CRITICAL EVALUATION OF PATIENT CARE

Critical Evaluation of Patient Care

Critical Evaluation of Patient Care

Introduction

A “transitional care pharmacist” (TCP) was deployed within an acute care setting to identify opportunities for improved continuity of care. The provision of medication reconciliation services, drug consultation, patient counseling and planning for after-hospital care was time consuming but also fruitful, resulting in roughly nine interventions per patient. Areas with the greatest potential for morbidity reduction were the resumption of home medications during the acute stay and at discharge. Allergy identification was a key contribution at admission, as was the provision of a detailed follow-up plan at discharge. Targeting high-risk patients and spreading portions of the work to other disciplines could achieve added efficiency in this service. Results have value to hospitals implementing medication reconciliation programs.

Patient transitions across settings of care are a major cause of medication errors and adverse drug events (ADEs) (Forster et al 2003; Boockvar et al 2004). An important component of these transitions is the accurate and complete transfer of a patient's medication information (Sexton et al 2000). In 2005, the Joint Commission on the Accreditation of Health Care Organizations (JCAHO) made “medication reconciliation” a national patient safety goal (JCAHO 2005). However, no direction in accomplishing this goal is widely available (Barnsteiner 2005) and limitations exist for many of the current localized attempts at safe practice (Gleason et al 2004).

One potential approach to improving medication safety during transitions in care is the development of integrated information systems. However, earlier work suggests that there are vulnerabilities in the care process despite attempts to smooth transitions using electronic medical record systems (Bayley et al 2003b). To address these vulnerabilities requires more than a conduit for the transmission of an improved care plan; it requires the use of a “linking agent” to bridge the gap across settings (Bayley and Savitz 2004).

A number of studies have explored the use of pharmacists at various points in the acute care stay. For example, admission medication histories taken by pharmacists have proved more accurate and complete than those taken by nurses (Gleason et al 2004), and pharmacy technicians are effective in the role of reconciling medication information (Michels and Meisel 2003). Pharmacists participating in medical rounds reduce medication errors in the ordering stage as well as acute care costs (Leape et al 1995, 1999; Boyko, Jr. et al 1997; McMullin et al 1999; Scarsi et al 2002; Kucukarslan et al 2003). Pharmacists provide effective discharge education (Cameron 1994) and can reduce later emergency department visits by making follow-up phone calls to patients post-discharge (Dudas et al 2001).

Literature Review

The present study describes the role of a TCP. We also describe the specific improvement opportunities available throughout a hospital stay and upon discharge.

The study was carried out at a 483-bed, tertiary care community hospital in Portland, Oregon. The study hospital is part of a fully-integrated delivery system that also includes health plans, medical group, and home and community services. Eligible participants in the study were HMO Medicare patients whose primary ...