Identifying opportunities to improve medication management in transitions of care.
OBJECTIVE
The types and causes of medication discrepancies during the transition from inpatient to ambulatory care were investigated.


METHODS
A descriptive study was conducted at an academic outpatient group practice affiliated with a private nonacademic hospital to (1) describe discrepancies between inpatient discharge summaries and patient-reported medication lists, (2) identify patient and system factors related to breakdowns in medication documentation, and (3) determine reasons for medication discrepancies. During a four-month period, 17 patients at high risk for medication misadventures while transitioning from hospital care to outpatient follow-up were contacted by telephone soon after discharge and asked to provide information on all medications they were taking. Patient-reported medication lists were compared with the corresponding discharge summaries, and medication discrepancies were categorized by patient- and system-level factors using a validated instrument.


RESULTS
Of the total of 96 discrepancies identified, more than two thirds (n = 67, 68%) involved the omission of a prescribed medication from either the patient-reported list or the discharge summary. Cardiovascular medications, including antihypertensives, antilipemics, diuretics, and antiarrhythmics, accounted for almost one quarter of all medication discrepancies. About 15% (n = 14) and 16% (n = 15) of identified discrepancies related to medication dose and frequency, respectively.


CONCLUSIONS
Among 17 patients transitioning from inpatient to outpatient care, nearly 100 discrepancies between patient-reported medication lists and discharge summaries were identified. Most discrepancies were attributed to nonintentional nonadherence and resumption of home medications without instructions to do so. All 17 patients had at least 1 medication discrepancy categorized as involving a system-level factor.
Jessica M. Downes, Pharm.D., BCACP, is Clinical Assistant Professor, Department of Pharmacy Practice, University of Nebraska Medical Center, Omaha, and Clinical Pharmacist, One-World Community Health Center, Omaha; at the time of writing, she was Postgraduate Year 2 Pharmacy Resident, University of Oklahoma (OU) College of Pharmacy-Tulsa. Katherine S. O'Neal, Pharm.D., M.B.A., BCACP, CDE, BC-ADM, AE-C, is Assistant Professor, Department of Pharmacy: Clinical and Administrative Sciences, OU College of Pharmacy-Tulsa and Department of Pediatrics, OU School of Community Medicine-Tulsa. Michael J. Miller, B.S.Pharm., Dr.P.H., FAPha, is Associate Professor; and Jeremy L. Johnson, Pharm.D., BCACP, CDE, BC-ADM, is Assistant Professor, Department of Pharmacy Practice, Southwestern Oklahoma State University College of Pharmacy, Weatherford. Brooke L. Gildon, Pharm.D., BCPS, AE-C, is Assistant Professor, Department of Pharmacy: Clinical and Administrative Sciences, OU College of Pharmacy-Tulsa and Department of Pediatrics, OU School of Community Medicine-Tulsa. Michael A. Weisz, M.D., MACP, is Professor, Department of Internal Medicine, OU School of Community Medicine-Tulsa. jessica.downes@unmc.edu.
Jessica M
JM
Downes
Jessica M. Downes, Pharm.D., BCACP, is Clinical Assistant Professor, Department of Pharmacy Practice, University of Nebraska Medical Center, Omaha, and Clinical Pharmacist, One-World Community Health Center, Omaha; at the time of writing, she was Postgraduate Year 2 Pharmacy Resident, University of Oklahoma (OU) College of Pharmacy-Tulsa. Katherine S. O'Neal, Pharm.D., M.B.A., BCACP, CDE, BC-ADM, AE-C, is Assistant Professor, Department of Pharmacy: Clinical and Administrative Sciences, OU College of Pharmacy-Tulsa and Department of Pediatrics, OU School of Community Medicine-Tulsa. Michael J. Miller, B.S.Pharm., Dr.P.H., FAPha, is Associate Professor; and Jeremy L. Johnson, Pharm.D., BCACP, CDE, BC-ADM, is Assistant Professor, Department of Pharmacy Practice, Southwestern Oklahoma State University College of Pharmacy, Weatherford. Brooke L. Gildon, Pharm.D., BCPS, AE-C, is Assistant Professor, Department of Pharmacy: Clinical and Administrative Sciences, OU College of Pharmacy-Tulsa and Department of Pediatrics, OU School of Community Medicine-Tulsa. Michael A. Weisz, M.D., MACP, is Professor, Department of Internal Medicine, OU School of Community Medicine-Tulsa.
Katherine S
KS
O'Neal
Jessica M. Downes, Pharm.D., BCACP, is Clinical Assistant Professor, Department of Pharmacy Practice, University of Nebraska Medical Center, Omaha, and Clinical Pharmacist, One-World Community Health Center, Omaha; at the time of writing, she was Postgraduate Year 2 Pharmacy Resident, University of Oklahoma (OU) College of Pharmacy-Tulsa. Katherine S. O'Neal, Pharm.D., M.B.A., BCACP, CDE, BC-ADM, AE-C, is Assistant Professor, Department of Pharmacy: Clinical and Administrative Sciences, OU College of Pharmacy-Tulsa and Department of Pediatrics, OU School of Community Medicine-Tulsa. Michael J. Miller, B.S.Pharm., Dr.P.H., FAPha, is Associate Professor; and Jeremy L. Johnson, Pharm.D., BCACP, CDE, BC-ADM, is Assistant Professor, Department of Pharmacy Practice, Southwestern Oklahoma State University College of Pharmacy, Weatherford. Brooke L. Gildon, Pharm.D., BCPS, AE-C, is Assistant Professor, Department of Pharmacy: Clinical and Administrative Sciences, OU College of Pharmacy-Tulsa and Department of Pediatrics, OU School of Community Medicine-Tulsa. Michael A. Weisz, M.D., MACP, is Professor, Department of Internal Medicine, OU School of Community Medicine-Tulsa.
Michael J
MJ
Miller
Jessica M. Downes, Pharm.D., BCACP, is Clinical Assistant Professor, Department of Pharmacy Practice, University of Nebraska Medical Center, Omaha, and Clinical Pharmacist, One-World Community Health Center, Omaha; at the time of writing, she was Postgraduate Year 2 Pharmacy Resident, University of Oklahoma (OU) College of Pharmacy-Tulsa. Katherine S. O'Neal, Pharm.D., M.B.A., BCACP, CDE, BC-ADM, AE-C, is Assistant Professor, Department of Pharmacy: Clinical and Administrative Sciences, OU College of Pharmacy-Tulsa and Department of Pediatrics, OU School of Community Medicine-Tulsa. Michael J. Miller, B.S.Pharm., Dr.P.H., FAPha, is Associate Professor; and Jeremy L. Johnson, Pharm.D., BCACP, CDE, BC-ADM, is Assistant Professor, Department of Pharmacy Practice, Southwestern Oklahoma State University College of Pharmacy, Weatherford. Brooke L. Gildon, Pharm.D., BCPS, AE-C, is Assistant Professor, Department of Pharmacy: Clinical and Administrative Sciences, OU College of Pharmacy-Tulsa and Department of Pediatrics, OU School of Community Medicine-Tulsa. Michael A. Weisz, M.D., MACP, is Professor, Department of Internal Medicine, OU School of Community Medicine-Tulsa.
Jeremy L
JL
Johnson
Jessica M. Downes, Pharm.D., BCACP, is Clinical Assistant Professor, Department of Pharmacy Practice, University of Nebraska Medical Center, Omaha, and Clinical Pharmacist, One-World Community Health Center, Omaha; at the time of writing, she was Postgraduate Year 2 Pharmacy Resident, University of Oklahoma (OU) College of Pharmacy-Tulsa. Katherine S. O'Neal, Pharm.D., M.B.A., BCACP, CDE, BC-ADM, AE-C, is Assistant Professor, Department of Pharmacy: Clinical and Administrative Sciences, OU College of Pharmacy-Tulsa and Department of Pediatrics, OU School of Community Medicine-Tulsa. Michael J. Miller, B.S.Pharm., Dr.P.H., FAPha, is Associate Professor; and Jeremy L. Johnson, Pharm.D., BCACP, CDE, BC-ADM, is Assistant Professor, Department of Pharmacy Practice, Southwestern Oklahoma State University College of Pharmacy, Weatherford. Brooke L. Gildon, Pharm.D., BCPS, AE-C, is Assistant Professor, Department of Pharmacy: Clinical and Administrative Sciences, OU College of Pharmacy-Tulsa and Department of Pediatrics, OU School of Community Medicine-Tulsa. Michael A. Weisz, M.D., MACP, is Professor, Department of Internal Medicine, OU School of Community Medicine-Tulsa.
Brooke L
BL
Gildon
Jessica M. Downes, Pharm.D., BCACP, is Clinical Assistant Professor, Department of Pharmacy Practice, University of Nebraska Medical Center, Omaha, and Clinical Pharmacist, One-World Community Health Center, Omaha; at the time of writing, she was Postgraduate Year 2 Pharmacy Resident, University of Oklahoma (OU) College of Pharmacy-Tulsa. Katherine S. O'Neal, Pharm.D., M.B.A., BCACP, CDE, BC-ADM, AE-C, is Assistant Professor, Department of Pharmacy: Clinical and Administrative Sciences, OU College of Pharmacy-Tulsa and Department of Pediatrics, OU School of Community Medicine-Tulsa. Michael J. Miller, B.S.Pharm., Dr.P.H., FAPha, is Associate Professor; and Jeremy L. Johnson, Pharm.D., BCACP, CDE, BC-ADM, is Assistant Professor, Department of Pharmacy Practice, Southwestern Oklahoma State University College of Pharmacy, Weatherford. Brooke L. Gildon, Pharm.D., BCPS, AE-C, is Assistant Professor, Department of Pharmacy: Clinical and Administrative Sciences, OU College of Pharmacy-Tulsa and Department of Pediatrics, OU School of Community Medicine-Tulsa. Michael A. Weisz, M.D., MACP, is Professor, Department of Internal Medicine, OU School of Community Medicine-Tulsa.
Michael A
MA
Weisz
D003266:Continuity of Patient Care / Q000706:statistics & numerical data*; D004282:Documentation; D005260:Female; D006801:Humans; D008297:Male; D059065:Medication Reconciliation / Q000145:classification / Q000706:statistics & numerical data*; D010351:Patient Discharge; D012959:Socioeconomic Factors