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Polypharmacy in the emergency department (ED) presents additional challenges for older adults with acute illnesses but is also an opportunity for healthcare providers to prevent adverse drug events as well as the use of potentially inappropriate medications. Older patients have complex health-related needs and are at risk for medication-related complications during an ED visit. Implementing mitigating strategies of performing medication reconciliation and review, using existing implicit or explicit tools to evaluate medications, and deprescribing or de-escalating high-risk medications are critical to positive health outcomes. These practices can help to optimize pharmacologic interventions for older patients in the ED.

The concept of integrating a clinical pharmacist (CP) within a Hospital-in-the-Home (HiTH) program is relatively new. Little is known about the role of a pharmacist in HiTH programs focused on mental health (MH).To describe the role of a CP within an MH-HiTH program, focusing on the specific tasks performed by a pharmacist in this position, their benefits and limitations.MEDLINE, CINAHL, EMBASE, Cochrane Database of Systematic Reviews, PsycINFO, Web of Science and the grey literature were searched without any date limits for references in English that included 2 or more of the following key terms (or their synonyms): "HiTH", "clinical pharmacist" and "mental health". Two reviewers independently screened and analysed the data.Of 60,482 screened references, 6 included all 3 key terms: 2 were HiTH guideline documents, 2 were conference abstracts and 2 were journal articles. These papers discussed MH-HiTH programs or similar home-care services where a CP was incorporated in the treating team to address medication management and adherence during a home visit. There is evidence that MH-HiTH CPs identify and resolve medication-related problems (MRPs), as well as improve medication adherence, patient care, hospital admission rates and emergency department presentations. An additional 54 references including 2 key terms provided corroborating evidence of an MH-HiTH CP role focused on improving patient care via 4 key groups of tasks: clinical pharmacy, mental healthcare, home medicines review and facilitation of care transition through medication reconciliation and follow-up.Although there is currently a paucity of literature describing the incorporation of a CP in an MH-HiTH program, preliminary evidence shows it can improve medication management. This has potential to improve patient outcomes as has been seen in similar home-based settings, but limitations such as time constraints are notable barriers. More robust studies are needed to evaluate these outcomes.

Background In the strained actual economic context, all clinical pharmacy activities cannot be achieved for all patients of all care pathways. So finding a way to prioritize moments and patients needing those activities is essential. This is the challenge of the “5P project” (Patient personalized clinical pharmacy program integrated into care pathway). Objective To present adverse event (AE) risk management approach applied to develop clinical pharmacy programs integrated into care pathway, using two methods. Method Used as a priori AE risk management approach, the Delphi method and inductive approach analysis of semi-directed interviews were realized from April 1st to October 3rd, 2019, respectively in orthogeriatric (OG) and pediatric kidney transplantation (PKT) care pathways. Complementarily to bibliographic research, participants were medical and paramedical healthcare providers involved in the concerned care pathway. They have been interrogated regarding AE risks to identify the clinical pharmacy activities required, the patients who need them, and the appropriate steps of the care pathway. Results The Delphi method for OG care pathway has revealed: 1/. Patients were prioritized by the presence of at least 2 among the following 4 criteria: age ≥90 years old, cardiovascular diseases, prescribed potentially inappropriate medication for elderly patients, obesity or diabetes; priority steps were the post-operative and rehabilitation care steps. 2/. Prescription reviews, medication reconciliation and targeted pharmaceutical informative interview about oral anticoagulants were required. Nine semi-directed interviews used for PKT care pathway has revealed: 1/. Clinical pharmacy activities were carried out for all patients. Priority steps were pre-transplantation, immediate post-operative, and post-transplantation. 2/. Prescription reviews and educative interviews were required. Conclusions The two presented methods can be used to both develop patient prioritization and targeting steps for clinical pharmacy activities, and integrate it into care pathway. Today, those two developed programs have been executed in our teaching hospital.

Background Transitions of care (TOC) issues contribute to approximately 76% of preventable hospital readmissions. Centers for Medicare and Medicaid Services (CMS) focus on improvement of quality of care through TOC services. Studies have not used both implementation science and patient input to develop a TOC program that fulfills CMS criteria and satisfies patients’ reported needs. Objectives The study objectives were to I) develop the TOC program in alignment with CMS criteria, identifying and remedying barriers during the process, and II) conduct a needs assessment and obtain patient perspectives on TOC service. Methods The implementation science approach was chosen to refine the TOC service at one university medical center ambulatory care clinic. Barriers within the TOC program that prevented CMS criteria from being followed were identified on site during patient care. Changes were implemented in a timely manner by the pharmacy resident and TOC team. A prospective nine-item open-answer survey was administered to patients discharged less than 90 days from inpatient care. Data was collected, categorized, and presented to the TOC team for incorporation into the TOC service. Results Barriers and gaps in care were identified in the sample of 19 patients undergoing service from November 2019 to January 2020. CMS criteria and established TOC protocol had not been fulfilled for all patients. Eight barriers were revealed throughout the TOC process. Solutions were implemented through an in-service, monthly reminders, and communication to staff from the resident pharmacist. Patient responses (n = 22) to the needs assessment indicated a desire for enhanced TOC education (discharge medications and therapy). Conclusions Through implementation science, the TOC program was adapted to fulfill CMS criteria and TOC protocol. The needs assessment highlighted desired changes by TOC patients. Long-term outcomes will need to be studied to determine if the implemented changes at this site are sustainable.

Involvement of pharmacists and trainees in care transitions reduces medication-related problems. Participation in the transitions-of-care (TOC) process may impact self-perceived growth of autonomy within selected entrustable professional activities (EPAs).A student-driven TOC documentation process was implemented within an inpatient family medicine advanced pharmacy practice experience. During the month-long rotation, students rounded with an interdisciplinary care team. Responsibilities included ensuring accurate medication reconciliation at care transitions throughout hospitalization and prior to discharge as well as medication optimization during hospitalization. Another responsibility was completing a medication-specific TOC note in the clinic-based electronic health record at discharge for patients receiving primary care from the associated clinic. The note was available to the outpatient interdisciplinary care team during the hospital follow-up appointment. Student-perceived growth in autonomy within selected EPAs was determined through an online anonymous survey.Ninety percent (n = 18) of eligible students completed the survey. For specific EPA statements (collecting information, establishing patient-centered goals and establishing a care plan, implementing a care plan, collaborating as an interdisciplinary team member, and ensuring immunization), student-perceived autonomy increased after involvement in this student-driven TOC process. During the study period, 215 notes were generated by student pharmacists and included interventions/recommendations within the following themes: evidence-based changes in therapy, patient counseling, and medication access.The importance of pharmacist and pharmacy trainee involvement in the TOC process has been well-documented. Involving students in student-driven TOC documentation processes serves to facilitate student-perceived growth in autonomy within selected EPAs.

Ensuring medication accuracy during transitions in care is one of the five highly prevalent patient safety problems focused on within the World Health Organization High 5s Project. Medication reconciliation is a standardized patient care process that can be used to address this problem. The aim of the current study is to implement medication reconciliation in a German university hospital.The study was conducted at the Emergency Department of the University Hospital Aachen, Germany. All discrepancies between the Best Possible Medication History and the Admission Medication Order were documented and classified as documentation errors or medication errors. The type of error was also recorded. A negative binomial regression model was used to test several factors influencing the number of discrepancies.The medications of 105 patients were reconciled. The mean number of discrepancies per patient was 4.6± 3.6, with a total of 298 medication errors and 189 documentation errors. The most common type of medication error was the omission of a drug (n=208; 69.8 %). In the negative binomial regression analysis, the care status (p=0.0015) as well as the number of preadmission drugs (p=0.0007) were significantly associated with medication errors.A high number of discrepancies was detected and analysed. Patients admitted from nursing homes were less likely to have discrepancies in their medication reconciliation, perhaps because a structured documentation system for medications is already in place at nursing homes including error prone products (special dosage forms or food supplements).In this study, medication reconciliation was implemented at a German full-care university hospital. The actual number of discrepancies observed strongly indicates the need for medication reconciliation at hospital admission.

The "Structured HIstory of Medication use" (SHIM) questionnaire is a tool developed to obtain an accurate pre-admission overview of medications, involving a structured interview with patients, and has demonstrated its potential to prevent reconciliation errors. The objective of this study was to cross-culturally adapt the SHIM questionnaire to Spanish.Forward and blind-back translations followed by a synthesis and adaptation, with the participation of an expert panel, to guarantee the equivalence between the original questionnaire and the Spanish version. Subsequently, pilot testing of the Spanish version was carried out through cognitive interviews in a sample of polymedicated patients under follow-up by the Department of Internal Medicine.The Spanish version of the SHIM questionnaire (SHIM-e) was obtained. Scores for difficulty assigned by translators involved in forward and back translations were low. During the synthesis and adaptation phase, three discrepancies were resolved, and the expert panel decided to include some terms commonly used for clinical interviews in the Spanish version of the questionnaire. The pilot testing, which was performed in a sample of 10 polymedicated patients admitted to the Department of General and Digestive Surgery, showed 100% comprehensibility for all items, except for number 13, which was 90%.This work presents the first cross-cultural adaptation to Spanish of the SHIM questionnaire. The forward and blind-back translations presented low difficulty and the results of the pilot testing showed a high level of comprehensibility for the Spanish version of this tool.

Background Antiseizure medications are commonly associated with adverse effects including behavioral and cognitive issues, drug interactions, idiosyncratic reactions, and long-term complications, which can lead to non-adherence. At the same time, there are limited reports describing multidisciplinary models of epilepsy care that include pharmacists. Objective To describe the pharmacist services in an epilepsy clinic for older adults and document the patient care delivered using this design. Practice Description A subspecialty older adult epilepsy clinic, embedded within a neurology clinic, in an urban academic medical center. Practice Innovation Integration of pharmacy services to document medication history, provide medication reconciliation, identify medication-related problems, and make interventions. Evaluation Methods Data were retrospectively evaluated for the patients seen by the pharmacist and epilepsy team between July 2019 and January 2021. Data were summarized with descriptive statistics. Results Fifty-eight patients with a total of 94 encounters (70.7% of all specialty clinic visits) were seen collaboratively by the physician and the pharmacist. The majority of patients were African American (87.9%), aged 63.7 ± 8.2 years, and more frequently male (58.6%), and a high proportion had some baseline memory loss or diagnosis of dementia (53.4%). Medication reconciliation occurred in 94 (100%) encounters. More than half the encounters required reconciliation to the existing medication list by adding medication (55.3 % of encounters) or deleting mediations (53.2% of encounters). Presence of adverse effects was the most common medication-related problem identified (23.4%). Resolutions to the medication-related problems were also reported. Conclusion The population of older adults with epilepsy is expected to increase in prevalence. Pharmacists are able to impact medication-related problems in a vulnerable, high-risk patient population. The multidisciplinary model we describe here can be used as a template to provide care in ambulatory care practices involving other neurology specialties with a high proportion of older adult patients.

Resume Objectifs L’erreur medicamenteuse peut etre prevenue par des actions de pharmacie clinique telle que la conciliation medicamenteuse. L’objectif principal de cette etude etait d’evaluer l’activite de conciliation medicamenteuse apres deux ans de pratique en service de chirurgie orthopedique. L’objectif secondaire etait de mesurer la satisfaction de l’equipe medicale et soignante. Methodes Il s’agit d’une etude retrospective des conciliations medicamenteuses d’entree realisees sur deux ans dans un service de chirurgie orthopedique. Les patients eligibles a cette activite etaient les patients âges d’au moins 65 ans, entrant par le service des urgences. Apres avoir etabli le bilan medicamenteux, les divergences etaient caracterisees en intentionnelles ou non intentionnelles. Les donnees ont ete traitees a l’aide des logiciels Excel et SPSS statistics®. Resultats Au total, 899 patients ont ete concilies. L’âge moyen etait de 78 ans (27 ; 104). 84 % des patients etaient entres par les urgences. Un total de 75 % de la population avait au moins une divergence non intentionnelle, avec en moyenne 2,3 divergences non intentionnelles par patient. Les classes medicamenteuses « cardiovasculaires » et « voies metaboliques et digestives » etaient les plus concernees. Un total de 75 % des divergences non intentionnelles ont ete prises en compte et corrigees. L’equipe medicale et soignante etait globalement satisfaite. Conclusions La conciliation medicamenteuse a permis de securiser la prise en charge medicamenteuse des patients.

Background Hospital stays are often associated with medication changes, which may lead to drug-related problems (DRPs). Medication reconciliation and medication reviews are strategies to detect and resolve DRPs. Methods A descriptive cohort study was conducted using DRPs collected during routine pharmacist-led medication reconciliation and medication reviews in the hospital's community pharmacy at discharge (Zug Cantonal Hospital, Switzerland). In a simulation experiment, we retrospectively analysed the detection and resolution possibilities of these DRPs and their dependency on different information sources. Results Overall, 6,087 prescriptions were filled in the hospital's community pharmacy (between June 2016 and May 2019). Among 1,352 prescriptions (with ≥ 1 documented DRP) a total of 1,876 DRPs were detected. The retrospective assessment showed that 1,115 DRPs could have been detected by performing simple medication reviews (based on the discharge prescription and the medication history), whereas in the remaining cases, additional clinical and/or patient-specific information would have been needed. In 944 (84.7 %) DRPs, which are detectable by simple medication reviews, the pharmacist would need to consult the prescriber for resolution. Conclusion The detection of DRPs is strongly influenced by the information available. These results support models with pre-discharge medication reconciliation and pharmacist-led medication review procedures enabling both comprehensive detection and facilitated resolution of DRPs.

The quality of comprehensive geriatric assessment and medication reconciliation by a nurse practitioner (NP) based in Japan was evaluated by a prospective observational study. Within the 64 inpatients seen by the NP at a postacute care clinic, the achievement rate of 8 comprehensive geriatric assessment items was 93.8%, compared with just 33.8% in the nearby hospital (P

Discharge counseling by pharmacists reduces adverse medication events, emergency department visits, and readmissions. Studies indicate that pharmacy students in advanced pharmacy practice experiences (APPE) can deliver effective medication-related activities. An open label randomized controlled trial was conducted in adults discharged on warfarin, insulin, or both. Pharmacy students performed medication reconciliation, structured medication counseling, and follow-up calls 72-hours post-discharge. The usual care arm received traditional education. The primary outcome was the 30-day readmission rate post-discharge. Ninety-eight patients on high-risk medications were randomized to intervention (n = 51) or usual care (n = 47). The 30-day hospital readmission rate was lower in the intervention group (8/51, 15% vs. 11/47, 23%); (p = 0.48). There was no statistical difference in the time to first unplanned health care use (hazard ratio = 0.49 (95 %CI, 0.19–1.24), or the time-to-first clinic visit post-discharge (p = 0.94) between the two arms. Students identified 26 drug-related problems during reconciliation. Patients in the intervention arm reported high satisfaction with the service (mean 3.94; SD 0.11). Involving APPE students in the transition of care activities presents an excellent opportunity to minimize pharmacists' workload while maintaining patient care services.

Background Published data on pharmacist-provided chronic care management (CCM) services is limited, particularly for programs led by community-based pharmacists. Objective The objective was to quantify the total revenue generated from a community pharmacist-led CCM service, including CCM billing and appointment referrals. A second objective was to identify the types and frequencies of medication discrepancies identified during medication reconciliation. Practice description Realo Drugs is a group of 18 independent community pharmacies serving eastern North Carolina. Practice innovation Exploration of revenue generated from a community pharmacist-led CCM service. Evaluation methods This retrospective analysis assessed interventions completed by pharmacists between April 1, 2018 through June 30, 2019. Data was extracted from the electronic health record (EHR), including revenue generated from CCM billing codes, appointment referrals made by the pharmacist resulting in a completed in-office appointment, and which patients received medication reconciliation. The types and frequencies of medication discrepancies were documented, including medication no longer being used by the patient, medication omission, and strength or dose mismatch. Descriptive statistics were used to analyze data. Results Over 15 months with a total of 112 patients, a total of $26,148 was generated from CCM services, representing an average of $15.56 per patient per month. The majority (approximately 80%) of the revenue was generated from noncomplex patient encounters. Of the 239 medication reconciliations completed, 609 medication discrepancies were identified. The majority of medication discrepancies (67%) were categorized as “patient no longer takes medication listed on EHR medication list.” The second most common discrepancy was “patient takes medication not listed on the EHR medication list” (22%), followed by “strength/dose mismatch” (10%). Conclusion These data can demonstrate to provider partners the sources of revenue that can be provided through CCM services. In addition to revenue, pharmacists can positively impact patient care through identification of medication discrepancies through medication reconciliation.

Background Patients who take aspirin and sustain traumatic intracranial hemorrhage (tICH) are often transfused platelets in an effort to prevent bleeding progression. The efficacy of platelet transfusion is questionable, however, and some medical societies recommend that platelet reactivity testing (PRT) should guide transfusion decisions. The study hypothesis was that utilization of PRT to guide platelet transfusion for tICH patients suspected of taking aspirin would safely identify patients who did not require platelet transfusion. Methods This was a retrospective study of patients with blunt tICH who received PRT for known or suspected aspirin use between June 2014 and December 2017 at a level I trauma center. Chart abstraction was conducted to determine home aspirin status, and PRT values were used to classify patients as therapeutic or nontherapeutic on aspirin. Differences were assessed with Kruskal-Wallis and chi-square tests. Results 157 patients met study inclusion criteria, and 118 (75%) patients had documented prior aspirin use. PRT results were available approximately 1.7 h (IQR: 0.9, 3.2) after arrival. Upon initial PRT, 70% of patients were considered inhibited and 88% of those patients had aspirin documented as a home medication. Conversely, 18% of patients with home aspirin use had normal platelet reactivity. Clinically significant worsening of the tICH did not significantly differ when comparing those who received platelet transfusion with those who did not (8% versus 7%, P = 0.87). Conclusions Platelet reactivity testing can detect platelet inhibition related to aspirin and should guide transfusion decisions for head injured patients in the initial hours after trauma.

Background Pharmacists have reduced 30-day hospital readmissions when involved with transitions of care (TOC). The impact of student pharmacists on readmissions is more limited. Objective The goal of this study was to describe student pharmacists' role in a new TOC service and determine their impact on 30-day hospital readmissions. Methods We designed a 3-step TOC service spanning inpatient, discharge, and follow-up led by student pharmacists and involving both inpatient and ambulatory care pharmacy preceptors. The student pharmacists followed inpatient care and discussed medications with the patients. Discharge orders were reviewed, and the student pharmacists provided discharge education. On discharge, the student pharmacists wrote a handoff to the ambulatory care pharmacist describing inpatient care, discharge medication list, follow-up, and unresolved medication issues. Finally, the student pharmacists participated in the outpatient follow-up at the primary care provider office with the provider and an ambulatory care pharmacist. Readmissions were compared between this process and a standard-of-care historical control group using chi-square analysis. Results The student pharmacist-led TOC service reduced 30-day hospital readmissions by 13.1% (P = 0.018) compared with standard of care. Conclusion Student pharmacists are effective members of the health care team in reducing readmissions. Student pharmacists are cost-effective, appropriately trained, and well positioned to assist with these services.

An estimated 20% of patients experience a postdischarge adverse event in the 30 days after hospital discharge, with approximately two-thirds of these events considered preventable or ameliorable. Numerous transitional care interventions have been developed and implemented by clinical pharmacists to reduce postdischarge adverse drug events and readmissions; however, most efforts are focused on the admission and discharge process. Low-quality evidence and mixed results from evaluations of postdischarge interventions have left health care organizations unsure which interventions provide the greatest value and how to optimize their implementation. Comprehensive medication management (CMM) is an approach, usually delivered by a pharmacist in collaboration with the health care team, which aims to standardize the wide variability in medication-specific pharmacist-led services to optimize medication use and improve clinical outcomes. This article aims to discuss how CMM can be used to cultivate best practices in care transitions.

Delirium is common in older emergency department (ED) patients. Although associated with significant morbidity and mortality, it often goes unrecognized. A consistent approach to evaluation of mental status, including use of validated tools, is key to diagnosing delirium. Identification of the precipitating event requires thorough evaluation, including detailed history, medication reconciliation, physical examination, and medical work-up, for causes of delirium. Management is aimed at identifying and treating the underlying cause. Meaningful improvements in delirium care can be achieved when prevention, identification, and management of older delirious ED patients is integrated by physicians and corresponding frameworks implemented at the health system level.

Introduction Despite widespread implementation of the electronic health record (EHR) in practice, the EHR curriculum in pharmacy schools is slow to emerge. This study used a single assessment tool to evaluate pharmacy students' perceived readiness to use an EHR after completion of two different curricula. Methods Pharmacy students at the University of Nebraska Medical Center (UNMC) and the University of California San Diego (UCSD) pharmacy schools voluntarily participated. A 14-item survey was administered asking students to rate their comfort on several different EHR skills. Baseline data on non-academic EHR exposure was also collected. Results Seventy students at UNMC and 69 students at UCSD participated in the survey (27.2% and 28.5% response rate, respectively). Gender and academic year were similar between institutions. Overall, students were more comfortable finding information compared to entering new information in the EHR. Students were most comfortable reviewing laboratory information, progress notes, and medication lists and less comfortable performing medication reconciliation and identifying clinical errors. There were no differences between institutions for overall comfort. Students with at least one month of extracurricular EHR experience rated themselves as more comfortable, but not all of those differences were statistically significant. Conclusions This study demonstrated that two different EHR curricula in two different pharmacy schools can result in similar student confidence. The information and assessment tool from this study can be a helpful starting point for other schools to determine student preparedness to work with the EHR as well as provide information to inform EHR curricula design and assessment.

Resumen: Introducción: Los errores de conciliación, o discrepancias no justificadas (DNJ), son frecuentes durante la admisión a hospitalización de los pacientes pediátricos crónicos y tienen impacto en la seguridad. Las intervenciones educativas podrían ser una estrategia para su reducción. Pacientes y métodos: Estudio cuasiexperimental, diseño antes-después en pacientes crónicos pediátricos. Se realizó en una primera etapa, la conciliación de los medicamentos prescritos tras la admisión hospitalaria, y se calculó la frecuencia de pacientes con al menos una DNJ. La intervención educativa consistió en una formación a cada médico con los conceptos de conciliación de la medicación, los resultados de la primera etapa y una infografía que se distribuyó en las áreas de prescripción. En una segunda etapa, se procedió de la misma forma que en la primera etapa. Para estudiar la asociación entre la intervención y el cambio en la frecuencia de DNJ se realizó un modelo de regresión logística, ajustando por covariables. Se utilizó un nivel de significación del 5%. Resultados: Se estudió una muestra de 54 pacientes en cada etapa. En la primera, un 42,6% de los pacientes presentó al menos una DNJ. Tras la intervención la proporción se redujo a un 24,1% (p = 0,041). En ambas etapas la omisión fue la principal categoría de DNJ. La reducción significativa tras la intervención se mantuvo al controlar por variables como ingreso por urgencia y servicio de preadmisión. Conclusiones: La frecuencia de DNJ en la admisión es alta en pacientes crónicos hospitalizados y puede ser reducida mediante una estrategia educativa. Abstract: Background: Medication reconciliation errors, also known as unintentional discrepancies, are frequent during admission, especially in chronic patients, and have an impact on safety. Educational interventions can be a reduction strategy. Material and methods: Quasi-experimental study, before-after design. Participants were chronic patients admitted into hospitalization services. Medication reconciliation was conducted at admission. The intervention consisted of a training to each prescribing physician with study contents and printed educational material. To study the association between intervention and change of frequency of unintentional discrepancies was made a logistic regression model, adjusting for selected variables. Results: A sample of 54 patients was studied in each stage. In the first stage it was observed that 42.6% of patients had at least one unintentional discrepancy. After intervention the proportion of patients with at least one unintentional discrepancy decreased to 24.1% (p = 0.041). In both stages, omission was the main category of unintentional discrepancy. The significant reduction after the intervention is maintained by controlling for variables such as emergency admission and pre-admission service. Conclusions: Incidence of unintentional discrepancies in admission is high in chronic hospitalized patients and can be reduced through an educative strategy.

Over the next several decades, rates of aged populations will increase rapidly. These populations are susceptible to multimorbidities and polypharmacy (concurrently, prescribed 5 or more medications). Many medications have side effects that manifest orally. Therefore, it essential to possess current pharmacologic knowledge to diagnose and treat oral implications of commonly prescribed medications. This article details common medication-induced oral lesions and patient assessment of risk factors for polypharmacy and provides a template to integrate medication reconciliation into dental clinical practice.

Objective To investigate the impact of medication reviews using collegial mentoring and systematic clinical evaluation on psychotropic prescriptions, behavioral and psychological symptoms of dementia (BPSD), and activities of daily living (ADL). Design Four-month multicenter, multicomponent, cluster-randomized, single-blinded controlled trial. Setting Thirty-three Norwegian nursing homes including 67 nursing home wards (clusters). Participants A total of 723 enrolled patients, of which 428 participated in the study; 217 were randomized to the intervention and 211 to care as usual (control). Intervention The COSMOS intervention consisted of Communication, Systematic pain management, Medication reviews, Organization of activities, and Safety. During medication review, the nursing home physician evaluated treatment with colleagues systematically using the results from validated clinical assessments. Measurements Mean changes from baseline to month 4 in the number of prescribed psychotropic drugs (antipsychotics, anxiolytics, hypnotics or sedatives, antidepressants, and antidementia drugs); Neuropsychiatric Inventory Nursing Home Version (NPI-NH) and Cornell Scale of Depression in Dementia (CSDD); Lawton and Brody's Physical Self Maintenance Scale (PSMS). Results Compared to control, the mean change in prescribed psychotropic drugs was reduced both in total and regular number, while mean changes in NPI-NH and CSDD scores did not differ between the groups. Mean change in PSMS showed improvement in the intervention group, and deterioration in the control group. Conclusion Medication reviews using collegial mentoring and systematic clinical evaluation led to safe deprescribing, as the reductions in psychotropic drug use did not negatively affect BPSD, while ADL improved.

Introduction A substantial proportion of hospital admissions and readmissions are directly attributable to preventable medication-related harm. Interventions that reduce these harms could avert significant suffering and healthcare costs. Objectives The Discharge Medications Reconciliation (DCMedsRec) trial will evaluate a structured medication reconciliation service by community pharmacists post hospital discharge on the risk of 30-day unplanned readmission. Electronic access to the Hospital Discharge Summary via My Health Record will underpin this service. Methods DCMedsRec is a non-blinded randomised controlled trial of an intervention by community pharmacists within 30 days of hospital discharge in Melbourne, Australia. Patients discharged from hospital will be assessed by a hospital pharmacist for trial eligibility. If eligible, patients will be randomised to either a control or intervention group by sequentially marked sealed envelopes. Intervention patients receive an invitation to the DCMedsRec service at a participating community pharmacy, who will be reimbursed. Control patients will receive usual care. A Number Needed to Treat of 20 will require 293 DCMedsRec interventions to achieve 80% power. With a predicted 30% uptake, a minimum sample of 977 in the intervention arm is required. Outcomes The primary outcome will be the rate of 30-day unplanned hospital readmission in intervention (DCMedsRec) versus usual care groups. Secondary analyses will evaluate the economic impact of the intervention and a qualitative thematic analysis of the experience and value of the service for both patients and service providers (community pharmacists). Analysis An intention-to-treat analysis will be used to assess intervention efficacy and results will be reported using risk ratios with 95% confidence intervals. Cost-effectiveness analysis will compare within-trial costs and outcomes of the DCMedsRec versus usual care from a health-system perspective. Trial registration and funding This trial is registered with the Australian and New Zealand Clinical Trials Register and funded by the Australian Digital Health Agency.

Background In older medical patients polypharmacy is often associated with poor prescription appropriateness and harmful drug-drug interactions. An effort that jointly involved hospital pharmacists and clinicians attending multimorbid older patients acutely admitted to medical wards was implemented for medication recognition and reconciliation aided by the use of a computerized support system. Methods Six internal medicine wards enrolled consecutively 90 acutely admitted multimorbid patients aged 75 years or more taking 5 or more different drugs. Two hospital pharmacists carried out the recognition of medications taken at hospital ward admission, and interacted with the clinicians in a process of drug reconciliation, using also the computerized support system to evaluate drug related problems, prescription inappropriateness or drug-drug interactions. The process was repeated at hospital discharge. Results Among a total number of 911 drugs prescribed to 90 older medical patients at ward admission, the pharmacists identified during their recognition/reconciliation 455 drug-related problems, mainly due to prescription of medications inappropriate for older multimorbid patients and clinically harmful drug-drug interactions. When these drug-related problems were identified by the pharmacist, the attending clinicians accepted and implemented the suggestions for changes for approximately two thirds of the discrepancies, thereby leading to deprescribing the implicated drugs or at least to their closer monitoring. Conclusions This interventional prospective study based upon the integrated expertise of hospital pharmacists and clinicians confirms that drug-related problems are frequent in multimorbid older patients acutely admitted to hospital medical wards, and demonstrates afresh the feasibility and mutual acceptance of a trajectory of recognition/reconciliation based upon an integrated collaboration between hospital pharmacists and ward clinicians in the process of medication optimization.

Medications to treat disease and extend life in our patients often amass in quantities, resulting in what has been termed "polypharmacy." This imprecise label usually describes the accumulation of 5, and often more, medications. Polypharmacy in advancing age frequently results in drug therapy problems related to interactions, drug toxicity, falls with injury, delirium, and nonadherence. Polypharmacy is associated with resulting increased hospitalizations and higher costs of care for individuals and health care systems. To reduce polypharmacy, we delineate a systematic, consultative approach to identify highest-risk medications and drug-therapy problems. We address strategic reductions (deprescribing) of medications in palliative care, long-term care, and ambulatory older adults. Best practices for reducing opioids, benzodiazepines, and other high-risk medications include education about risk and agreement by patients and their families, advocates, and care teams. Addressing deprescribing should be within the framework of patients' health status as their care and goals transition from longevity to a plan of maintaining alertness, comfort, and satisfaction of quality of life. A team approach to address polypharmacy and avoidance of high-risk therapy is optimal within long-term care. Patients with terminal illnesses or those moving toward a comfort-care emphasis benefit from medication adjustments that are recognized beneficially within each patient's care goals. In caring for older adults, the acknowledgement that complicated regimens and high-risk medications requires a care plan to reduce or prevent medication-related problems and costs that are associated with polypharmacy.

The objective of this quality improvement project was to design and implement a systematic team-based care approach to medication reconciliation, with a goal of physician-documented medication reconciliation at 70% of all patient office visits.Ambulatory clinics located in urban, underserved communities in Minneapolis and St. Paul, MN.Four family medicine residency clinics, with pharmacists integrated at each site. All clinics use the Epic electronic medical record (Epic Systems Corporation).A team-based care approach to medication reconciliation was designed and implemented involving medical assistants (MAs), physicians, and pharmacists. The MAs did an initial review with patients, the physicians addressed discrepancies, and difficult situations were escalated to the pharmacist for a detailed assessment.The percentage of visits with physician-documented medication reconciliation was measured preintervention and then for 18 months postintervention in 6-month intervals involving more than 118,000 patient visits. Satisfaction surveys of team members were done pre- and postintervention.The percentage of visits with physician-documented medication reconciliation improved significantly from 6.5% preintervention to 58.7% (P0.001) postintervention, and was sustained and further improved to 70.3% (P0.001) 1 year later. The team members had a statistically significant improvement in their ability to articulate the medication reconciliation process. Satisfaction improved significantly for physicians, but MAs did not experience a statistically significant change.A team-based care approach to medication reconciliation was successfully implemented and sustained at 4 family medicine clinics. There was significant improvement in physician-documented medication reconciliation. Future studies need to address whether this process improves medication-list discrepancies, completeness, and accuracy.

Background Medication plans are instruments used to document drug therapies, guide patients, and ensure medication safety. In Germany, patients who take at least 3 long-term medications are eligible to receive a medication plan. It has been statutory to use the federal standard layout (German: “Bundeseinheitlicher Medikationsplan”) since April 2017. Objectives This study explores the prevalence, availability, medication discrepancies, and conformance with statutory regulations of medication plans since the introduction of the format of the federal standard medication plan in Germany. Methods Medication reconciliation was performed for hospitalized patients according to the Best Possible Medication History principle. The collected medication lists were analyzed for medication discrepancies and conformance with the statutory regulations. The medication discrepancies were (1) omitted drugs, (2) additional drugs, and (3) dosing errors. Results After hospitalization, 524 patients taking drugs were included. The majority (n = 424 patients) were eligible for a medication plan. While 241 medication lists were present, only 24.1% (n = 58) matched the federal standard format. The mean number of drugs was 6.3 ± 3.6, with 3315 medications (3046 long-term and 269 as needed) reconciled totally. The 84 medication lists with omitted or additional drugs included 166 medication discrepancies upon 774 drugs listed. Of the 253 patients with dosing errors, 146 had a medication list. Inappropriate dosages were due to single dose (n = 195), daily dose (n = 225) or frequency of application (n = 255). Conclusion Medication plans are valuable tools for patients and health care providers. This study shows that the introduced paper-based federal standard medication plan in Germany falls short of its expectations regarding availability and correctness. Switching to an electronic patient record system may overcome some of the current pitfalls.

Background The impact of medication reconciliation (MR) in low-middle-income countries, including Thailand, may differ from other developed countries. Objective To evaluate the effect of medication reconciliation (MR) on the reduction of medication error in Thailand. Methods A systematic search was conducted in the following databases: PubMed, CENTRAL, CINAHL, Scopus, Thai Journals Online, Thai index Medicus, Thai Medical Index, and Health Science Journal in Thailand from inception to January 2018. Studies that evaluated the effect of MR compared to usual care within hospitals in Thailand and reported the occurrence of medication error were included. Meta-analyses were performed using random-effects model. Results Of the 107 articles retrieved, 7 articles involving 1581 patients were included in quantitative synthesis. Three of the included studies were randomized controlled trials (RCT). Overall, the risk of medication error in patients who received MR in all transitions of care was 75% lower than those receiving usual care (RR 0.25; 95%CI 0.15–0.43). The effect on the reduction of medication error appeared higher when MR was provided to ambulatory patients (RR 0.17 [95%CI 0.04–0.80] compared with hospitalized patients during admission (RR 0.37 [95%CI 0.20–0.65]) and discharge (RR 0.27 [95%CI 0.17–0.43]). Effects on reducing medication error was greater when MR was provided in secondary care hospitals compared with primary care hospitals both during admission (RR 0.49 [95%CI, 0.34–0.69] vs RR 0.25 [95%CI, 0.05–1.26]), and discharge transition (RR 0.19 [95%CI, 0.09–0.39] vs RR 0.30 [95%CI, 0.12–0.79]). Conclusion Overall, current evidence indicates that the provision of MR in Thailand is effective in reducing medication errors in all transitions of care. However, to promote patient safety, appropriate strategies should be developed to support MR in specific transition of care and hospital setting so patients can benefit most from this service.

The objectives of this study were to assess 30- and 60-day hospitalizations and to determine the number of medication therapy problems (MTPs) identified during pharmacy technician-driven medication reconciliation for high- to very high-risk home health patients.The study was conducted in 8 independent community pharmacy locations.Realo Discount Drugs is a group of 16 independent community pharmacies serving eastern North Carolina.Realo Discount Drugs partnered with Well Care Home Health to provide medication reconciliation services to high- and very high-risk patients. A pharmacy technician contacts the patient to obtain an accurate medication list and complete a falls risk assessment and depression screening. The technician updates the medication list, allergies, and vaccination status in the electronic health record (EHR). The pharmacist reviews the medication list for completeness; assesses for falls risk, depression, and medication interactions; and generates communication to the provider for clarifications or recommendations, if needed. Additional counseling points that need to be conveyed to the patient by the home health nurse are documented in the EHR.Thirty- and 60-day hospitalizations for enrolled patients were manually pulled from documented transfers in the EHR and compared with data from a third-party administrator. MTPs were categorized by the pharmacist and documented. Descriptive statistics were used to evaluate the data collected.At 30 days from the start of care, 13.4% (93/695) of patients who received pharmacy services were hospitalized compared with 26.8% (143/534) of patients who did not receive pharmacy services (P0.01). At 60 days from the start of care, 20.9% (145/695) of patients who received pharmacy services were hospitalized compared with 33.3% (178/534) of patients who did not receive pharmacy services (P0.01).A technician-driven medication reconciliation process led to a reduction in hospitalizations and identified MTPs in home health patients.

This study aimed to evaluate the impact of a pharmacist-led postsurgical discharge medication reconciliation program in an accountable care organization-like setting.Multidisciplinary primary care network in Central Ohio.Ambulatory care pharmacists are integrated in a primary care network, which includes a centralized focus on assistance with population health metrics, along with an interdisciplinary team.In May 2018, a pharmacist-led medication reconciliation postdischarge (MRP) program was initiated focused on a postsurgical discharge population.A retrospective chart review was conducted to compare the 2 primary end points of overall MRP rates from 4 payers in 2017 and 2018, and the postsurgical MRP rates from May 25 to November 30 of 2017 and 2018. Secondary outcomes included description of pharmacist interventions in pharmacy-led service and 30-day readmission or emergency department (ED) utilization rates for postsurgical population.A total of 5837 hospitalizations were identified as eligible for overall MRP completion in 2017 (n = 2621) and 2018 (n = 3216). A 20% relative increase in overall MRP completion was reported in 2018 (P0.001). In 2017, 55.9% of postsurgical MRPs were completed. The implementation of the pharmacy-led MRP program led to a 41% relative increase in postsurgical MRP completion (78.9% in 2018, P0.001). Pharmacists completed 220 postsurgical MRPs in the 6-month study period, including 765 total recommendations for intervention and an average of 3 recommendations and 4 medication list updates per MRP. There was no statistically significant reduction in 30-day readmission and ED utilization rates in 2018 (6.8% in 2017 vs. 6.2% in 2018, P = 0.74).A pharmacy-led postsurgical discharge program led to an increase in MRP completion rates in the target postsurgical MRP population, which also positively affected the overall MRP completion rate. Pharmacists can be key players in the improvement and quality of MRP measures.

The Joint Commission has established medication reconciliation as a National Patient Safety Goal, but it has not been studied much in trauma even though it is integral to safe patient care. This article reviews the existing medication reconciliation strategies and their applicability to the trauma setting. To perform medication reconciliation, hospitals use a variety of strategies including pharmacists or pharmacy technicians, electronic medical record tools, and patient-centered strategies. All of these strategies are limited in trauma. Subpopulations such as injured children, the elderly, and those with brain trauma are particularly challenging and are at risk for suboptimal care from inaccurate medication reconciliation. Further research is necessary to create a safe and efficient system for trauma patients.

Background Medication discrepancies directly impact patient safety and can adversely impact quality of care and resource utilization at transitions of care. Objectives To develop a common nomenclature and taxonomy for classifying and reporting medication discrepancies and to assess the content validity and reliability of the taxonomy. Methods The taxonomy was developed following a multi-stage process. The content of the taxonomy was then assessed using expert opinion through a two-round modified Delphi process. The expert panel comprised 10 experts who were selected based on pre-defined selection criteria. Six experienced pharmacists were then invited to classify medication discrepancies from a number of fictitious cases (adapted from authentic cases) using the taxonomy. Results The medication discrepancy taxonomy (MedTax) comprises 12 main types and 28 sub-types of discrepancies. A set of operational instructions and definitions to aid the use of the taxonomy was formulated. The overall Average content validity index (Ave-CVI) was 0.93 and interrater reliability was 0.67 (multirater κfree), indicating substantial agreement. An excellent internal consistency of the taxonomy was established (Kuder–Richardson Formula 20 (KR-20) = 0.92). Conclusions A content valid and reliable taxonomy for classifying medication discrepancies was developed. The MedTax may be used to classify medication discrepancies identified following medication reconciliation services. The clear and consistent reporting of medication discrepancies arising from medication reconciliation services may be of value to policy makers, healthcare professionals and researchers, when evaluating such services. The MedTax was designed to fill an essential void in global endeavors to reinforce standardization of medication reconciliation practices and to improve medication safety across transitions of care.

Background Despite years of attention, hospitals continue to struggle to implement successful medication reconciliation. This study aimed to increase the percentage of hospital admission medication reconciliation (AdmMedRec) completion to ≥ 95% in 12 months at a large academic children's hospital. Methods A quality improvement (QI) project was initiated in April 2017 by an interdisciplinary team of physicians, nurses, pharmacists, and analysts, co-led by a pediatric hospitalist and chief medical information officer. Interventions were implemented through sequential Plan-Do-Study-Act cycles. Process maps, fishbone diagrams, and failure mode and effects analysis were used to identify AdmMedRec failures. Baseline data from 12,481 admission encounters July 2016–April 2017 were analyzed. Interventions included electronic health record (EHR) workflow redesign, clarification of clinicians' responsibilities, targeted training, Best Practice Advisory alert, and weekly reporting of specialty- and physician-specific performance data. Data from 13,082 postintervention period admission encounters were examined. Reconciliation by therapeutic drug classes was calculated as a proxy for quality. Results AdmMedRec completion rate increased from a baseline of 73% to 95% within 7 months from the start of this project and was sustained at 94% during the postintervention period. Psychiatry and hospital medicine demonstrated the largest improvements, with rates increasing from 17% to 88% and 76% to 98%, respectively. Percentages of reconciled medications in all 13 therapeutic classes, including high-risk drugs, improved significantly (p Conclusions Using an interdisciplinary team and interventions focused on process and culture changes, this QI initiative was successful at increasing AdmMedRec rates and reducing omission errors across all therapeutic drug classes.

The primary objective of this study was to determine the proportion of patients with medication discrepancies when using a self-administered medication history form in the emergency department (ED). The secondary objectives were to identify predictors of medication discrepancies and determine the proportion of patients with a high-risk medication discrepancy.This was a cross-sectional study conducted in an urban ED in Australia. Patients completed a self-administered medication history form while waiting to be seen by a physician. Subsequently, a best possible medication history was taken by a pharmacist to determine accuracy of the self-reported medication lists for patients with planned admissions. Discrepancies between the two medication lists were reported descriptively. A Poisson regression analysis was conducted to identify predictors of the rate of discrepancies. Associations were reported as incident rate ratios (IRR).A total of 138 patients were included in the study. The total number of discrepancies was as follows: 0 (25%, n = 34), 1 (34%, n = 47), 2 (11%, n = 15), and ≥3 (30%, n = 42). The number of medications (IRR 1.11, 95% CI 1.09 to 1.14, p 0.001), female (IRR 1.51, 95% CI 1.18 to 1.92, p = 0.001), and missing community pharmacy information (IRR 2.10, 95% CI 1.64 to 2.68, p 0.001) were significantly associated with rate of discrepancies. Overall, 20% (n = 28) of patients had one or more high-risk medication discrepancies.Patient self-administered medication history forms have a high rate of discrepancies and should be verified by a best possible medication history.

Agreement between surgical and anesthesia teams regarding appropriate perioperative management strategies is vital to delivering safe and effective patient care. Perioperative guidelines serve as a valuable reference in optimizing patients for surgery. The article provides a broad set of guidelines related to cardiovascular evaluation, medication reconciliation, and preoperative fasting and includes a framework for the care of patients with comorbidities, such as coronary artery disease and obstructive sleep apnea.

Background Pharmacist involvement in medicines reviews for older adults can improve prescribing and reduce adverse drug reactions. Māori experience poorer health outcomes than non-Māori resulting, in part, from inequitable access to and quality of medicine-related care. Despite international data showing benefit, it is unclear whether pharmacist-led medicines review services can improve outcomes for Māori older adults. Objective This systematic review aims to describe pharmacist-led medicines review services for community-dwelling adults in New Zealand, assess effectiveness of these interventions and identify their effect on health equity for Māori and older adults. Methods The review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses – Equity (PRISMA-E 2012). Observational studies were included. The intervention in included studies had to involve a pharmacist, occur in the outpatient setting in New Zealand, and involve review of all medicines for an individual patient. At least one patient-related outcome had to be reported. Results The search identified seven observational studies with 542 total participants. Study interventions included adherence-based reviews in community pharmacies and multi-step comprehensive clinical reviews in outpatient haemodialysis units. Medicines reviews identified up to a median of 3 drug-related problems per review. The effect of interventions on medicines adherence and knowledge was not clear. Māori may have been less likely than non-Māori to benefit from improved medicines knowledge as a result of interventions. None of the studies incorporated aspects in study design or delivery to address inequities for Māori. Conclusion Further investigation is needed to understand whether the development of culturally safe pharmacist-led medicines review services, responsive to community identified needs, can help to achieve equity in health outcomes for Māori older adults.

Background and purpose Transitions of Care (ToC) is an important clinical practice area requiring trained health care professionals, but there is limited literature describing ToC in the didactic curriculum. The purpose of this study was to describe and evaluate a ToC telemedicine simulation activity in a doctor of pharmacy curriculum. Educational activity and setting A one-hour lecture and simulation activity was incorporated into a second-year course. Student teams participated in discharge and telemedicine encounters with standardized patients (SPs). Six medication-related problems (MRPs) were incorporated into the activity. Activity documents were collected to identify student competency. Findings Fifty-nine student pharmacists in 16 teams participated. All teams accurately identified five of the six MRPs. Fourteen teams (87.5%) accurately identified the sixth MRP after completion of the telemedicine encounter. Six teams (62.5%) completed the discharge medication list accurately and completely. All teams provided medication education, and 93.8% (n = 15) of teams identified follow-up was needed. Ten teams utilized effective interview sequence and structure during both encounters. Activity challenges included resources, financial support and SP training. Summary Case-based learning and the use of simulation has good evidence supporting its use in education. Utilizing these techniques to reinforce concepts may be a beneficial way for students to be trained effectively to deliver impactful ToC services.

Introduction Obtaining accurate patient medication histories and performing medication reconciliation are core pharmacy practice skills that optimize patient safety at transitions of care. Competency-based learning and assessment of medication reconciliation skills are essential methods in undergraduate pharmacy education. The aim of this study was to investigate the impact of an in-classroom simulation- and feedback-driven training activity on pharmacy students' medication reconciliation skills, self-perceived confidence, and overall student satisfaction. Methods Over a three-day learning activity in 2016, pharmacy students from a private university in Jordan were assessed by roleplay on their ability to conduct a simulated patient medication interview, obtain the Best Possible Medication History, reconcile the history against a hospital medication chart, identify discrepancies, and document findings. Students received immediate feedback and observed peers undergo the assessment process. Pre- and post-simulation questionnaires and supplementary focus groups enabled collection of quantitative and qualitative data pertaining to student self-perceived confidence, perceptions, experiences, and usefulness of the course. Results Assessment-based competency scores demonstrated significant improvement in student performance during the activity. Self-perceived confidence scores significantly improved after the medication reconciliation training intervention. Focus group content analysis yielded positive responses such as students valuing receiving feedback on performance and recommendations for future training. Conclusions Simulation with feedback was a useful tool to teach pharmacy students medication reconciliation in Jordan. Subsequent to the study, medication reconciliation and interactive teaching methods were added to curriculum to supplement traditional teaching modalities.

Objective To characterize medication discrepancies for patients with chronic illnesses seen at outside facilities. Methods This was a retrospective evaluation of a medication reconciliation across care transitions (MRAT) program developed and piloted for one year in an academic pediatric primary care medical home. The MRAT involved chart review and contacting caregivers upon receiving external specialist notes or hospital discharge summaries. Data obtained from the program were used to determine the frequency and types of medication discrepancies for children with complex and noncomplex chronic conditions. Results MRATs for 124 encounters were evaluated, 74.0% in response to specialist appointments. Chart review revealed a mean of 3.64 discrepancies per patient, and telephone calls revealed 1.39 additional discrepancies per patient. The number of medication discrepancies from both chart review and telephone calls between complex and noncomplex patients was statistically significant, with a mean of 5.63 vs. 3.77 per patient (p = 0.005). Therapy delays occurred in 16.1% of patients due to insurance rejections, family not starting a new medicine, or confusion about the medication change. Mean time required for reconciliation was 24 minutes. In addition to medication reconciliation, 107 interventions completed during MRATs included patient education, adjusting drug therapy, coordinating care between providers, recommending laboratory monitoring, and facilitating patient appointments. Conclusion Children with chronic illness often experience medication changes and delays in therapy when seen in the hospital or by specialists. Timely identification of these changes improves communication and offers the opportunity to identify and prevent problems with medication therapy.

To develop and implement an integrated cloud technology with the aim of ensuring medication reconciliation during transitions of care and improve medication safety in aged societies.PharmaCloud is a new technical platform adopted by the National Health Insurance Administration of Taiwan to collect patients' medication information via cloud technology. Using this platform, healthcare providers can access patients' medication-related information with patient consent. Our hospital applied this technology and developed several approaches to collect and detect medication-related information and alert physicians for the purpose of enhancing patients' medication safety. In addition, pharmacists were involved in the admission process to access medication data and provide optimal suggestions to physicians. Several indicators, including a reduction in the number of drug items in each prescription and medication expenditure, were employed to evaluate the overall effects of the cloud inquiry.After the application of PharmaCloud, the average number of prescribed drug items significantly decreased (change of 0.04 to -0.35 per prescription, p 0.05), and the median medication expenditure significantly decreased by an average of 3.55 USD, (p 0.05) per prescription. Intra-hospital medication duplication rates also showed a downward trend.The use of the cloud technology and value-added applications significantly improved patient medication safety. Further long-term beneficial effects in terms of medication safety and medical cost savings are expected.

BACKGROUND: The Association of Pharmacists in Belgium (APB) and local pharmacy associations launched a pilot project in collaboration with research teams from three Belgian universities to study the impact and implementation-related issues of a medication review (MR) service type 2a in Belgian community pharmacies. OBJECTIVE: The aim of this paper is to describe the implementation process of the MR service and to present the implementation evaluation of the pilot study (testing stage). METHODS: The pilot project was a prospective observational study using mixed methods. The implementation evaluation was based on the RE-AIM model and the framework for the implementation of services in pharmacy (FISpH). Collected implementation outcomes were classified into four dimensions: reach, adoption, implementation and intent of maintenance. RESULTS: During the testing stage, 80 pharmacies participated in the study, but 25 dropped out (31%), mainly because of a reported lack of time (adoption). The 55 remaining pharmacies included 457 patients. Recruiting patients into the service was challenging for pharmacists as 48.5% of patients refused the pharmacists' proposal (reach). Internal organizational factors were major barriers for pharmacists, followed by the lack of adoption by the pharmacy team. Large pharmacies in which pharmacy owner led the project were observed to be more proactive in implementing the MR service by integrating organizational strategies to assist the implementation process (implementation). Interviewed pharmacists perceived this new service as a professionally satisfying activity. Among participating pharmacists, 92.5% found this service feasible in practice, but believed it required adapted resources to reorganize the internal pharmacy workload, additional support, such as broad-based media campaigns to increase physicians' and patients' awareness and attitudes towards the service, and modified software (maintenance). CONCLUSIONS: The medication review service was implemented in 68% of participating pilot Belgian community pharmacies but would require adapted resources and supports for larger scale implementation. ispartof: RESEARCH IN SOCIAL & ADMINISTRATIVE PHARMACY vol:15 issue:6 pages:710-723 ispartof: location:United States status: published

Background In Australia, the Home Medicines Review (HMR) is a nationally-funded program, led by pharmacists to optimize medication use for older people. A Medicines Conversation Guide was developed for pharmacists to use in the context of a HMR. The Guide aims to increase patient involvement and support discussions about: general health understanding, decision-making and information preferences, health priorities related to medicines, patient goals and fears, views on important activities and trade-offs. Objective This study describes the development and feasibility testing of a Medicines Conversation Guide in HMRs with pharmacists and older patients. Methods The Guide was developed using a systematic and iterative process, followed by testing in clinical practice with 11 pharmacists, 17 patients (aged 65+) and their companions. A researcher observed HMRs, surveyed and qualitatively interviewed patients and pharmacists to discuss feasibility. Transcribed recordings of the interviews were thematically coded and a Framework Analysis method used. Results Pharmacists found the Guide to be an acceptable and useful component to the HMR, especially among patients with limited knowledge of their medicines. The Guide seemed most effective when integrated with the HMR and tailored to suit the individual patient. Some questions were difficult for patients to grasp (e.g. trade-offs) or sounded formal. Most patients found the Guide focused the HMR on their perspective and encouraged a more holistic approach to the HMR. From the quantitative survey, pharmacists found the Guide easy to implement, balanced and understandable. Conclusions Pharmacists and patients reported the Guide fits with the HMR encounter relatively easily and promoted communication about goals and preferences in relation to medications. This study highlighted some key challenges for communication about medicines and how the Guide may help support the process of involving patients more in the HMR.

Background Implementation of collaborative Medication Review (MR) into routine care faces several barriers. Objective The study aim was to gain information on patient selection for a MR by general practitioners (GPs). GP selection was compared to objective selection criteria on identifying patients, who would benefit from a MR the most. A secondary objective of this study was to get insight into GPs perception on interprofessional collaboration with pharmacists. Methods GPs were interviewed for a qualitative study on expected outcomes of MR in former study patients. They were asked to select patients, for whom they expected a major benefit from the MR. Results were compared to objective selection criteria, obtained from the WestGem study. Further interviews were done on aspects of patient selection and perception of interprofessional collaboration, results were presented descriptively. Results The study covered 6 GPs with 78 former study patients. GPs would have chosen 45 out of the 78 patients (57.7%) for a MR. According to changes in the Medication Appropriateness Index, 24 of these patients had a greater benefit from the MR. Patient selection by the number of prescribed drugs had reached a higher specificity at a cut-off of 9 drugs, compared to selection by the GP (67% vs. 61.5%). GPs mentioned medication safety, certain diseases, polymedication, multimorbidity as selection criteria. Increasing quality of therapy and better insight into the patient's drug regimen was appreciated by the GPs as perceived personal advantage of the MR. GPs preferred to have a MR initiated by themselves, but appraised concise interprofessional collaboration with pharmacists. Conclusions Patient selection for MR should take objective parameters into account and combine them with subjective impressions. GPs preferred the initiation of a MR by themselves but expressed a positive attitude towards collaboration with a pharmacist afterwards. Recommendations should be relevant and concise.

Background Systems approaches in healthcare address complexities of care related to medication safety. Adverse drug events can be prevented by communication between providers. Thus, methods that depict the structures and processes of communications are foundational for prevention efforts. Social network analysis is a methodology applied in healthcare settings to describe and quantify communication patterns. Knowledge of the structures and processes surrounding medication management communications will be useful to explain and intervene on related quality or safety outcomes. Objectives The aim of this study was to use social network analysis as a tool to describe the communication structures and processes of medication management for patients on warfarin therapy in an ambulatory care setting. Method A longitudinal, roster-based assessment was used for the social network analysis. Data were collected from electronic medical records and coded using a fixed-list format. Information was collected regarding who was involved as well as frequency and type of communications. The analysis followed 16 subjects at one internal medicine clinic over six months. Results Structurally, communications were unidirectional and most often connected actors from different groups. Most communications were directed from nursing staff to patients. Central actors were a pharmacist, several nursing staff and one prescriber. Difference in processes were identified by characterizing communications according to level of impact on patient safety. Moderate impact communications corresponded to focused connections between providers. Further, the pharmacist was measured as the most prominent gatekeeper in moderate impact communications compared to an advanced registered nurse practitioner for low impact communications. Conclusions Medication management reflected a unidirectional and interdisciplinary communication structure that maintained process variation according to the potential impact on patient safety. The level of influence of the pharmacist as a connector in the network rose in conjunction with the level of potential impact the communication had on patient safety.

Refugees all over the world are facing several health-related problems. Chronic diseases among Syrian refugees in Jordan are high. The Home Medication Management Review (HMMR) service could be ideal to optimize refugees' health management.To assess the impact of the HMMR service on the type and frequency of Treatment Related Problems (TRPs) among Syrian refugees living in Jordan.This prospective randomized single blinded intervention-control study was conducted in three main cities in Jordan, between May and October 2016. Syrian refugees with chronic conditions were recruited and randomized into intervention and control groups. The HMMR service was conducted for all patients to identify TRPs at baseline. Data were collected via two home visits for all study participants. Clinical pharmacist's recommendations were written in a letter format to the physicians managing the patients in the intervention group only. Physicians' approved recommendations were conveyed to the patients via the pharmacist. Interventions at the patient level were delivered by the pharmacist directly. Patients were reassessed for their TRPs and satisfaction 3 months after baseline.Syrian refugees (n = 106) were recruited with no significant differences between the intervention (n = 53) and control groups (n = 53). A total of 1141 TRPs were identified for both groups at baseline, with a mean number of 10.8 ± 4.2 TRPs per patient. At follow-up, there was a significant decrease in the number of TRPs among the intervention group (P 0.001, paired sample t-test) but not among the control group (P = 0.116). Physicians' approval rate of the pharmacist's recommendations was high (82.9%), and more than 70.0% of refugees in the intervention group reported high satisfaction with the HMMR service.Identified TRPs are high amongst Syrian refugees living in Jordan. The HMMR service significantly reduced the number of TRPs, and was highly accepted by the physicians. Refugees reported high satisfaction with this service.

To determine the rate of patients visiting the emergency department who are at risk of opioid overdose.The electronic records of a 412 bed tertiary care county teaching hospital were searched for emergency department (ED) visits from January 1, 2013 to October 31, 2016 to find patients on at least 100mg morphine equivalents (MME) of oral opioid therapy, or an opioid in combination with a benzodiazepine. Records were also searched for patients with a positive urinalysis for opioids when no opioid was present on their home medication list. Medication reconciliations were searched for patients at risk of opioid overdose who were subsequently discharged on naloxone.An analysis of 2521 patients visiting the ED was performed, and the overall rate of risk of opioid overdose increased from 25.84% to 47.41% (p0.0001) in patients meeting inclusion criteria from 2013 to 2016. For patients on opioids, the rate of patients on 100 MME daily or greater increased from 9.72% to 28.24% (p0.0001) from 2013 to 2016. The rate of patients on opioid therapy in combination with benzodiazepine therapy did not change significantly from 2013 to 2016. When comparing patients at risk of opioid overdose to total emergency department visits, we found the rate of at risk patients increased significantly from 0.12% to 0.56% (p0.0001) from 2013 to 2016.The rate of patients visiting the emergency department at risk of opioid overdose increased significantly from 2013 to 2016. Naloxone was not routinely prescribed to this patient cohort.

Objectives To describe a community pharmacist–led transitions of care process for patients discharged from the inpatient to the outpatient setting. Setting Independent community pharmacy chain in northwestern and central Missouri and a rural nonprofit hospital in Marshall, Missouri. Practice description and innovation This innovative transitions of care service model relies on the inpatient pharmacy team for recruitment and referral of patients who use Red Cross Pharmacy. On discharge, patient information was transmitted to Red Cross Pharmacy via direct messaging in the form of a continuity of care document. Pharmacists used the patients' continuity of care documents to perform telephone-based medication reconciliations and comprehensive medication reviews. Drug-related problems and pharmacists' recommendations were documented in a subjective, objective, assessment, and plan (SOAP) note that was transmitted to the hospital and primary care provider. Evaluation The number and type of drug-related problems and pharmacists' recommendations were assessed with the use of descriptive statistics. Pharmacists' time spent was tracked, and its relationship to alternate variables was assessed with the use of bivariate correlations. Results Pharmacists identified 69 drug-related problems and made 145 recommendations for the 35 patients meeting study criteria. The mean time for total service completion was 65 minutes and positively correlated with a number of variables, including identification of the drug-related problem and unnecessary drug therapy and recommendation to decrease the dosage of a medication. Conclusion Community pharmacists have the ability to identify drug-related problems and make recommendations for patients moving from the inpatient to an outpatient setting. In addition, the data suggest that when given adequate time, pharmacists performing service responsibilities may identify more drug-related problems, resulting in additional recommendations.

Background Anticoagulated patients are particularly vulnerable to ADEs when they experience changes in medical acuity, pharmacotherapy, or care setting, and resources guiding care transitions are lacking. The New York State Anticoagulation Coalition convened a task force to develop a consensus list of requisite data elements (RDEs) that should accompany all anticoagulated patients undergoing care transitions. Methods A multidisciplinary panel of 15 anticoagulation experts voluntarily completed an iterative Delphi process. Resources were disseminated and deliberated via remote technology, with consensus achieved via blinded electronic polling. Results The panel reached consensus on a list of 15 RDEs for anticoagulation communication at discharge (the ACDC List). Consensus was rapidly achieved by the full panel on 13 elements, while 3 (2 of which were combined into 1 element) required multiple iterations and achieved consensus with votes from 8 available panelists. The elements encompassed a range of factors, including drug use and indications, previous exposure and duration of therapy, recent drug exposure and laboratory results and expectations for subsequent administration, therapy goals, patient education and comprehension, and expectations for clinical management. Twelve of the elements are applicable to any anticoagulant, and 3 are specific to warfarin. Conclusion The ACDC List identifies specific pieces of clinical information that a panel of anticoagulant experts agree should be communicated to downstream providers for all anticoagulated patients undergoing care transitions. Additional study is needed to objectively evaluate the ability of existing care systems to communicate the elements and to assess possible relationships between communication of the elements and clinical outcomes.

Polypharmacy is an underappreciated factor in undesirable patient outcomes. In older adults, polypharmacy is considered a syndrome of harm and presents a challenge to primary care providers. The United States has one of the highest medication use rates per capita in the world. With the aging population, and polypharmacy a significant part of the lives of older adults, management of polypharmacy poses both a growing challenge and an opportunity for all health care providers. This article provides an overview of skills to improve medication use management in older adults living with polypharmacy.

Introduction La conciliation medicamenteuse consiste a etablir une liste precise de l’ensemble des traitements pris par le patient lors de son hospitalisation. Elle est desormais recommandee par la HAS et vise a ameliorer la continuite des soins. En outre, une etude recente realisee aupres de medecins generalistes a mis en evidence des defauts importants de transmission d’informations entre les secteurs hospitalier et ambulatoire, notamment concernant l’ordonnance de sortie. Actuellement, la realisation d’une fiche de conciliation medicamenteuse a la sortie du patient est effectuee dans notre service de medecine interne et est remise au patient a l’intention de son medecin traitant. Neanmoins, la perception du medecin traitant vis-a-vis de cette fiche n’a pas ete evaluee et serait interessante afin d’en determiner l’interet et d’y apporter des ameliorations. L’objectif de cette etude est d’evaluer la perception des medecins generalistes vis-a-vis de la fiche de conciliation de sortie effectuee lors de l’hospitalisation de leurs patients. Materiels et methodes Il s’agit d’une etude qualitative prospective. Des d’entretiens individuels semi-directifs etaient realises aupres de medecins traitants ayant recu une fiche de conciliation suite a l’hospitalisation de l’un de leurs patients. Cette fiche comportait l’ensemble des traitements prescrits a la sortie du patient ainsi qu’une courte note expliquant les raisons des modifications des traitements. Les differentes reponses ont ete regroupees par themes et ont fait l’objet d’une analyse descriptive. Resultats D’octobre 2015 a juillet 2016, 33 fiches de conciliation de sortie ont ete realisees. Parmi les 33 medecins generalistes contactes, 16 ont revu le patient avec la fiche de conciliation et ont accepte un entretien. La majorite des medecins interroges soulignent un manque d’information quant aux modifications de traitement effectuees pendant l’hospitalisation. Ils ont apprecie la fiche de conciliation car elle est disponible des la sortie du patient, justifie les modifications realisees et permet de diminuer le risque d’erreur medicamenteuse. Ils ont egalement note l’interet de ce document pour que le patient comprenne les modifications realisees. Certains medecins ont repere des erreurs, d’autres ont suggere des modifications aussi bien sur la forme que sur le contenu. Par ailleurs, un nombre important de medecins generalistes n’avaient pas eu acces a cette fiche car ils n’en connaissaient pas l’existence. Enfin, un acces immediat a cette fiche des la sortie, par le patient et via une messagerie electronique securisee est souhaite. Discussion/conclusion Cette etude a permis de demontrer l’interet de la realisation d’une fiche de conciliation medicamenteuse a la sortie d’hospitalisation du patient pour ameliorer sa prise en charge et de proposer des pistes pour l’optimiser. Une transmission de cette fiche au medecin traitant par messagerie securisee, en y associant un resume d’hospitalisation, est actuellement en cours dans notre service. L’evaluation de cette pratique, a la fois en termes de reduction des erreurs medicamenteuses mais egalement en termes d’economies de sante, fera l’objet d’une etude ulterieure.

Introduction To determine the allocation of faculty and curricular time to the teaching of transitions of care (ToC) concepts by colleges of pharmacy (COPs) to equip students with the necessary skills for the provision of these services. Methods A novel 15-question anonymous electronic survey was sent to 136 pharmacy practice chairpersons. Results Response rate was 26.5% (n = 36). Of these, 47% employed ToC faculty while 44% are not actively recruiting for that position in the foreseeable future. Median total curriculum hours dedicated to teaching ToC was four (interquartile range two to 10 hours). Medication reconciliation skills were taught didactically and via interactive lab sessions by 53% of respondents. Only 11% offered an interdisciplinary ToC program. A significant association between not having ToC faculty and lack of implementation of ToC concepts within a pharmacy curriculum (p = 0.02, Fisher's Exact) and practice site (p = 0.045, Pearson's) was observed. Barriers to adopting ToC within the curriculum (e.g., uncertainty of placement within curriculum, resistance by faculty and administrators) and at a practice site (e.g., inadequate infrastructure to accommodate ToC delivery, ToC faculty unavailability and resistance by other health care providers) were reported. Discussion and conclusions This study demonstrated that COPs devote curricular time to ToC activities and involve dedicated faculty in the provision of these services. Several barriers to employing ToC faculty and planning additional time in the curriculum for teaching these skills were identified. Future research should determine the best methods for training students to ensure competence in performing ToC tasks.