Discussion
In our study, our team observed a good number of medication
discrepancies, more than half (73.5%) of which were likely to cause
patients moderate to significant discomfort or clinical deterioration.
These results endorsed that clinical pharmacists are crucial in both
detection and avoidance of medication errors and consistent to the
findings of earlier studies on pharmacists’ positive role in medication
reconciliation[2-4], and also a recent systematic
review demonstrated that medication reconciliation performed by
pharmacist was effective in reducing medication
discrepancies[21]. In addition, our study further
supported the role of pharmacist trainees for obtaining medication
histories. Moreover, as far as we know, this is the first study to
explore the prevalence and risk factors for UMDs and
involve clinical pharmacist trainees
in the medication reconciliation procedure in China.
Our results found that 22.4% of study patients experienced one or more
UMDs between physician admission medication orders and a BPMH; this
result is in line with the earlier studies, which revealed UMD rate of
between 8.1% and 53.6% in various clinical
settings[4, 19, 22]. These high rates of UMD at
admission highlight the importance of close monitoring on drug treatment
plan at transitions. And these differences of the UMD rate may because
of the various study designs, clinical settings and studied patients. We
also found that more than half of these UMDs involved medications
belongs to the ATC class C (cardiovascular system) (53.0%), which is
also consistent with findings of previous studies[4,
23].
The most frequent type of UMD in our study was the omission of home
medications (40.8%), followed by incorrect dose (20.5%), which is in
accordance with previous research findings[4, 24].
While most of medication omissions were unlikely to cause severe
discomfort or clinical deterioration, however, patient clinical
consequences of related errors may be more disastrous in some cases. For
example, one of the potential severe medication errors identified in our
study was omission of warfarin in a patient with valvular atrial
fibrillation and cerebral infarction. It is well known that doctors have
difficulty in obtaining an accurate and through medication history on
hospital admission and pharmacists are more competent than doctors in
this field[12], which is also verified by our
study.
Our study showed that 73.5% of UMDs were evaluated to be prone to cause
moderate to severe discomfort or clinical deterioration. We applied the
same approach to assess clinical impact as Cornish PL et
al[19] that firstly developed the method to
evaluate the potential damage of medication discrepancy at transitions.
However, previous studies have identified a wide range of UMDs at the
rate of 10% up to 68% which were likely to cause moderate to severe
potential damage to patients[4, 23-25]. Our
results are higher than that of previous studies possibly because
cardiovascular drugs were responsible for more than half of all these
which were more likely to cause significant damage than other kind of
drugs. Besides comparing clinical impact between different studies is
challenging due to the considerable variability and subjectivity in
methods of evaluation of clinical impact. The potentially severe nature
of some UMDs emphasizes the importance of conducting medication
reconciliation within 48 hours after hospital admission.
There are different results from earlier studies on risk factors for
UMDs at admission. In our study, 2 or more chronic diseases at admission
and 5 or more drugs on the BMPH were identified as independent
predictors of UMDs. Our study found a 3.25-fold higher risk in patients
receiving more than 5 drugs at hospital admission compared with 3.03-4.7
-fold in other studies[2, 26]. While other studies
also reported a correlation between unintentional discrepancies and the
number of medications at hospital admission[4,
23]. Besides that, our study identified 2 or more chronic diseases as
predictors of UMDs, while Pardo-Cabello AJ et
al[27] identified a Charlson Comorbidity score ≥2
as a predictive factor for UMDs which is not as convenient as our
predictor.
None of the sociodemographic
variables (i.e. age, sex, educational level, or living alone)
investigated in the current study were correlated with the presence of
UMDs at admission, in line with previous studies[4,
28]. However, unlike previous studies[29, 30],
admitting physician experience was not an independent risk factor for
medication reconciliation errors at admission. Perhaps because that
overwhelming majority of our study patients were admitted by interns,
which is very common in China that intern and junior doctors
generally take charge
of medication history collection work due to the shortage of medical
staff and overhospitalization.
Our findings have underlined the
significance of accurate medication
reconciliation conducted by a pharmacist in diminishing medication
discrepancy errors and promoting patient safety at hospital admission.
We would like to vigorously promote
the application of a systematic medication reconciliation procedure in
our hospital and other hospitals in China as well as the participation
of clinical pharmacists in conducting this process by the WHO High 5s
protocol at transitions. We are aware that not all Chinese hospitals
have a certificated clinical pharmacist to perform the medication
reconciliation process[31], therefore we would
recommend that strictly trained pharmacists shall participate this task.
This study has some important limitations. Firstly, it was conducted at
a single teaching hospital on a limited sample size of patients admitted
to four medicine units due to the shortage of clinical pharmacists.
Other departments may have different rates of UMDs. Secondly, the
categorization of unintentional medication discrepancies into medication
errors was partially based on subjective judgment from expert panel and
is accordingly subject to bias. Thirdly, our clinical harm evaluation
for UMDs was ‘potential’ harm rated by expert panel and the actual harm
of errors prevented is unclear. It’s hard to know the effect of
pharmaceutical interventions on medical outcomes since the eligible
patients were not followed beyond the study.