Use of complete medication history to identify and correct transitions-of-care medication errors at psychiatric hospital admission

Abstract

Methods for categorizing the scale and severity of medication errors corrected by pharmacy staff during admission medication reconciliation using complete medication history continue to evolve. We established a rating scale that is effective for generating error reports to health system quality leadership. These reports are needed to quantify the value of investment in transitions-of-care pharmacy staff. All medication errors that were reported by pharmacy staff in the admission medication reconciliation process during a period of 6 months were eligible for inclusion. Complete medication history data source was utilized by admitting providers and all pharmacist staff and a novel medication error scoring methodology was developed. This methodology included: medication error category, medication error type, potential medication error severity, and medication non-adherence. We determined that 82 medication errors were detected from 72 patients and assessed that 74 of these errors may have harmed patients if they were not corrected through pharmacist intervention. Most of these errors were dosage discrepancies and omissions. With hospital system budgets continually becoming leaner, it is important to measure the effectiveness and value of staff resources to optimize patient care. Pharmacists performing admission medication reconciliation can detect subtle medication discrepancies that may be overlooked by other clinician types. This methodology can serve as a foundation for error reporting and predicting the severity of adverse drug events.