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Multicenter Study
. 2008 Sep;23(9):1414-22.
doi: 10.1007/s11606-008-0687-9. Epub 2008 Jun 19.

Classifying and predicting errors of inpatient medication reconciliation

Affiliations
Multicenter Study

Classifying and predicting errors of inpatient medication reconciliation

Jennifer R Pippins et al. J Gen Intern Med. 2008 Sep.

Abstract

Background: Failure to reconcile medications across transitions in care is an important source of potential harm to patients. Little is known about the predictors of unintentional medication discrepancies and how, when, and where they occur.

Objective: To determine the reasons, timing, and predictors of potentially harmful medication discrepancies.

Design: Prospective observational study.

Patients: Admitted general medical patients.

Measurements: Study pharmacists took gold-standard medication histories and compared them with medical teams' medication histories, admission and discharge orders. Blinded teams of physicians adjudicated all unexplained discrepancies using a modification of an existing typology. The main outcome was the number of potentially harmful unintentional medication discrepancies per patient (potential adverse drug events or PADEs).

Results: Among 180 patients, 2066 medication discrepancies were identified, and 257 (12%) were unintentional and had potential for harm (1.4 per patient). Of these, 186 (72%) were due to errors taking the preadmission medication history, while 68 (26%) were due to errors reconciling the medication history with discharge orders. Most PADEs occurred at discharge (75%). In multivariable analyses, low patient understanding of preadmission medications, number of medication changes from preadmission to discharge, and medication history taken by an intern were associated with PADEs.

Conclusions: Unintentional medication discrepancies are common and more often due to errors taking an accurate medication history than errors reconciling this history with patient orders. Focusing on accurate medication histories, on potential medication errors at discharge, and on identifying high-risk patients for more intensive interventions may improve medication safety during and after hospitalization.

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Figures

Figure 1
Figure 1
Classification of medication discrepancies.

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References

    1. {'text': '', 'ref_index': 1, 'ids': [{'type': 'DOI', 'value': '10.1001/archinte.165.16.1842', 'is_inner': False, 'url': 'https://doi.org/10.1001/archinte.165.16.1842'}, {'type': 'PubMed', 'value': '16157827', 'is_inner': True, 'url': 'https://pubmed.ncbi.nlm.nih.gov/16157827/'}]}
    2. Coleman EA, Smith JD, Raha D, Min SJ. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 2005;165:1842–7. - PubMed
    1. {'text': '', 'ref_index': 1, 'ids': [{'type': 'PMC', 'value': 'PMC1188190', 'is_inner': False, 'url': 'https://pmc.ncbi.nlm.nih.gov/articles/PMC1188190/'}, {'type': 'PubMed', 'value': '16129874', 'is_inner': True, 'url': 'https://pubmed.ncbi.nlm.nih.gov/16129874/'}]}
    2. Tam VC, Knowles SR, Cornish PL, Fine N, Marchesano R, Etchells EE. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. CMAJ. 2005;173:510–5. - PMC - PubMed
    1. Using medication reconciliation to prevent errors. Jt Comm J Qual Patient Saf. 2006;32:230–2. - PubMed
    1. {'text': '', 'ref_index': 1, 'ids': [{'type': 'DOI', 'value': '10.1001/archinte.165.4.424', 'is_inner': False, 'url': 'https://doi.org/10.1001/archinte.165.4.424'}, {'type': 'PubMed', 'value': '15738372', 'is_inner': True, 'url': 'https://pubmed.ncbi.nlm.nih.gov/15738372/'}]}
    2. Cornish PL, Knowles SR, Marchesano R, et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005;165:424–9. - PubMed
    1. {'text': '', 'ref_index': 1, 'ids': [{'type': 'DOI', 'value': '10.1001/archinte.166.5.565', 'is_inner': False, 'url': 'https://doi.org/10.1001/archinte.166.5.565'}, {'type': 'PubMed', 'value': '16534045', 'is_inner': True, 'url': 'https://pubmed.ncbi.nlm.nih.gov/16534045/'}]}
    2. Schnipper JL, Kirwin JL, Cotugno MC, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006;166:565–71. - PubMed

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