Medication discrepancies upon hospital to skilled nursing facility transitions
Authors
Tjia, JenniferBonner, Alice F.
Briesacher, Becky A.
McGee, Sarah M.
Terrill, Eileen F.
Miller, Kathleen H.
UMass Chan Affiliations
Graduate School of NursingMeyers Primary Care Institute
Department of Medicine, Division of Geriatric Medicine
Document Type
Journal ArticlePublication Date
2009-05-18Keywords
AdultAged
Aged, 80 and over
Continuity of Patient Care
Cross-Sectional Studies
Female
Hospitals
Humans
Male
*Medication Errors
Middle Aged
Patient Transfer
Pharmaceutical Preparations
Skilled Nursing Facilities
Health Services Research
Nursing
Primary Care
Metadata
Show full item recordAbstract
BACKGROUND: Failure to reconcile medications across transitions in care is an important source of harm to patients. Little is known about medication discrepancies upon admission to skilled nursing facilities (SNFs). OBJECTIVE: To describe the prevalence of, type of medications involved in, and sources of medication discrepancies upon admission to the SNF setting. DESIGN: Cross-sectional study. PARTICIPANTS: Patients admitted to SNF for subacute care. MEASUREMENTS: Number of medication discrepancies, defined as unexplained differences among documented medication regimens, including the hospital discharge summary, patient care referral form and SNF admission orders. RESULTS: Of 2,319 medications reviewed on admission, 495 (21.3%) had a medication discrepancy. At least one medication discrepancy was identified in 142 of 199 (71.4%) SNF admissions. The discharge summary and the patient care referral form did not match in 104 of 199 (52.3%) SNF admissions. Disagreement between the discharge summary and the patient care referral form accounted for 62.0% (n = 307) of all medication discrepancies. Cardiovascular agents, opioid analgesics, neuropsychiatric agents, hypoglycemics, antibiotics, and anticoagulants accounted for over 50% of all discrepant medications. CONCLUSIONS: Medication discrepancies occurred in almost three out of four SNF admissions and accounted for one in five medications prescribed on admission. The discharge summary and the patient care referral forms from the discharging institution are often in disagreement. Our study findings underscore the importance of current efforts to improve the quality of inter-institutional communication.Source
J Gen Intern Med. 2009 May;24(5):630-5. Epub 2009 Mar 17. Link to article on publisher's siteDOI
10.1007/s11606-009-0948-2Permanent Link to this Item
http://hdl.handle.net/20.500.14038/37067PubMed ID
19291332Related Resources
Link to Article in PubMedae974a485f413a2113503eed53cd6c53
10.1007/s11606-009-0948-2