Resumen de Errors in hospitalization related to care transitions: What comes after medication reconciliation?
Elena Villamañán Bueno, Yolanda Larrubia, Cristina Rueda Pérez, M. Moro, A. Sierra
Objective: To evaluate drug prescription and administration errors after Medication Reconciliation (MR) involving Medications Not Available in the Hospital (MNAH) prescribed prior to admission. Method: We conducted a cross-sectional, observational study in an academic medical center using Computerized Physician-Order Entry (CPOE). After MR at admission, when clinicians decided that these medications need to be continued during hospitalization, since they are not included in the CPOE database, they are prescribed selecting in the program a generic product, «MNAH». Then in a free text field the name and dose of the drug has to be typed. For these types of prescriptions, unlike with available drugs in the program, the Clinical Decision Support (CDS) of the CPOE does not work. The main measured outcome was medication errors involving MNAH detected in prescription and administration phases. Results: We analyzed 338 MNAH prescribed to 207 inpatients, mainly for chronic cardiovascular diseases. We detected 211 prescription errors (62.4%, 95% CI: 57-67.6) most of them related to administration route and dose and 47 drug administration errors (13.9%, 95% CI: 10.4-18). Omission was the principal type of error in both cases. The main causes of these errors were CPOE program deficiencies (62.1%, 95% CI: 55.1-68.6) and lack of information about medication history in medical records (31.3%, 95% CI: 25.1-38). Most errors did not reach the patient or reached the patient without causing harm. Errors that caused harm to patients were due in all cases to duplicity in the drug administration. Clinicians considered that 65.9% (95% CI: 59-72.2) of errors were avoidable by improving CPOE characteristics. Conclusion: Errors associated with prescription and administration of MNAH after medication reconciliation are prevalent among adult inpatients. Our results suggest that there are three main weak points regarding prescription and administration of chronic treatments in care transitions that lead to errors. First, lack of coordination and available information for clinicians, both in primary care and hospitalization, about medication history of patients. Second, CPOE deficiencies related to MNAH prescription. Finally, lack of standardization in the phases of the medication use process, mainly in administration phase, increases likelihood of failures
