Medication Reconciliation: It's in the Bag

Background:

Medication discrepancies, defined as unexplained differences in documented medications between various sites of care, occur in 70% of patients at hospital admission or discharge. These discrepancies may result in serious harm to patients, prolonged hospitalizations, post-discharge emergency department visits, readmissions and use of other healthcare resources. Unplanned readmissions due to medication discrepancies alone cost $17.4 million annually and represented 17% of total hospital payments. Approximately 15% of patients experience a medication error or discrepancy after hospital discharge. These medication errors cost organizations $5.6 million annually. Literature identifies multiple reasonds for the descrepancies including: miscommunication, financial disparities, personal preference, lack of understanding, physical abilities amd health literacy. This prompted the practice question: In adult, in-patient, medical-surgical patients discharged to home with prescriptions, does the implementation of a bag medication reconciliation initiative compared to usual care, result in decreased medication discrepancies?

Evidence Synthesis: 

The Johns Hopkins Nursing Evidence-based Practice Model (Dearholt & Dang, 2012) was used to evaluate the literature. Databases searched included CINAHL, PubMed, AHRQ with key words: “brown bag,” “discharge,” “adverse drug events” and “medication discrepancies”. A total of 41 articles were used for the synthesis. There were 34 quantitative articles, 3 qualitative articles,  1 expert opinion and 3 quality improvement articles deemed good or high quality that were used for the basis of the project.

Translation Model:

The Ottawa model of Research Utilization by Logan and Graham was chosen for translation because of its non-linear approach to translating evidence as well as focusing on patient and family involvement  in projects. This model has a holistic approach to research translation, it is meant to be a guide not a recipe for translation.  

Methods:

The setting was a 572-bed, teaching facility located in south central Pennsylvania. The project unit was general medical telemetry, consisting of 22 beds with a 1:5 nurse-to-patient ratio. Upon discharge, the nurses on the unit gave the medication bag to any patients from either the medical or family practice residency services. Most of the patients received follow-up care at one of two local clinics. The staff at the clinics were required to file a Safety Reporting System (SRS) report when medication discrepancies were noted.  As part of usual care follow-up phone calls were made within 2 days of discharge as well as post-hospitalization follow-up appointments within 7days of discharge. Providers continued to complete medication reconciliation at follow-up. Safety Reporting System events (SRS) were used to document and monitor medication discrepancies. A list was kept of all patients receiving a bag at d/c. The clinics were asked to keep a record of the patients who returned for their follow-up visit with the bag. The only change to the discharge/post-hospitalization care was the initiation of the bag with instructions to bring ALL medications back to the first post-hospitalization follow-up visit. The primary source for data collection was the SRS reports. Demographic data were obtained by chart review and utilized to identify correlations. Pre and post-intervention data were evaluated.

The medication bag had specific instructions for the patients and family which included: all prescription medications, all over-the-counter medications, all herbal alternative medications, any organizational medication boxes, a list of all doctors with phone numbers, a list of all allergies especially to foods or medications, a list of any questions or concerns related to medications, and a spouse or caregiver. 

Results:

A decrease in recorded SRS was noted after the implementation. Pre-implementation data revealed 22 SRS filed from a total of 236 patients discharged to home (9.3%). Post-implementation: 4 SRS filed from a total of 203 patients (2.0%). No specific demographic correlations were identified. According to hospital administrators patients readmitted to the hospital stay approximately three days at a cost of $10,240.00 per patient. The cost of implementing the bag medication reconciliation intervention was $1782.00.  If the implementation of a medication bag prevented 1 readmission per quarter, there would be cost avoidance of 40,960.00 annually. 

 

Implications:

Evidence suggests bag medication reconciliation events decrease medication discrepancies and offer a complete picture of individual medication usage. This community-based bag medication reconciliation project demonstrated effectiveness in evaluating current medication use and identifying medication discrepancies. The bag medication reconciliation project was an overall success. Patients received an intervention which helped with medication reconciliation. Though limitations and potential future projects were identified, the benefit of the intervention was established.