CANADIAN SOCIETY OF HOSPITAL PHARMACISTS S TO ASK QUESTION ATIONS UR MEDIC ABOUT YeOyour doctor,
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CPDN thanks all front line workers for making a difference during the pandemic
You keep essential medicines in stock for patients in need.
24 HOSPITAL NEWS JUNE 2021
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may cause errors, such as improper inntegration of medication changes from m the hospital with the patient’s home me medication regimen. Niagara Health identified the trannsition of care at patient discharge as an n opportunity to enhance patient care. e. To address this, a team participated in the Medication Safety at Care Transitions – Safety Improvement Project led by the Canadian Patient Safety Institute (Healthcare Excellence Canada) with subject matter expertise support from ISMP Canada. Led by a pharmacist, the team implemented medication reconciliation (MedRec) at discharge for vascular surgical post-operative patients. Prior
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atients discharged from a hospital may have mixed feelings: on the one hand, grateful to go home, but on the other hand, stressed and confused. Healthcare providers sometimes forget that patients are receiving a large volume of information at once, including new, changed, or discontinued medications. In fact, patients’ lack of understanding of their medication changes is a common cause of preventable adverse drug events. A recent study by Weir showed that patients did not accurately follow 25 per cent of all hospital medication changes after being discharged from the hospital. At the same time, system issues
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to patient discharge, the pharmacist harmacist compared the discharge prescription i ti with the patient’s best possible medication history (BPMH) from admission and resolved any discrepancies with the prescriber in order to prevent medication errors. The pharmacist also counselled patients on opioid safety, and on any new changes to their medications. This intervention had a significant impact. In July 2019, only 22 per cent of vascular surgical patients were receiving medication reconciliation on discharge. By the end of the intervention, that number changed to over 90 per cent. The team saw first-hand the effects this had on patient safety. For instance, one patient experiencing post-procedure diabetic ketoacidosis had changes made to their insulin regimen while in hospital. Upon discharge, the patient received instructions to go back on their home insulin regimen. However, their home regimen did not match the insulin regimen that the patient was currently receiving in hospital. This could have caused a repeat adverse drug event, re-admission, or potential harm to the patient. Thanks to this intervention, a pharmacist caught this “near miss” during the MedRec at discharge. They counselled the patient to ensure they understood the changes to their insulin regimen, and the patient went home safely. Along with patients, healthcare providers also found this new practice tremendously valuable. One prescriber at Niagara Health shared: “A multitude of surgical patients are seen for
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differentt reasons by diff b generall internal i t l medicine. Prescriptions can change dramatically from home and the surgeons are unfamiliar with many of the changes and meds. I am feeling 100 per cent more comfortable with the prescriptions being sent home after the pharmacy review.” Even when the COVID-19 pandemic hit, the team at Niagara Health was determined to continue conducting MedRec and patient counselling on discharge. They showed their creativity with some innovative methods of reaching patients, like using phone interviews to connect with personal care providers at home. With COVID-19 restricting hospital visitors, patients often did not have their loved ones with them at the time of discharge to help retain critical information about medication changes. To make sure that the key information made it home, a Niagara Health pharmacist completed patient counselling with the patient and their personal care provider in a drive-thru lane outdoors prior to the patient going home – a true example of curbside service! MedRec on discharge and patient medication discharge counselling is an integral component of the care process. In addition to the vascular patients, the team observed collateral benefits across the entire surgical program. The team at Niagara Health plans to build a long-term sustainability plan with additional pharmacy support at discharge. www.hospitalnews.com
