Serious Post-Discharge Medication Errors Are Common

By: Pharma Tips | Views: 1830 | Date: 17-Aug-2013

A study in two academic hospital centers in the U.S. finds that medication errors after discharge for treatment of cardiovascular disease are common and that a pharmacist-based intervention to address the problem may have little benefit. The study appears in the Annals of Internal Medicine.

Serious Post-Discharge Medication Errors Are Common




A study in two academic hospital centers in the U.S. finds that medication errors after discharge for treatment of cardiovascular disease are common and that a pharmacist-based intervention to address the problem may have little benefit. The study appears in the Annals of Internal Medicine.

Researchers studied 850 patients hospitalized with acute coronary syndrome or heart failure. Participants were randomized to usual care or to an intervention consisting of medication reconciliation by a pharmacist, counseling, provision of aids (like pill boxes) to increase adherence, and telephone follow-up. The incidence of medication errors at 30 days did not differ significantly between the groups (about 50% in each). Roughly 75% of errors were characterized as "significant" in severity, 23% as "serious," and 2% as "life-threatening."

Examples of adverse drug events included a patient found to have an INR higher than 14 at 8 days after discharge, and a patient whose insulin dose was poorly managed, resulting in several episodes of hypoglycemia.

In conclusion, they found that clinically important medication errors commonly occur during the 30 days after a cardiac hospitalization, and we report a much higher incidence than previously shown for preventable or ameliorable ADEs, as well as potential ADEs. A health-literacy–sensitive pharmacist intervention that included postdischarge telephone follow-up did not improve medication safety overall. Reducing ADEs and potential ADEs in the postdischarge period is becoming more critical as hospitals have increasing financial penalties tied to rehospitalization rates. Further work is needed to develop and test interventions in this setting, including strategies for higher-risk populations, as well as additional methods, such as postdischarge medication reconciliation (33) or closer postdischarge surveillance.


Background: Clinically important medication errors are common after hospital discharge. They include preventable or ameliorable adverse drug events (ADEs), as well as medication discrepancies or nonadherence with high potential for future harm (potential ADEs).

Objective: To determine the effect of a tailored intervention on the occurrence of clinically important medication errors after hospital discharge.

Design: Randomized, controlled trial with concealed allocation and blinded outcome assessors. (ClinicalTrials.gov registration number: NCT00632021)

Setting: Two tertiary care academic hospitals.

Patients: Adults hospitalized with acute coronary syndromes or acute decompensated heart failure.

Intervention: Pharmacist-assisted medication reconciliation, inpatient pharmacist counseling, low-literacy adherence aids, and individualized telephone follow-up after discharge.

Measurements: The primary outcome was the number of clinically important medication errors per patient during the first 30 days after hospital discharge. Secondary outcomes included preventable or ameliorable ADEs, as well as potential ADEs.

Results: Among 851 participants, 432 (50.8%) had 1 or more clinically important medication errors; 22.9% of such errors were judged to be serious and 1.8% life-threatening. Adverse drug events occurred in 258 patients (30.3%) and potential ADEs in 253 patients (29.7%). The intervention did not significantly alter the per-patient number of clinically important medication errors (unadjusted incidence rate ratio, 0.92 [95% CI, 0.77 to 1.10]) or ADEs (unadjusted incidence rate ratio, 1.09 [CI, 0.86 to 1.39]). Patients in the intervention group tended to have fewer potential ADEs (unadjusted incidence rate ratio, 0.80 [CI, 0.61 to 1.04]).

Limitation: The characteristics of the study hospitals and participants may limit generalizability.

Conclusion: Clinically important medication errors were present among one half of patients after hospital discharge and were not significantly reduced by a health-literacy–sensitive, pharmacist-delivered intervention.

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