Prevalence of medication transfer errors in nephrology patients and potential risk factors

Abstract

Background: Medication reconciliation in transitions of care can prevent medication transfer errors (MTE). MTE can cause patient harm. Since performing medication reconciliation for every patient is not always feasible, identification of potential risk factors of MTE could aid in targeting this intervention to the right patients.

Objective: To establish the proportion of patients with one or more MTE in the outpatient nephrology setting. Secondary patient characteristics associated with MTE, type and potential harm, and medication groups were investigated.

Methods: This retrospective observational cohort study was conducted in the Leiden University Medical Center, the Netherlands, between November 2017 and April 2018. The cohort involved patients in whom medication reconciliation was performed by a medical attendant using the electronic tool 'Medical Dashboard' prior to visiting the nephrologist. MTE were defined as unintended discrepancies between the medication in the hospital system and the result of the medication reconciliation. The proportion of patients with one or more MTE was calculated and the association of patient characteristics (age, sex, number of medications and kidney function (CKD-EPI)) with MTE was analyzed using multivariate logistic regression.

Results: Of 380 patients, 235 patients (61.8%) had at least one MTE. On average patients used 10.3 medications. The number of medications per patient was significantly associated with MTE; OR 1.11 (95%CI 1.05-1.16). No association was found for age, sex, and kidney function.

Conclusion: In ambulatory nephrology patients 61.8% had at least one MTE. Nephrology patients using a higher number of drugs are more prone to MTE.

Keywords: Medication errors; Medication reconciliation; Nephrology; Outpatients; Risk factor.