Article Figures & Tables
Figures
- Figure 1
Prepopulated medication reconciliation form for a hypothetical patient. Electronic medication dispensing data from PharmaNet are used to automatically prepopulate medication reconciliation forms. A member of the health care team must verify the patient's medication history and note in the middle column any discrepancies between the prepopulated information and how the patient is taking the medication. The treating physician then indicates in the right-hand column whether to continue or alter the medication.
Tables
Type of error Definition Example Medication discrepancy Discontinuation Discontinuing a patient's regular medication without explanation Patient is taking 20 mg of citalopram at home, but this is discontinued on admission to hospital Omission Patient's regular medication is not listed on medication reconciliation form and is not reordered Patient is taking 81 mg of acetylsalicylic acid (over the counter) daily, but this is not listed on medication reconciliation form. It is not ordered during hospital stay. Change in dosage Medication is ordered at dosage indicated on medication reconciliation form, but patient is taking different dosage Patient was prescribed 25 mg of metoprolol twice daily, but family doctor had decreased dosage to 12.5 mg by mouth twice daily. Patient receives 25 mg twice daily in hospital without indication for increased dosage. Change in route Medication is ordered via route indicated on medication reconciliation form, but patient is taking it differently at home Patient was prescribed acetaminophen, 1000 mg by mouth 3 times daily per rectum, in nursing facility because of decreased level of consciousness. It is ordered by mouth in hospital. Change in frequency Medication is ordered at frequency indicated on medication reconciliation form, which differs from patient's regimen Patient was prescribed gabapentin, 300 mg 3 times daily, but is taking it only at bedtime because of daytime somnolence. Medication is ordered as 300 mg 3 times daily in hospital. As needed to regular Medication is ordered regularly as per medication reconciliation form, but patient is taking it as needed Patient was prescribed zopliclone, 7.5 mg at bedtime, but is using it as needed, and only infrequently. It is ordered regularly in hospital. Regular to as needed Medication is ordered as needed as per medication reconciliation form, but the patient is taking it regularly Patient was prescribed lorazepam, 0.5-1 mg 3 times daily as needed, but is taking 1 mg 3 times daily regularly. It is ordered as needed in hospital. Error of commission Reorder error Reordering a medication that had previously been stopped Patient was prescribed indomethacin for acute gout flare-up but had stopped it when flare-up subsided. It is erroneously reordered in hospital. Inappropriate continuation Ordering a medication that patient is taking in the setting of a new contraindication Patient is taking indomethacin for acute gout flare-up and then presents with gastrointestinal bleed. Indomethacin is inappropriately continued in hospital. Characteristic No. (%)*n = 151 Sex Male 80 (53.0) Female 71 (47.0) Age, mean ± SD, yr 66.8 ± 18.8 Length of hospital stay, median (IQR), d 6 (3-13) Most responsible diagnosis Pneumonia 14 (9.3) Cancer 11 (7.3) Sepsis 9 (6.0) Stroke syndrome 8 (5.3) Extremity fracture 7 (4.6) Upper gastrointestinal bleed 6 (4.0) Chronic obstructive pulmonary disease 4 (2.6) Skin/soft tissue infection 4 (2.6) Bipolar affective disorder 4 (2.6) Asthma 3 (2.0) Comorbid condition Hypertension 68 (45.0) Dyslipidemia 29 (19.2) Diabetes mellitus type 2 25 (16.6) Atrial fibrillation 24 (15.9) Depression/anxiety 21 (13.9) Hypothyroidism 21 (13.9) Gastroesophageal reflux disease 20 (13.2) Coronary artery disease 19 (12.6) Congestive heart failure 18 (11.9) Osteoarthritis 18 (11.9) No. of medications on admission, mean ± SD 6.8 ± 4.7 Note: IQR = interquartile range, SD = standard deviation.
*Except where noted otherwise.
Type of error No. (%) Overall Class I Class II Class III Medication discrepancy Discontinuation 32 (38) 29 (91) 2 (6) 1 (3) Omission 24 (28) 19 (79) 5 (21) 0 Change in dosage 15 (18) 11 (73) 4 (27) 0 Change in frequency 6 (7) 5 (83) 1 (17) 0 As needed to regular 6 (7) 5 (83) 1 (17) 0 Regular to as needed 2 (2) 2 (100.0) 0 0 Total 85 (100) 71 (84) 13 (15) 1 (1) Error of commission Reordering error 17 (63) 14 (82) 3 (18) 0 Inappropriate continuation 10 (37) 3 (30) 7 (70) 0 Total 27 (100) 17 (63) 10 (37) 0 *Based on a previously published classification system:1 class I errors were those deemed "unlikely to cause patient discomfort or clinical deterioration," class II errors had "the potential to cause moderate discomfort or clinical deterioration," and class III errors were defined as having "the potential to result in severe discomfort or clinical deterioration."
Admission diagnosis Description of error Type and clinical significance Extremity fracture Patient had drug-eluting stent placed within previous year and was taking dual antiplatelet therapy; acetylsalicylic acid was omitted from admission orders
Perindopril-indapamide was ordered on admission; however, this medication had been previously stopped and patient was no longer taking itOmission, class III
Reorder error, class IIUpper gastrointestinal bleed Patient's hydrochlorothiazide was reordered despite symptomatic hypotension at presentation
Gliclazide was ordered on admission; however, this medication had been previously stopped and patient was no longer taking itInappropriate continuation, class II
Reorder error, class IIPneumonia, COPD Patient's budesonide was omitted despite regular use in setting of severe COPD Omission, class II Depression Patient's budesonide-formoterol was discontinued on admission orders despite regular use in setting of severe COPD and asthma
Patient's prednisone was discontinued on admission orders despite regular useDiscontinuation, class II
Discontinuation, class IISyncope Patient's hydrochlorothiazide was continued despite symptomatic orthostatic hypotension at presentation Inappropriate continuation, class II Schizophrenia Patient's zuclopenthixol was ordered as 60 mg intramuscularly every 2 wk as per PharmaNet; however, patient was taking 40 mg intramuscularly every 2 wk Change in dosage, class II Weakness Patient's acetylsalicylic acid was omitted from admission orders (indication transient ischemic attacks) Omission, class II Asthma Indomethacin was ordered on admission; however, patient was no longer taking this medication Reorder error, class II Dyspnea Patient's acetylsalicylic acid was omitted from admission orders (indication coronary artery disease) Omission, class II Fall Patient's amlodipine was continued despite symptomatic hypotension Inappropriate continuation, class II Cancer Celecoxib was ordered regularly as per PharmaNet; however, patient took this as needed As needed to regular, class II Pulmonary embolism Patient's metoprolol was continued despite symptomatic hypotension
Patient's perindopril was continued despite symptomatic hypotension
Patient's acetylsalicylic acid was omitted from admission orders (indication coronary artery disease)Inappropriate continuation, class II
Inappropriate continuation, class II
Omission, class IIHypovolemia, atrial flutter Imatinib was ordered on admission as per PharmaNet; however, patient was no longer taking this medication Reorder error, class II Transient ischemic attack Patient was taking 7.5 mg of zopiclone at bedtime; however, it was ordered as 11.25 mg at bedtime as needed as per PharmaNet Change in dosage, class II Pneumonia, sepsis Patient was taking dantrolene, 100 mg 4 times daily, but it was ordered as 400 mg 4 times daily as per PharmaNet Change in dosage, class II Urinary tract infection, sepsis Patient was using fluticasone regularly for asthma but this was omitted Omission, class II Urinary tract infection Patient was taking carbidopa-levodopa extended release 3 times daily and at bedtime as needed; however, this was ordered as once daily as per PharmaNet Change in frequency, class II Sepsis Patient was taking methadone, 3 mg every 8 h, but this was ordered as 2 mg every 8 h as per PharmaNet Change in dosage, class II Pyelonephritis Patient's bisoprolol was continued in setting of symptomatic hypotension Inappropriate continuation, class II Note: COPD = chronic obstructive pulmonary disease.
Type of error; characteristic No. of errors per patient, mean ± SD Difference (95% CI) With characteristic Without characteristic Medication discrepancy Nighttime admission (after 8 pm) 0.43 ± 0.81 0.61 ± 1.11 0.18 (-0.19 to 0.57) Length of stay ≥ 48 hr 0.57 ± 1.06 0.46 ± 0.78 -0.11 (-0.71 to 0.49) Age ≥ 80 yr 0.75 ± 1.28 0.48 ± 0.89 -0.27 (-0.63 to 0.08) Female sex 0.63 ± 1.11 0.50 ± 0.97 -0.13 (-0.47 to 0.20) ≥ 8 medications on best-possible medication history 1.09 ± 1.41 0.24 ± 0.50 -0.84 (-1.16 to -0.53) Prepopulated medication reconciliation form 0.55 ± 1.05 0.75 ± 0.89 0.20 (-0.55 to 0.94) Cognitive impairment 1.31 ± 1.84 0.49 ± 0.91 -0.81 (-1.40 to -0.23) Error of commission Nighttime admission (after 8 pm) 0.20 ± 0.46 0.17 ± 0.46 -0.03 (-0.20 to 0.14) Length of stay ≥ 48 hr 0.17 ± 0.45 0.23 ± 0.60 0.06 (-0.21 to 0.32) Age ≥ 80 yr 0.21 ± 0.50 0.17 ± 0.44 -0.04 (-0.20 to 0.12) Female sex 0.24 ± 0.55 0.13 ± 0.37 -0.11 (-0.26 to 0.03) ≥ 8 medications on best-possible medication history 0.28 ± 0.56 0.12 ± 0.38 -0.16 (-0.32 to -0.01) Prepopulated medication reconciliation form 0.18 ± 0.47 0.13 ± 0.35 -0.06 (-0.39 to 0.28) Cognitive impairment 0.15 ± 0.38 0.18 ± 0.47 0.03 (-0.24 to 0.29) Note: CI = confidence interval, SD = standard deviation.
- Table 6: Univariate and multivariate associations of patient characteristics with medication discrepancies or errors of commission
Characteristic Unadjusted OR
(95% CI)Adjusted OR
(95% CI)*Age ≥ 80 yr 1.64 (0.82-3.29) 1.14 (0.50-2.64) Female sex 1.52 (0.79-2.93) 1.52 (0.74-3.12) ≥ 8 medications on best possible medication history 5.00 (2.45-10.17) 5.05 (2.44-10.46) Cognitive impairment 2.64 (0.82-8.52) 2.29 (0.55-9.58) Medication history not verified 0.84 (0.42-1.70 1.10 (0.49-2.44) Note: CI = confidence interval, OR = odds ratio.
*Adjusted for age, sex, cognitive impairment, ≥ 8 medications on best-possible medication history and not having a medication history completed.
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