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Medication reconciliation during internal hospital transfer and impact of computerized prescriber order entry.
MedLine Citation:
PMID:  21098753     Owner:  NLM     Status:  In-Process    
Abstract/OtherAbstract:
BACKGROUND: Internal hospital transfer is a vulnerable time during which patients are at high risk of medication discrepancies that can result in clinically significant harm, medication errors, and adverse drug events.
OBJECTIVE: To identify, characterize, and assess the clinical impact of unintentional medication discrepancies during internal hospital transfer and to investigate the influence of computerized prescriber order entry (CPOE) on medication discrepancies.
METHODS: All patients transferred between 10 inpatient units at 2 tertiary care hospitals were prospectively assessed to identify discrepancies. Interfaces included transfers between (1) units that both used paper-based medication ordering systems; (2) units that both used CPOE-based systems; and (3) units that used both paper-based and CPOE-based systems (hybrid transfer). The primary endpoint was the number of patients with at least 1 unintentional medication discrepancy during internal hospital transfer. Discrepancies were identified through assessment and comparison of a best possible medication transfer list with the actual transfer orders. A multidisciplinary team of clinicians assessed the potential clinical impact and severity of unintentional discrepancies.
RESULTS: Overall, 190 patients were screened and 129 patients were included. Eighty patients (62.0%) had at least 1 unintentional medication discrepancy at the time of transfer, and the most common discrepancy was medication omission (55.6%). Factors that independently increased the risk of a patient experiencing at least 1 unintentional discrepancy included lack of best possible medication history, increasing number of home medications, and increasing number of transfer medications. Forty-seven patients (36.4%) had at least 1 unintentional discrepancy with the potential to cause discomfort and/or clinical deterioration. The risk of discrepancies was present regardless of the medication-ordering system (paper, CPOE, or hybrid).
CONCLUSIONS: Clinically significant medication discrepancies occur commonly during internal hospital transfer. A structured, collaborative, and clearly defined medication reconciliation process is needed to prevent internal transfer discrepancies and patient harm.
Authors:
Justin Y Lee; Kori Leblanc; Olavo A Fernandes; Jin-Hyeun Huh; Gary G Wong; Bassem Hamandi; Neil M Lazar; Dante Morra; Jana M Bajcar; Jennifer Harrison
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Publication Detail:
Type:  Journal Article     Date:  2010-11-23
Journal Detail:
Title:  The Annals of pharmacotherapy     Volume:  44     ISSN:  1542-6270     ISO Abbreviation:  Ann Pharmacother     Publication Date:  2010 Dec 
Date Detail:
Created Date:  2010-12-08     Completed Date:  -     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  9203131     Medline TA:  Ann Pharmacother     Country:  United States    
Other Details:
Languages:  eng     Pagination:  1887-95     Citation Subset:  IM    
Affiliation:
Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.
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