Boockvar KS (James J. Peters Bronx VAMC), Liu S
(Yale University School of Medicine), Goldstein N
(James J. Peters Bronx VAMC), Siu A
(James J. Peters Bronx VAMC), Fried T
(Yale University School of Medicine)
Medication discrepancies are used as a quality measure of interprovider communication, medication reconciliation, and prescribing decisions for patients transferred between sites of care. The objective of this study was to quantify the rate of adverse drug events (ADEs) caused by medication discrepancies and the discrimination of an index of high-risk transition drug prescribing.
We examined medical records of patients transferred between 7 nursing homes and 3 hospitals between 1999-2005 in New York and Connecticut for transfer-associated prescribing discrepancies and ADEs. ADEs were determined by 2 clinician raters who used an established algorithm for independently rating causality, after which they provided a final consensus rating for each event. We calculated the rates of ADEs caused by medication discrepancies in specific drug classes by calculating positive predictive values (PPVs). We also calculated the c-statistic (i.e., discrimination capacity) of a count of high-risk drug discrepancies, defined as those with PPV > .03.
208 patients were hospitalized 304 times. Patients had a mean of 2.8 (s.d. 2.1) prescribing discrepancies associated with nursing home-to-hospital transfer and a mean of 1.5 (s.d. 1.7) discrepancies associated with hospital-to-nursing home transfer. Overall, 65 of 1,350 prescribing discrepancies caused ADEs, for a PPV of .048 (65/1350) (95%CI .037-.061). PPVs by drug class ranged from 0 - .28. Drug classes with the highest PPVs were opioid analgesics, metronidazole, and non-opioid analgesics. Pain from omission of an analgesic was the most common scenario. Number of high-risk drug discrepancies demonstrated good discrimination with a c-statistic of .650. Patients with 0, 1-2, and > 3 high-risk discrepancies had 10%, 21%, and 45% chance of experiencing a discrepancy-related ADE, respectively.
Discrepancies in certain drug classes, in particular opioid and non-opioid analgesics, more often caused ADEs than other types of discrepancies in hospitalized nursing home patients. Number of high-risk discrepancies discriminated between patients that experienced a discrepancy-related ADE and those that did not.
Information about ADEs caused by medication discrepancies can be used to enhance measurement of care quality, identify high-risk patients, and inform development of decision-support tools at the time of patient transfer.