The effect of a clinical pharmacist discharge service on medication discrepancies in patients with heart failure

Rixt Nynke Eggink, Albert W Lenderink, Jos W M G Widdershoven, Patricia M L A van den Bemt, Rixt Nynke Eggink, Albert W Lenderink, Jos W M G Widdershoven, Patricia M L A van den Bemt

Abstract

Objective: Heart failure patients are regularly admitted to hospital and frequently use multiple medication. Besides intentional changes in pharmacotherapy, unintentional changes may occur during hospitalisation. The aim of this study was to investigate the effect of a clinical pharmacist discharge service on medication discrepancies and prescription errors in patients with heart failure.

Setting: A general teaching hospital in Tilburg, the Netherlands.

Method: An open randomized intervention study was performed comparing an intervention group, with a control group receiving regular care by doctors and nurses. The clinical pharmacist discharge service consisted of review of discharge medication, communicating prescribing errors with the cardiologist, giving patients information, preparation of a written overview of the discharge medication and communication to both the community pharmacist and the general practitioner about this medication. Within 6 weeks after discharge all patients were routinely scheduled to visit the outpatient clinic and medication discrepancies were measured.

Main outcome measure: The primary endpoint was the frequency of prescription errors in the discharge medication and medication discrepancies after discharge combined.

Results: Forty-four patients were included in the control group and 41 in the intervention group. Sixty-eight percent of patients in the control group had at least one discrepancy or prescription error against 39% in the intervention group (RR 0.57 (95% CI 0.37-0.88)). The percentage of medications with a discrepancy or prescription error in the control group was 14.6% and in the intervention group it was 6.1% (RR 0.42 (95% CI 0.27-0.66)).

Conclusion: This clinical pharmacist discharge service significantly reduces the risk of discrepancies and prescription errors in medication of patients with heart failure in the 1st month after discharge.

Figures

Fig. 1
Fig. 1
Study participant flowchart

References

    1. Jaarsma T, Haaijer-Ruskamp FM, Sturm H, Van Veldhuisen DJ. Management of heart failure in The Netherlands. Eur J Heart Fail. 2005;7:371–375. doi: 10.1016/j.ejheart.2005.01.007.
    1. Dickstein K, Cohen-Solal A, Filippatos G, McMurray JJ, Ponikowski P, Poole-Wilson PA et al. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM). Eur Heart J. 2008;29(19):2388–442.
    1. Michalsen A, Köning G, Thimme W. Preventable causative factors leading to hospital admission with decompensated heart failure. Heart. 1998;80:437–441.
    1. Coleman EA, Smith JD, Raha D, Min SJ. Posthospital medication discrepancies, prevalence’s and contributing factors. Arch Intern Med. 2005;165:1842–1847. doi: 10.1001/archinte.165.16.1842.
    1. Koshman SH, Charrois TL, Simpson SH, McAlister FA, Tsuyuki RT. Pharmacist care of patients with heart failure, a systematic review of randomized trials. Arch Intern Med. 2008;168(7):687–694. doi: 10.1001/archinte.168.7.687.
    1. Yu DSF, Thompson DR, Lee DTF. Disease management programmes for older people with heart failure: crucial characteristics which improve post-discharge outcomes. Eur J Heart Fail. 2006;27:596–612.
    1. Murray MD, Young J, Hoke S, Tu W, Weiner M, Morrow D, et al. Pharmacist intervention to improve medication adherence in heart failure, a randomized trial. Ann Intern Med. 2007;146:714–725.
    1. Holland R, Brooksby I, Lenaghan E, Ashton K, Hay L, Smith R, et al. Effectiveness of visits from community pharmacists for patients with heart failure: HeartMed randomised controlled trial. BMJ. 2007. doi:10.1136/.
    1. Kripalani A, LeFevre F, O’Philips C, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians, Implications for patient safety and continuity of care. JAMA. 2007;297:831–841. doi: 10.1001/jama.297.8.831.
    1. Al-Rashed SA, Wright DJ, Roebuck N, Sunter W, Chrystyn H. The value of inpatient pharmaceutical counselling to elderly patients prior to discharge. Br J Clin Pharmacol. 2002;54:657–664. doi: 10.1046/j.1365-2125.2002.01707.x.
    1. Duggan C, Feldman R, Hough J, Bates I. Reducing adverse prescribing discrepancies following hospital discharge. Int J Pharm Pract. 1998;6:77–82.
    1. Van den Bemt PM, van den Broek S, van Nunen AK, Harbers JB, Lenderink AW. Effect of medication reconciliation performed by pharmacy technicians on medication discrepancies at the time of pre-operative screening. Ann Pharmacother. 2009;43:868–874. doi: 10.1345/aph.1L579.
    1. Karapinar-Çarkit F, Borgsteede SD, Zoer J, Smit HJ, Egberts AC, van den Bemt PM. The effect of medication reconciliation with and without patient counseling on the number of pharmaceutical interventions among patients discharged from the hospital. Ann Pharmacother. 2009;43:1001–1010. doi: 10.1345/aph.1L597.
    1. von Korff M, Wagner EH, Saunders K. A chronic disease score from automated pharmacy data. J Clin Epidemiol. 1992;45(2):197–203. doi: 10.1016/0895-4356(92)90016-G.
    1. Svarstad BL, Chewining BA, Sleath BL, Claesson C. The brief medication questionnaire: a tool for screening patient adherence and barriers to adherence. Patient Educ Couns. 1999;37(2):113–124. doi: 10.1016/S0738-3991(98)00107-4.
    1. National Coordinating Council for Medication Error Reporting and Prevention (NNCMERP). . Accessed 26 June 2010.
    1. Dupont WD, Plummer WD Jr. PS power and sample size calculation. . Accessed 26 June 2010.
    1. Moore C, Wisnivesky J, Williams S, McGinn T. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. J Gen Intern Med. 2003;18:646–651. doi: 10.1046/j.1525-1497.2003.20722.x.
    1. Omori Dm, Potyk RP, Kroenke K. The adverse effects of hospitalization on drug regimens. Arch Intern Med. 1991;151:1562–1564. doi: 10.1001/archinte.151.8.1562.
    1. Koelling TM, Johnson ML, Cody RJ, Aaronson KD. Discharge education improves clinical outcomes in patient with chronic heart failure. Circulation. 2005;111:179–185. doi: 10.1161/01.CIR.0000151811.53450.B8.
    1. Phillips CO, Wright SM, Kern DE, Singa RM, Shepperd S, Rubin HR. Comprehensive discharge planning with post discharge support for older patients with congestive heart failure, a meta analysis. JAMA. 2004;291(11):1358–1367. doi: 10.1001/jama.291.11.1358.
    1. Rainville EC. Impact of pharmacist interventions on hospital readmissions for heart failure. Am J Health Syst Pharm. 1999;56(13):1339–1342.
    1. Stewart S, Pearson S, Horowitz JD. Effects of a home-based intervention among patients with congestive heart failure discharged from acute hospital care. Arch Intern Med. 1998;158(10):1067–1072. doi: 10.1001/archinte.158.10.1067.
    1. Walker PC, Bernstein SJ, Jones JN, Piersma J, Kim HW, Regal RE, et al. Impact of a pharmacist-facilitated hospital discharge program, a quasi-experimental study. Arch Intern Med. 2009;169(21):2003–2010. doi: 10.1001/archinternmed.2009.398.
    1. Wong JD, Bajcar JM, Wong GG, Alibhai SMH, Huh JH, Cesta A, et al. Medication reconciliation at hospital discharge: evaluating discrepancies. Ann Pharmacother. 2008;42(10):1373–1379.
    1. Vira T, Colquhuin M, Etchells E. Reconciliable differences: correcting medication errors at hospital admission and discharge. Qual Saf Health Care. 2006;15(2):122–126. doi: 10.1136/qshc.2005.015347.
    1. Haynes RB, Ackloo E, Sahota N, McDonald HP, Yao X. Interventions to enhance medication adherence. Cochrane Database Syst Rev. 2008, Issue 2. Art No: CD000011. doi:1002/14651858.CD000011.pub3.
    1. Bolas H, Brookes K, Scott M, McElnay J. Evaluation of a hospital-based community liaison pharmacy service in northern Ireland. Pharm World Sci. 2004;26:114–120. doi: 10.1023/B:PHAR.0000018601.11248.89.
    1. van Doormaal JE, Mol PG, van den Bemt PM, Zaal RJ, Egberts AC, Kosterink JG, et al. Reliability of the assessment of preventable adverse drug events in daily clinical practice. Pharmacoepidemiol Drug Saf. 2008;17(7):645–654. doi: 10.1002/pds.1586.

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