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August 7, 2019

The Hospitalist, March 2009: New Design for Discharge–Four-part process improves patient outcomes, lowers readmission rates

01/25/2011
With hospitalists playing key roles in improving transitions in care, a new study has tested a low-cost process that shows increases in outpatient follow-up and completed workups soon after hospital discharge. The improvements potentially could lead to better patient outcomes and lower readmission rates, according to Richard B. Balaban, MD, […]
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With hospitalists playing key roles in improving transitions in care, a new study has tested a low-cost process that shows increases in outpatient follow-up and completed workups soon after hospital discharge. The improvements potentially could lead to better patient outcomes and lower readmission rates, according to Richard B. Balaban, MD, who as the medical director of Cambridge Health Alliance’s (CHA) Somerville, Mass., primary-care center and a hospitalist at CHA’s Cambridge Hospital has a unique, dual perspective on the discharge process. Dr. Balaban’s team’s discharge-transfer intervention process, tested in one of the few randomized controlled studies on the subject of transitions of care, is intended to improve communication between hospitalists and primary-care providers, as well as promptly connect inpatients to outpatient providers. It’s also designed to better equip patients to participate in their care and to improve accountability within the medical team.
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http://www.the-hospitalist.org/details/article/182425/New_Design_for_Discharge.html
August 7, 2019

Committee on Identifying and Preventing Medication Errors. Preventing Medication Errors: Quality Chasm Series

01/21/2011
Online Book
In 1996 the Institute of Medicine launched the Quality Chasm Series, a series of reports focused on assessing and improving the nation s quality of health care. Preventing Medication Errors is the newest volume in the series. Responding to the key messages in earlier volumes of the series To Err […]
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In 1996 the Institute of Medicine launched the Quality Chasm Series, a series of reports focused on assessing and improving the nation s quality of health care. Preventing Medication Errors is the newest volume in the series. Responding to the key messages in earlier volumes of the series To Err Is Human (2000), Crossing the Quality Chasm (2001), and Patient Safety (2004) this book sets forth an agenda for improving the safety of medication use. It begins by providing an overview of the system for drug development, regulation, distribution, and use. Preventing Medication Errors also examines the peer-reviewed literature on the incidence and the cost of medication errors and the effectiveness of error prevention strategies. Presenting data that will foster the reduction of medication errors, the book provides action agendas detailing the measures needed to improve the safety of medication use in both the short- and long-term. Patients, primary health care providers, health care organizations, purchasers of group health care, legislators, and those affiliated with providing medications and medication- related products and services will benefit from this guide to reducing medication errors.
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http://www.nap.edu/catalog.php?record_id=11623#description
August 7, 2019

Redefining and Redesigning Hospital Discharge to Enhance Patient Care: A Randomized Controlled Study

01/25/2011
BACKGROUND: Patients are routinely ill-prepared for the transition from hospital to home. Inadequate communication between Hospitalists and primary care providers can further compromise post-discharge care. Redesigning the discharge processmay improve the continuity and the quality of patient care. OBJECTIVES: To evaluate a low-cost intervention designed to promptly reconnect patients to […]
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BACKGROUND: Patients are routinely ill-prepared for the transition from hospital to home. Inadequate communication between Hospitalists and primary care providers can further compromise post-discharge care. Redesigning the discharge processmay improve the continuity and the quality of patient care. OBJECTIVES: To evaluate a low-cost intervention designed to promptly reconnect patients to their “medical home” after hospital discharge. DESIGN: Randomized controlled study. Intervention patients received a “user-friendly” Patient Discharge Form, and upon arrival at home, a telephone outreach from a nurse at their primary care site. PARTICIPANTS: A culturally and linguistically diverse group of patients admitted to a small community teaching hospital. MEASUREMENTS: Four undesirable outcomes were measured after hospital discharge: (1) no outpatient follow-up within 21 days; (2) readmission within 31 days; (3) emergency department visit within 31 days; and (4) failure by the primary care provider to complete an outpatient workup recommended by the hospital doctors. Outcomes of the intervention group were compared to concurrent and historical controls. RESULTS: Only 25.5% of intervention patients had 1 or more undesirable outcomes compared to 55.1% of the concurrent and 55.0% of the historical controls. Notably, only 14.9% of the intervention patients failed to follow-up within 21 days compared to 40.8% of the concurrent and 35.0% of the historical controls. Only 11.5% of recommended outpatient workups in the intervention group were incomplete versus 31.3% in the concurrent and 31.0% in the historical controls. CONCLUSIONS: A low-cost discharge–transfer intervention may improve the rates of outpatient follow-up and of completed workups after hospital discharge.
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http://www.springerlink.com/content/j81085h6634x2665/fulltext.pdf
August 7, 2019

Case Study: Identifying Potential Problems at the Human/Technical Interface in Complex Clinical Systems

01/21/2011
Journal Article
Many who would like to improve patient safety in health care have advocated for the widespread adoption of computerized physician order entry and electronic medical records. However, unforeseen consequences of this new technology may put patients at greater risk of harm, not less. The authors present a clinical scenario that […]
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Many who would like to improve patient safety in health care have advocated for the widespread adoption of computerized physician order entry and electronic medical records. However, unforeseen consequences of this new technology may put patients at greater risk of harm, not less. The authors present a clinical scenario that demonstrates system vulnerabilities in the interface between humans and such technology. Furthermore, the authors suggest that managers could anticipate these vulnerabilities by using techniques such as cause-and-effect analysis or failure mode and effect analysis, both before the installation of electronic medical records and as ongoing surveillance mechanisms. The case study demonstrates that adoption of technology is not a quick fix to the patient safety issue; proactive and ongoing efforts to address the human factors issues raised by the introduction of new technology will be required to prevent patient harm.
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http://ajm.sagepub.com/content/20/6/353.abstract
August 7, 2019

Acute Care/ Hospitalization: Studies suggest ways to improve the hospital discharge process to reduce post-discharge adverse events and rehospitalizations.

01/25/2011
After patients are discharged from U.S. hospitals, 13 percent require rehospitalization and one in five patients suffers an adverse event. Many of these problems are due to inadequate postdischarge followup of patients’ unresolved medical problems. More patients with unresolved problems would receive outpatient workups if their primary care doctors received […]
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After patients are discharged from U.S. hospitals, 13 percent require rehospitalization and one in five patients suffers an adverse event. Many of these problems are due to inadequate postdischarge followup of patients' unresolved medical problems. More patients with unresolved problems would receive outpatient workups if their primary care doctors received the hospital doctors' discharge summary recommendations, concludes a study supported by the Agency for Healthcare Research and Quality (HS14020). A second AHRQ-supported study (HS14289 and HS15905) describes 11 factors that could be modified during the hospital discharge process to reduce posthospital adverse events and rehospitalizations. Both studies are briefly discussed here.
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http://archive.ahrq.gov/research/dec07/1207RA12.htm
August 7, 2019

Drug-Related Problems on Hospital Admission: Relationship to Medication Information Transfer

01/21/2011
Journal Article
BACKGROUND Patients with end-stage renal disease (ESRD) are at risk for drug-related problems (DRPs), especially on hospital admission. OBJECTIVE To identify and characterize the DRPs experienced by patients with ESRD on admission and investigate how these DRPs could be related to gaps in medication information transfer. METHODS Patients with ESRD […]
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BACKGROUND Patients with end-stage renal disease (ESRD) are at risk for drug-related problems (DRPs), especially on hospital admission. OBJECTIVE To identify and characterize the DRPs experienced by patients with ESRD on admission and investigate how these DRPs could be related to gaps in medication information transfer. METHODS Patients with ESRD admitted to the hospital were prospectively identified and clinically assessed by a pharmacist to identify and categorize DRPs on admission. Each DRP was evaluated to determine whether it could have been caused by a gap in medication information transfer. For DRPs caused in this manner, the interface in the information transfer process where the gap may have occurred was determined. RESULTS A total of 199 DRPs were identified in 47 patients with ESRD over a 12 week period. Ninety-two percent of patients had at least one DRP on admission, with an average of 4.2 ± 2.2 DRPs per patient. The most common DRP identified was indication for drug therapy—patient requires drug but is not receiving it (51.3%). Of the total DRPs, 130 (65%) were related to gaps in medication information transfer, with 21.5% occurring between the inpatient hospital and the ambulatory clinic pharmacists and 17.7% between the admitting physician and the patient. CONCLUSIONS Results of this study demonstrate that, in patients with ESRD, DRPs on admission are frequently related to gaps in medication information transfer between healthcare professionals and also between healthcare providers and patients. Improved communication is required at medication information transfer interfaces to prevent these DRPs. Key Words: drug-related problems, end-stage renal disease
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http://www.theannals.com/cgi/content/abstract/40/3/408
August 7, 2019

Adverse drug events due to discontinuations in drug use and dose changes in patients transferred between acute and long-term care facilities

01/21/2011
Journal Article
Background: Care transitions are commonplace for ill older adults, but no studies to our knowledge have examined the occurrence of iatrogenic harm from medication changes during patient transfer. Objectives: To identify medication changes during transfer between hospital and nursing home and adverse drug events (ADEs) caused by these changes. Methods: […]
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Background: Care transitions are commonplace for ill older adults, but no studies to our knowledge have examined the occurrence of iatrogenic harm from medication changes during patient transfer. Objectives: To identify medication changes during transfer between hospital and nursing home and adverse drug events (ADEs) caused by these changes. Methods: Participants were residents of 4 nursing homes in the New York City metropolitan area admitted to 2 academic hospitals. Nursing home and hospital medical records were reviewed to identify changes in medication regimens between sites. Medications were matched and compared regarding dosage, route, and frequency of administration. Two physician investigators used structured implicit review to identify ADEs attributable to transfer-related medication changes. Results: During a total of 122 admissions, the mean numbers of medications altered during transfer from nursing home to hospital and hospital to nursing home were 3.1 and 1.4, respectively (P<.001 for comparison). Most changes in drug use were discontinuations, followed by dose changes and class substitutions. Of 71 bidirectional transfers that were reviewed by 2 physician investigators, ADEs attributable to medication changes occurred during 14 (20%). The overall risk of ADE per drug alteration (n = 320) was 4.4% (95% confidence interval, 2.5%-7.4%). Although most medication changes (8/14) implicated in causing ADEs occurred in the hospital, most ADEs (12/14) occurred in the nursing home after nursing home readmission. Conclusions: Medication changes are common during transfer between hospital and nursing home and are a cause of ADEs. Research is needed on interinstitutional patient care and systems interventions designed to prevent ADEs.
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http://archinte.ama-assn.org/cgi/content/abstract/164/5/545
August 7, 2019

Continuity of Outpatient and Inpatient Care by Primary Care Physicians for Hospitalized Older Adults

04/22/2009
Journal Article
Sharma G, Fletcher K, Zhang D, et.al. JAMA. 2009;301(16):1671-1680. http://jama.jamanetwork.com/article.aspx?articleid=183797 . Accessed August 1, 2014. Continuity of Outpatient and Inpatient Care by Primary Care Physicians for Hospitalized Older Adults. Context Little is known about the extent of continuity of care across the transition from outpatient care to hospitalization. Objectives To […]
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Sharma G, Fletcher K, Zhang D, et.al. JAMA. 2009;301(16):1671-1680. http://jama.jamanetwork.com/article.aspx?articleid=183797 . Accessed August 1, 2014. Continuity of Outpatient and Inpatient Care by Primary Care Physicians for Hospitalized Older Adults. Context Little is known about the extent of continuity of care across the transition from outpatient care to hospitalization. Objectives To describe continuity of care in older hospitalized patients, change in continuity over time, and factors associated with discontinuity.
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http://jama.ama-assn.org/cgi/content/abstract/301/16/1671
August 7, 2019

Rationale and Design of the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD)

03/01/2010
Journal Article
Schnipper J, Roumie C, Cawthon C, et.al. Rationale and Design of the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) Study. Circulation: Cardiovascular Quality and Outcomes. 2010; 3: 212-219. http://circoutcomes.ahajournals.org/content/3/2/212.abstract . Accessed August 1, 2014. Background— Medication errors and adverse drug events are common after hospital discharge due to […]
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Schnipper J, Roumie C, Cawthon C, et.al. Rationale and Design of the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) Study. Circulation: Cardiovascular Quality and Outcomes. 2010; 3: 212-219. http://circoutcomes.ahajournals.org/content/3/2/212.abstract . Accessed August 1, 2014. Background— Medication errors and adverse drug events are common after hospital discharge due to changes in medication regimens, suboptimal discharge instructions, and prolonged time to follow-up. Pharmacist-based interventions may be effective in promoting the safe and effective use of medications, especially among high-risk patients such as those with low health literacy.
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http://circoutcomes.ahajournals.org/content/3/2/212.abstract
August 7, 2019

Design and Implementation of an Application and Associated Services to Support Interdisciplinary Medication Reconciliation Efforts at an Integrated Healthcare Delivery Network

01/21/2011
Journal Article
Confusion about patients’ medication regimens during the hospital admission and discharge process accounts for many preventable and serious medication errors. Many organizations have begun to redesign their clinical processes to address this patient safety concern. Partners HealthCare, an integrated delivery network in Boston, Massachusetts, has answered this interdisciplinary challenge by […]
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Confusion about patients’ medication regimens during the hospital admission and discharge process accounts for many preventable and serious medication errors. Many organizations have begun to redesign their clinical processes to address this patient safety concern. Partners HealthCare, an integrated delivery network in Boston, Massachusetts, has answered this interdisciplinary challenge by leveraging its multiple outpatient electronic medical records (EMR) and inpatient computerized provider order entry (CPOE) systems to facilitate the process of medication reconciliation. This manuscript describes the design of a novel application and the associated services that aggregate medication data from EMR and CPOE systems so that clinicians can efficiently generate an accurate pre-admission medication list. Information collected with the use of this application subsequently supports the writing of admission and discharge orders by physicians, performance of admission assessment by nurses, and reconciliation of inpatient orders by pharmacists. Results from early pilot testing suggest that this new medication reconciliation process is well accepted by clinicians and has significant potential to prevent medication errors during transitions of care.
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http://jamia.bmj.com/content/13/6/581.abstract
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