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.

This study was published in 

Annals of Internal Medicine. 2012 Jul;157(1):1-10. CLICK HERE
BY
Akshaya Srikanth
Pharm.D Intern
Hyderabad, India