research paper

Research Article

Use of an Anti-Infective Medication Review Process at Hospital Discharge to Identify Medication Errors and Optimize Therapy

Christy P. Su, PharmD, BCPS 1 , Levita Hidayat, PharmD

2 ,

Shafiqur Rahman, MD 3 , and Veena Venugopalan, PharmD, BCPS, AQ-ID

4

Abstract Background: Medication reconciliation is a major patient safety concern, and the impact of a structured process to evaluate anti- infective agents at hospital discharge warrants further review. Objective: The aim of this study was to (1) describe a structured, multidisciplinary approach to review anti-infectives at discharge and (2) measure the impact of a stewardship-initiated anti- microbial review process in identifying and preventing anti-infective-related medication errors (MEs) at discharge. Methods: A prospective study to evaluate adult patients discharged on anti-infectives was conducted from October 2013 to May 2014. The antimicrobial stewardship program (ASP) classified interventions on anti-infective regimens into predefined ME categories. Results: Forty-five patients who were discharged on 59 anti-infective prescriptions were included in the study. The most common indications for anti-infective regimens at discharge were pneumonia (22%, n ¼ 10), bacteremia (18%, n ¼ 8), and skin and soft tissue infections (16%, n ¼ 7). An ME was identified in 42% (n ¼ 19/45) of anti-infective regimens. Seventy percentage of ASP team recommendations were accepted which resulted in an avoidance of MEs in 68% (n ¼ 13/19) of patients with an ME prior to discharge. Conclusion: This study describes the outcomes of a stewardship-initiated review process in preventing MEs at discharge. Developing a systematic process for a multidisciplinary ASP team to review all anti-infectives can be a valuable tool in preventing MEs at hospital discharge.

Keywords antimicrobial stewardship, transitions of care, hospital discharge, medication errors, medication reconciliation

Introduction

Transition of care from hospital to community can be a high-

risk period for medication errors (MEs). 1

The National

Coordinating Council for Medication Error Reporting and

Prevention (NCCMERP) defines ME as any preventable event

that may cause or lead to inappropriate medication use or

patient harm, while the medication is in the control of the

health-care provider, patient, or consumer. 2

Forster and col-

leagues noted that 66% of adverse events (AEs) occurring in patients following hospital discharge were medication related

and could be prevented in 27% of cases. Furthermore, anti- infective agents were identified as one of the most common

medication classes associated with adverse drug events with a

reported rate of 5.1 AE per 100 prescriptions. 3,4

ME prevention is a major patient safety concern which has

received national attention. 5

Many patients who receive anti-

microbials in hospitals are also discharged on antimicrobial

therapy, to complete the treatment course at home, in long-

term acute care centers, skilled nursing facilities, outpatient

infusion centers, or dialysis centers. 6,7

In the absence of anti-

microbial stewardship oversight at these transitions of care

points, patients may be discharged from hospitals on

inappropriate therapy. This presents a unique opportunity for

antimicrobial stewardship programs (ASP) to be involved in

the discharge process. We conducted a pilot study at The

Brooklyn Hospital Center (TBHC), a 416-bed community

teaching facility in Brooklyn, New York. The objectives of this

study were to (1) describe a structured, multidisciplinary

approach to review anti-infective prescriptions at discharge and

(2) measure the impact of a stewardship-initiated anti-infective

review process in identifying and preventing anti-infective-

related MEs at discharge. The experience gained from this

1 Department of Pharmacy, Memorial Hermann Greater Heights Hospital,

Houston, TX, USA 2 Global Health Science, The Medicines Company, Parsipanny, NJ, USA 3 Division of Infectious Diseases, The Brooklyn Hospital Center, Brooklyn, NY,

USA 4 Department of Pharmacotherapy and Translational Research, College of

Pharmacy, University of Florida, Gainesville, FL, USA

Corresponding Author:

Christy P. Su, Department of Pharmacy, Memorial Hermann Greater Heights

Hospital, 1635 North Loop West, Houston, TX 77008, USA.

Email: christy.su@memorialhermann.org

Journal of Pharmacy Practice 2019, Vol. 32(5) 488-492 ª The Author(s) 2018 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/0897190018761411 journals.sagepub.com/home/jpp

study is critical in identifying institutional resources needed to

implement an anti-infective review process and sustain it to

produce desired outcomes.

Methods

A single-center prospective study was conducted at TBHC

from October 2013 to May 2014. TBHC has a centralized

pharmacy model. Pharmacists in the central inpatient pharmacy

provide distributional services and primarily serve in a drug

dispensing role. There are also clinical pharmacy specialists

integrated into the patient care teams within the medical inten-

sive care, family medicine, and pediatrics units. These pharma-

cists perform a combination of clinical and distributional

activities. At the time of this study, the pharmacy department

operated with 11 clinical pharmacy specialists which included

coverage for inpatient and outpatient clinical services. The

ASP was established in 2004 and comprised of infectious dis-

eases (ID) physicians, ID clinical pharmacists, and a PGY-2 ID

resident. The ASP was actively involved in prospective anti-

infective review during hospitalization; however, no process

was in place for the assessment of discharge treatment.

To begin the development of a systematic process to review

anti-infective agents at discharge, one hospital service was

selected during this study period, with future plans to expand

the initiative hospital-wide. Patients greater than 18 years of age

who were discharged from the family medicine service on intra-

venous (IV) or oral anti-infective therapy were included in this

initiative. MEs were identified according to NCCMERP and

were classified into the following predefined categories by

Heintz and colleagues: safety, efficacy, or simplification. 8

Safety

interventions included those related to ordering laboratory tests,

adjusting doses due to renal dysfunction, avoiding central line

placement, avoiding unnecessary anti-infective agents, reassess-

ment of patient’s stability, or adjusting therapy due to drug

interactions. Efficacy interventions included those related to

anti-infective selection, dose, or extending the duration of ther-

apy. Simplification interventions included those related to reduc-

ing the frequency of dosing, performing IV to oral interchange,

reducing the number of anti-infective agents prescribed, or short-

ening the duration of therapy (Table 1). Each anti-infective agent

prescribed could have more than 1 type of intervention.

The stepwise process of implementing the review process is

depicted in Figure 1. The ASP clinical pharmacist contacted the

family medicine team daily for a list of patients with an anticipated

discharge within 48 hours. The ASP team then screened these

patients for anti-infective prescriptions through electronic medi-

cal records. Patients who had a prescribed anti-infective agent

were evaluated by the ASP team for appropriateness based on

evidence-based practice guidelines. Potential interventions that

were identified were then verbally communicated and discussed

with the primary team physician. However, if a patient received an

ID consultation during hospital admission, the ID consultant

would be contacted and changes to treatment regimens were made

collaboratively with the ASP team. All recommendations were

made prior to patient discharge and the number of accepted inter-

ventions and types were quantified. Descriptive statistics were

used to present the results. This study was conducted in compli-

ance with the hospital’s institutional review board.

Results

Forty-five patients discharged from the family medicine ser-

vice were included in the final analysis. Of 59 anti-infective

agents prescribed, the route of administration was oral for

42 (71%) agents and intravenous for 17 (29%) agents. The most common indications for anti-infective regimens at discharge

were pneumonia (22%, n ¼ 10), bacteremia (18%, n ¼ 8), and skin and soft tissue infections (16%, n ¼ 7; Table 2). Four patients were discharged on regimens for more than 1 indica-

tion. Most patients were discharged on an oral cephalosporin,

penicillin, or fluoroquinolone.

Table 1. Study Definitions.

Safety interventions

Ordering laboratory tests, adjusting dose, avoiding central line placement, avoiding unnecessary anti-

infective agents, patient stability, and drug interactions

Efficacy interventions

Optimizing anti-infective selection, dose, and extending duration of therapy

Simplification

interventions

Reducing the frequency of dosing, IV-PO interchange,

reducing the number of anti-infective agents prescribed, and shortening duration of therapy

Abbreviations: IV, intravenous; PO, oral. Intervention types at hospital discharge for prescribed anti-infective agents.

Primary team contacted for list of an�cipated discharges in following

48 hours

Prescrip�on entered in electronic medical record for

an�-infec�ve therapy

An�-infec�ve therapy evaluated by ASP team

Recommenda�ons made to primary team prior to pa�ent

discharge

Figure 1. Flowchart process of identifying and evaluating anti- infective therapies prescribed at hospital discharge.

Su et al 489

An ME was identified in 42% (n ¼ 19/45) of patients reviewed. Overall, 56% (n ¼ 33/59) individual anti- infectives had at least 1 associated ME which were further clas-

sified as being related to safety, efficacy, and simplification in

33% (n ¼ 11), 33% (n ¼ 11), and 33% (n ¼ 11) of cases, respec- tively (Figure 2).

Most frequent interventions in each category made by the

ASP team were as follows: optimizing selection of anti-

infective (n ¼ 7), avoidance of unnecessary anti-infectives (n ¼ 6), reduction in number of anti-infectives prescribed (n ¼ 5). The duration of anti-infective therapy was reduced for 4 prescriptions. Recommendations were made in multiple ME

categories in 10 patients. Seventy percentage (n ¼ 23/33) of ASP team recommendations were accepted which resulted in

an avoidance of MEs in 68% (n ¼ 13/19) of patients with an ME prior to discharge. Recommendations made in the simpli-

fication category had a higher acceptance rate (Figure 2). Nine

patients overall from this study were readmitted within 30 days

of discharge, of which 1 patient had an infection-related read-

mission. Of note, this patient did have a simplification-related

ME identified on the previous admission that was intervened

upon and accepted.

Discussion

This study evaluated the impact of a structured, multidisciplin-

ary approach of anti-infective prescription review at discharge

to prevent MEs. The Joint Commission on Accreditation of

Healthcare Organizations designated medication reconciliation

as a National Patient Safety Goal, recognizing its potential impact

on reducing patient harm during transitions of care. 5

Studies have

revealed that medication discrepancies occur more frequently on

discharge than on admission. 9

In our evaluation, MEs were iden-

tified in 42% of anti-infective regimens prescribed at discharge which is similar to the findings by Yogo and colleagues.

10 These

investigators conducted a retrospective cohort study on the appro-

priateness of therapy in adult patients discharged on oral antibio-

tics. Prescriptions were retrospectively reviewed for antibiotic

selection, indication, dose, and duration of therapy. Overall, they

concluded that 53% of antibiotic prescriptions reviewed were deemed inappropriate. The most common reasons for inappropri-

ateness were related to efficacy due to excessive treatment dura-

tion, suboptimal antibiotic selection, and incorrect dose. Our

study noted MEs in 12% (n ¼ 4), 21% (n ¼ 7), and 6% (n ¼ 2) of cases in similar categories. Scarpato and colleagues also iden-

tified 70.7% of antibiotic prescriptions at discharge to be inap- propriate and concluded that on average, patients were sent from

the hospital on 3.8 days of unnecessary antibiotics. 11

Our comprehensive anti-infective review process was suc-

cessful in averting MEs in 68% of patients. However, a more targeted approach to performing this review includes identifi-

cation of specific indications highly prone to MEs. In our

cohort, pneumonia and skin and soft tissue infections were

among the top 3 infections that required an intervention. This

result further suggests that prescriptions for these common

infections should be closely reviewed for appropriateness prior

Figure 2. Medication error classifications (n ¼ 33). A total of 33 interventions were recommended in 19 patients. Each anti-infective agent could have more than one type of intervention. Reasons for rejected interventions were as follows for safety: avoiding unneces- sary anti-infectives (n ¼ 2), adjusting dose (n ¼ 1), ordering labora- tory tests (n ¼ 1), patient stability (n ¼ 1); efficacy: anti-infective selection (n ¼ 1), anti-infective dosing (n ¼ 1), extending duration of therapy (n ¼ 1); simplification: reducing number of anti-infectives prescribed (n ¼ 2).

Table 2. Baseline Demographics.

Patient Characteristics n ¼ 45

Age in years, mean (SD) 60 (19)

Female, n (%) 22 (49) Location, n (%)

Medical floor 45 (100) Indicationa, n (%)

Pneumonia 10 (22)

Bacteremia 8 (18) SSTI 7 (16)

UTI 7 (16) Clostridium difficile infection 5 (11)

Osteomyelitis 4 (9) Other 8 (18)

Anti-infectives prescribed n ¼ 59

Route, n (%) Oral 42 (71)

Intravenous 17 (29) Anti-infective classa, n (%)

Cephalosporin 12 (20) Penicillin 10 (17)

Fluoroquinolone 7 (12) Vancomycin 6 (10)

Macrolide 5 (8) Anti-tuberculosis 4 (7)

Tetracycline 3 (5) Sulfamethoxazole/trimethoprim 3 (5)

Metronidazole 3 (5)

Other 6 (10)

Abbreviations: SD, standard deviation; SSTI, skin and soft tissue infection; UTI, urinary tract infection. Fifty-nine anti-infective agents were prescribed for 45 patients. a Four patients were discharged on regimens for more than 1 indication.

490 Journal of Pharmacy Practice 32(5)

to discharge. Due to the small study sample size, there were no

obvious trends with respect to safety interventions having the

lowest intervention success rate. One possible explanation for

this observation is that safety interventions could prolong dis-

charge since it included ordering of additional laboratory tests

and required extended monitoring of patient stability.

Our results highlight the impact of ASP teams in assisting

with the review of antimicrobial therapy prior to discharge to

enhance patient safety and treatment efficacy. 5,9-11

In our expe-

rience, there is tremendous value in integrating an ID-trained

practitioner in this process. However, the lack of resources with

regard to ID-trained personnel can be a barrier to implementa-

tion of an anti-infective review process. In such settings with

limited resources, clinical pharmacists with an interest in ID

may assume this role. Trained pharmacists that perform med-

ication reconciliation at discharge have demonstrated a

decrease in MEs and a reduction in readmission rates. 12

Through this study, it was determined that immense man-

power and resources are required for long-term sustainability

of a discharge antibiotic review program. The major limitation

of this study was inability of the study investigators to capture

all patients discharged on anti-infectives from the family med-

icine service. The lack of dedicated personnel such as social

workers, clinical case managers, or patient navigators focused

on coordinating discharge planning contributed to this limita-

tion. The investigators in this study spent approximately

1 to 2 hours each day reviewing patients for the study, 20 to

30 minutes of this time was utilized in identifying, reviewing,

and making recommendations. The rest of the time was used to

contact teams to obtain anticipated patient discharge lists. This

ineffective system of communication resulted in patients being

discharged without anti-infective treatment review. At the time

of the study, there was a clinical pharmacy specialist that

rounded with one of the family medicine teams. This pharma-

cist could only assist with identifying patient discharges for this

team. So, the number of patients reported as discharged on anti-

infectives represents a convenience sample suggesting that the

scope and impact of this type of program on ME identification

is much greater. Another limitation of the study was that this

review process was only conducted for 1 hospital service.

Other hospital services may have different prescribing patterns,

which could lead to different types and rates of MEs than

described here. Expanding this study throughout the hospital

would allow for the assessment of MEs in a variable patient

population.

“Transitions of care” refers to the movement of patients

between health-care practitioners, settings, and home as their

condition and care needs change. 13

Pharmacists, as members of

a multidisciplinary team, can facilitate effective transitions of

care by conducting medication intervention. Phatak and col-

leagues described the impact of pharmacist involvement at

transitions of care by targeting patients on high-risk medica-

tions, which included anti-infectives. 14

This study was able to

demonstrate a reduction in readmission rates and MEs.

We were unable to continue the discharge anti-infective

review program at our institution beyond this study because

the immense manpower and resources required for long-term

sustainability were unattainable. ASPs should work collabora-

tively with unit-based pharmacists who are responsible for des-

ignated areas, as they are most familiar with patients and their

hospital course. Engaging frontline pharmacists in this process

is essential since they are more likely to have direct contact

with primary teams, and other relevant staff members involved

with the discharge planning process. An additional benefit of

having unit-based pharmacists involved is that conversations

with primary teams can be initiated during patient care rounds

and recommendations to optimize anti-infective regimens can

be made together. For example, if a discharge medication

requires therapeutic drug monitoring, labs can be ordered while

the patient is still admitted to ensure dose appropriateness at

discharge. With time, working with the same hospital person-

nel should foster a stronger understanding of the value of an

anti-infective review process at discharge.

Conclusion

Anti-infectives are highly prone to MEs at discharge. This

study describes the outcomes of a stewardship-initiated review

process in preventing MEs at discharge. Over half of anti-

infective agents reviewed at discharge in this study had an

identified ME. The ASP team’s recommendations were suc-

cessful in preventing MEs in the majority of patients with an

inappropriate anti-infective regimen at discharge. Despite the

identification of MEs, not all of the ASP team’s recommenda-

tions were accepted, which suggests there is a need for further

education of house staff on patient safety, MEs, and the goals of

antimicrobial stewardship. Developing a systematic process for

a multi-disciplinary ASP team to review all anti-infectives can

be a valuable tool in preventing MEs at hospital discharge.

However, without dedicated, trained personnel to assist with

coordinating this process, long-term sustainability is a chal-

lenge. Use of a transitions of care program with unit-based

pharmacists to review anti-infective prescriptions at discharge

should be considered.

Authors’ Note

Presented as a poster at the 2014 Interscience Conference on Antimi-

crobial Agents and Chemotherapy Annual Meeting, Washington, DC,

September 6, 2014. News feature published in Am J Health Syst

Pharm. 2015 Feb;72(4):264-5.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to

the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, author-

ship, and/or publication of this article.

References

1. Hume AL, Kirwin J, Bieber HL, et al; American College of Clin-

ical Pharmacy. Improving care transitions: current practice and

Su et al 491

future opportunities for pharmacists. Pharmacotherapy. 2012;

32(11):e326-e337.

2. National Coordinating Council for Medication Error Reporting

and Prevention. About medication errors. http://www.nccmerp.

org/about-medication-errors. Accessed January 1, 2018.

3. Forster AJ, Murff HJ, Peterson JF, et al. The incidence and sever-

ity of adverse events affecting patients following discharge from

the hospital. Ann Intern Med. 2003;138(3):161-167.

4. Forster AJ, Murff HJ, Peterson JF, et al. Adverse drug events

occurring following hospital discharge. J Gen Intern Med.

2005;20(4):317-323.

5. The Joint Commission. National patient safety goals. https://

www.jointcommission.org/assets/1/6/NPSG_Chapter_HAP_

Jan2017.pdf. Published January 2017. Accessed January 2017.

6. Hamilton K, Fishman N. Antimicrobial stewardship interven-

tions: thinking inside and outside the box. Infect Dis Clin North

Am. 2014;28(2):301-313.

7. Shrestha NK, Bhaskaran A, Scalera NM, et al. Antimicrobial

stewardship at transition of care from hospital to community.

Infect Control Hosp Epidemiol. 2012;33(4):401-404.

8. Heintz BH, Halilovic J, Christensen CL. Impact of a multidisci-

plinary team review of potential outpatient parenteral

antimicrobial therapy prior to discharge from an academic med-

ical center. Ann Pharmacother. 2011;45(11):1329-1337.

9. Wong JD, Bajcar JM, Wong GG, et al. Medication reconciliation

at hospital discharge: evaluating discrepancies. Ann Pharmac-

other. 2008;42(10):1373-1379.

10. Yogo N, Haas MK, Knepper BC, et al. Antibiotic prescribing at the

transition from hospitalization to discharge: a target for antibiotic

stewardship. Infect Control Hosp Epidemiol. 2015;36(4):474-478.

11. Scarpato SJ, Timko DR, Cluzet VC, et al; CDC Prevention Epi-

centers Program. An evaluation of antibiotic prescribing practices

upon hospital discharge. Infect Control Hosp Epidemiol. 2017;

38(3):353-355.

12. Fera T, Anderson C, Kanel KT, et al. Role of a care transition

pharmacist in a primary care resource center. Am J Health Syst

Pharm. 2014;71(18):1585-1590.

13. The Joint Commmission. Transitions of care: the need for a more

effective approach to continuing patient care. https://www.jointcom

mission.org/assets/1/18/Hot_Topics_Transitions_of_Care.pdf.

14. Phatak A, Prusi R, Ward B, et al. Impact of pharmacist involve-

ment in the transitional care of high-risk patients through med-

ication reconciliation, medication education, and postdischarge

call-backs (IPITCH study). J Hosp Med. 2016;11(1):39-44.

492 Journal of Pharmacy Practice 32(5)