Nurse-pharmacist teams trained to track down discrepancies between lists of drugs patients take at home and those they are scheduled to take in the hospital might substantially reduce potentially harmful conflicts, according to a study.

Researchers with the Johns Hopkins University School of Medicine said the program could make patients safer while also saving money by reducing potential complications and readmissions.

The researchers said findings of the study, which encompassed more than 500 patients admitted to and discharged from a big-city medical center, lend support to the idea of relieving physicians of the job of reconciling medication lists. Instead, they said, nurses and consulting pharmacists should ensure the list of drugs ordered on admission to and discharge from the hospital matches what each patient was originally taking at home. Such an approach would reduce both the risk of adverse drug interactions and the chance of forgetting vital medications for chronic diseases.

In a report published in the Journal of Hospital Medicine, the researchers found a 40% rate of unintentional discrepancies between lists of drugs patients said they were taking when admitted, drugs they actually receive during a hospital stay and medicines they should be taking on discharge.

Each additional medication a patient took increased by nearly 9% the odds of a medication discrepancy at some point in the admission-to-discharge process, the researchers wrote.

"When we give dedicated time for teams of nurses and consulting pharmacists to find and fix discrepancies, patients will be safer and hospitals will be delighted that patients are being readmitted less often in a day and age when 'readmission’ is a bad word," Leonard S. Feldman, MD, the study’s leader and an assistant professor in the Division of General Internal Medicine at the Johns Hopkins University School of Medicine, said in a news release. "It’s just the right thing to do."

With the increase in chronic conditions, the number of prescription and over-the-counter medications that patients already are on when they arrive at the hospital is ballooning, Feldman said. But once admitted, patients are not always able to remember the names and doses of the drugs they have been taking.

Especially in the rush of a hospital admission, Feldman said, patients cannot always remember everything they take. They may remember only the color and shape of the pill, not its name, dose or reason for taking it. Sometimes the physician will call a primary-care doctor or a pharmacist looking for more information, but he or she often does not have the time, Feldman said. Errors during the taking of medication history — whether of omission or commission — are common and clinically important, he added.

"Many of our patients have limited literacy skills, and we expect them to handle three, four or a dozen medications," Feldman said. "So it’s not hard to imagine that getting accurate medication histories requires some detective work on our part."

Giving such an assignment to nurses and pharmacists should not only prevent errors and potentially save lives, but also save money and reduce complications and readmissions, Feldman said.

Study data

Physicians took a medication history for each of 563 patients, asking them for a home medication list, or HML. That list would typically form the basis of each patient’s medication regimen in the hospital.

In the next part of the study, a nurse interviewed each of the same patients and compiled a separate list. If a patient could not recall medications or specific regimens, the nurse would review the electronic medical record to see whether the patient had a list of medications from a previous hospital discharge. If necessary, the nurse also called the patient’s family, primary care physician and pharmacist for more information. Then the patient was asked to verify the new HML.

The nurses then compared the HML to admission medication orders, creating a list of discrepancies and determining which ones were inadvertent. If the nurse had questions about whether a discrepancy was intended — for example, if a physcian substituted one medication for another upon admission — a pharmacist was consulted. If the nurse found what appeared to be an unintentional discrepancy, the physician was notified and had the opportunity to correct the mistake before it became a problem. Upon discharge, the nurse compared the HML to the discharge orders, again reconciling any discrepancies and bringing potential errors to the physician’s attention.

Of the 563 hospital patients studied between January 2008 and March 2009, 225 had at least one unintended discrepancy. Although there were more unintended discrepancies on admission, 55% of those discrepancies rated a 1 on a potential harm scale, meaning they were unlikely to cause any harm or discomfort. But the unintended discrepancies upon discharge were potentially more harmful, with 85% of them rating a 2 or 3 on the scale, meaning a risk of moderate to severe harm.

Among the problems that can arise from inadvertent omission of medications during a hospital stay are adverse effects such as withdrawal from statins, anti-depressants and blood pressure drugs. Long-term problems may arise if someone is taken off an important osteoporosis medication, aspirin or other drugs for chronic diseases.

Feldman said the additional work cost roughly $32 per patient, and about $114 to find one discrepancy that could cause harm. If each harmful event costs a hospital roughly $9,300 to treat, then preventing one discrepancy in every 290 patient encounters would offset the intervention costs. The researchers believe they might be able to prevent more than 80 adverse events for every 290 patients admitted.

The study, conducted at The Johns Hopkins Hospital, was funded by the Interdisciplinary Nursing Quality Research Initiative of the Robert Wood Johnson Foundation.

To read the study abstract and access the study via subscription or purchase, visit http://bit.ly/K52wJw.