.
20. Tong EY, Roman CP, Mitra B, Yip GS, Gibbs H, Newnham HH, Smit V, Galbraith K, Dooley MJ. Reducing medication errors in hospital discharge summaries: A randomised controlled trial. Med J Aust. 2017;206(1):36-39. https://doi.org/10.5694/mja16.00628
21. Beardsley JR, Schomberg RH, Heatherly SJ, Williams BS. Implementation of a standardized discharge time-out process to reduce prescribing errors at discharge. Hosp Pharm. 2013;48(1):39-47. https://doi.org/10.1310/hpj4801-39.test
22. Midlöv P, Holmdahl L, Eriksson T, Bergkvist A, Ljungberg B, Widner H, Nerbrand C, Höglund P. Medication report reduces number of medication errors when elderly patients are discharged from hospital. Pharm World Sci. 2008;30(1):92-98. https://doi.org/10.1007/s11096-007-9149-4
23. Portela MC, Pronovost PJ, Woodcock T, Carter P, Dixon-Woods M. How to study improvement interventions: A brief overview of possible study types. Postgrad Med J. 2015;91(1076):343-354. https://doi.org/10.1136/postgradmedj-2014-003620rep
24. Cheung YY, Jung B, Sohn JH, Ogrinc G. Quality Initiatives: Statistical Control Charts: Simplifying the Analysis of Data for Quality Improvement. Radiographics. 2012;32(7):2113-2126. https://doi.org/10.1148/rg.327125713
25. Mohammed MA, Worthington P, Woodall WH. Plotting basic control charts: Tutorial notes for healthcare practitioners. Qual Saf Health Care. 2008;17(2):137-145. https://doi.org/10.1136/qshc.2004.012047
26. Benneyan JC. Statistical process control as a tool for research and healthcare improvement. Qual Saf Health Care. 2003;12(6):458-464. https://doi.org/10.1136/qhc.12.6.458
27. Lim WY, Hss AS, Ng LM, Rani S, Jasudass J, Sararaks S, Vengadasalam P, Hashim L, Praim Singh RK.The impact of a prescription review and prescriber feedback system on prescribing practices in primary care clinics : a cluster randomised trial. BMC Fam Pract. 2018;19(1):120.
28. Al-Hashar A, Al-Zakwani I, Eriksson T, Sarakbi A, Al-Zadjali B, Al Mubaihsi S, Al Za'abi M. Impact of medication reconciliation and review and counselling, on adverse drug events and healthcare resource use. Int J Clin Pharm. 2018;40(5):1154-1164. https://doi.org/10.1007/s11096-018-0650-8
29. Breuker C, Abraham O, di Trapanie L, Mura T, Macioce V, Boegner C, Jalabert A, Villiet M, Castet-Nicolas A, Avignon A, Sultan A. Patients with diabetes are at high risk of serious medication errors at hospital: Interest of clinical pharmacist intervention to improve healthcare. Eur J Intern Med. 2017;38:38-45. https://doi.org/10.1016/j.ejim.2016.12.003
30. Assiri T, Khurshid F, Almutairi M, Alhusayyen M, Alkharji F, Alsultan M. Impact of pharmacist intervention in patient counseling at point of hospital discharge in a specialized cardiac center in Saudi Arabia. Trop J Pharm Res. 2017;16(5):1187-1193. http://doi.org/10.4314/tjpr.v16i5.29
31. Rogers J, Pai V, Merandi J, Catt C, Cole J, Yarosz S, Wehr A, Durkin K, Kaczor C. Impact of a pharmacy student–driven medication delivery service at hospital discharge. Am J Health Syst Pharm. 2017;74(5 Supplement 1):S24-S29. https://doi.org/10.2146/ajhp150613
32. Khalil V, deClifford JM, Lam S, Subramaniam A. Implementation and evaluation of a collaborative clinical pharmacist’s medications reconciliation and charting service for admitted medical inpatients in a metropolitan hospital. J Clin Pharm Ther. 2016;41(6):662-666. https://doi.org/10.1111/jcpt.12442
33. Grimes T, Delaney T, Duggan C, Kelly JG, Graham IM. Survey of medication documentation at hospital discharge: Implications for patient safety and continuity of care. Ir J Med Sci. 2008;177(2):93-97. https://doi.org/10.1007/s11845-008-0142-2
34. Cesarz J, Steffenhagen A, J S, Hamedani A. Emergency Department Discharge Prescription Interventions by Emergency Medicine Pharmacists. Ann Emerg Med. 2013;61(2):209-214. https://doi.org/10.1016/j.annemergmed.2012.04.011
35. Walker PC, Bernstein SJ, Tucker Jones JN, Piersma J, Kim H-W, Regal RE, Kuhn L, Flanders SA. Impact of a pharmacist-facilitated hospital discharge program: A quasi-experimental study. Arch Intern Med. 2009;169(21):2003-2010. https://doi.org/10.1001/archinternmed.2009.398
36. Kwan JL, Lo L, Sampson M, Shojania KG. Medication reconciliation during transitions of care as a patient safety strategy: A systematic review. Ann Intern Med. 2013;158(5 Pt 2):397-403. https://doi.org/10.7326/0003-4819-158-5-201303051-00006
37. García-Molina Sáez C, Urbieta Sanz E, Madrigal De Torres M, Vicente Vera T, Pérez Cárceles MD. Computerized pharmaceutical intervention to reduce reconciliation errors at hospital discharge in Spain: An interrupted time-series study. J Clin Pharm Ther. 2016;41(2):203-208. https://doi.org/10.1111/jcpt.12365
38. Barr R, Chin KY, Yeong K. Improving patient discharge process using electronic medication input tool and on-line guide to arranging follow-ups. BMJ Qual Improv Rep. 2013 Sep 17;2(1): u756.w711. https://doi.org/10.1136/bmjquality.u756.w711
39. Brooke Myers, Charles Mitchell, Jenny A. Whitty, Peter Donovan IC. Prescribing and medication communication on the post-take ward round. Intern Med J. 2017;47(4):454-457. https://doi.org/10.1111/imj.13280
40. Marvin V, Kuo S, Poots AJ, Woodcock T, Vaughan L, Bell D. Applying quality improvement methods to address gaps in medicines reconciliation at transfers of care from an acute UK hospital. BMJ Open. 2016;6(6):e010230. https://doi.org/10.1136/bmjopen-2015-010230

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