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Background: Obtaining accurate medication histories at transitions of care is challenging, but important for patient safety. Prescription exchange services (PES) securely transfer electronic prescription and dispensing records between prescribers and pharmacies, which is potentially useful data for determining medication histories. Aim: To evaluate the accuracy of PES‐derived medication histories. Methods: Prospective observational study, at two Australian tertiary‐referral health services. A convenience sample of adult inpatients was recruited. The main outcome measure was: proportion of patients with ≥1 errors in their PES‐derived pre‐admission medication histories, compared with gold‐standard best‐possible medication histories, including prescribed and non‐prescribed medications, obtained by pharmacists using multiple sources including patient/carer interview. Results: Of 154 patients (median age 76 years; interquartile range (IQR) 64–84 years; median 10.0 pre‐admission medications; IQR 6.0–14.0), 153 (99.4%) had ≥1 errors in their PES‐derived medication history (median 6.0 errors per patient; IQR 4.0–9.0). Excluding when‐required medications, 146 (94.8%) patients had >1 errors (median 4.0 errors per patient; IQR 2.0–6.0). Omission was the most common error, affecting 549 (33.3%) of 1648 current medications (median 3.0; IQR 1.0–5.0 per patient); 396 (72.1%) omissions were over‐the‐counter medicines. Dose‐regimen errors affected 276 (25.1%) of 1099 current medications captured in PES‐derived medication histories (median 1.0 error per patient; IQR 0.0–3.0). Commission errors (medications in PES‐derived histories that were not current) affected 224 (16.9%) of 1323 medications (median 1.0 error per patient; IQR 1.0–2.0). Conclusions: Medication histories derived solely from a cloud‐based medication record repository had a high error rate compared with patients' actual medication use. Like all medication history sources, data from cloud‐based repositories need to be verified with additional sources including the patient and/or their carer. [ABSTRACT FROM AUTHOR]

Background: Pharmacist‐assisted prescribing (also known as pharmacist charting) has been adopted widely across Australia. The perspectives of medical and nursing staff, however, is poorly understood. Aim: To explore the perceived benefits and drawbacks of pharmacist‐assisted prescribing on admission and discharge, from the perspective of hospital medical officers (HMOs) and nurses. Methods: Face‐to‐face, semi‐structured interviews were conducted with orthopaedic junior HMOs, the orthogeriatric HMO and nurses during a study evaluating pharmacist‐assisted prescribing in an orthopaedic unit. Participants were individually interviewed to explore the perceived impacts of pharmacist‐assisted prescribing on patient safety, workflow and HMO skill development. Interviews were audio‐recorded and verbatim transcriptions were analysed independently by two investigators using a simple thematic analysis. Results: Interviews were conducted with six HMOs and six nurses. Emergent themes highlighted various factors which may affect the ability of HMOs to prescribe medications accurately and in a timely manner when there is no pharmacist assisting with prescribing, and the impact of pharmacist‐assisted prescribing on patient flow, safety and staff workload. Participants felt that having a pharmacist assist with prescribing improved patient safety by reducing prescribing errors and admission charting delays, and assisted with patient flow by reducing delays in discharging patients. Participants felt that pharmacist‐assisted prescribing reduced their workload. They noted a drawback was the potential to de‐skill HMOs, but felt this was outweighed by the benefits. Conclusions: Hospital medical officers and nurses reported that pharmacist‐assisted prescribing had benefits on patient safety, patient flow and workload and that these outweigh the potential drawbacks of potentially de‐skilling junior HMOs. [ABSTRACT FROM AUTHOR]

Objectives: To explore wastage of hospital‐supplied medications for patients discharged to residential care facilities (RCFs). Methods: Telephone interviews with staff at 52 RCFs and nine community pharmacies after patients were discharged from three hospitals in metropolitan Victoria, Australia, with medication supplied in original packs. Results: Hospital‐supplied medication was used by most RCFs, for a median of 48 hours, while waiting for community pharmacies to deliver medications packed in the RCFs' preferred dose administration aid system (unit‐dose or multi‐dose blister packs or sachets). All RCFs reported sending unused hospital‐supplied medications to their community pharmacy. Six of the nine community pharmacies (managing 83% patients) indicated they did not reuse hospital‐supplied medications, with the exception of select difficult‐to‐source medications. Conclusion: There was significant wastage of hospital‐supplied discharge medications. Changes to the way hospital discharge medications are funded and quantities supplied are needed to ensure continuity of medication administration while minimising financial and environmental impacts of medication wastage. [ABSTRACT FROM AUTHOR]

Background: Problems with continuity of medication administration after discharge from hospitals to residential care facilities (RCFs) have been reported in Australia and internationally. The MedGap study in 2009 reported a significant decline in post‐discharge missed or delayed doses and locum doctor call‐outs at RCFs following implementation of a hospital pharmacy‐prepared interim residential care medication administration chart (IRCMAC). Aim: To determine whether reductions in missed or delayed doses and locum doctor call‐outs were sustained nearly 10 years after the IRCMAC was implemented, and evaluate RCFs' use of IRCMACs and discharge medications supplied in original packaging. Method: Structured telephone interviews with nurses at 52 RCFs were conducted approximately 48‐h after discharge for randomly selected patients discharged from hospitals within a major metropolitan health service in Melbourne, Australia in 2018. Results were compared with pre‐ and post‐intervention data collected using the same method in 2009. Primary endpoints were the proportion of patients for whom the RCF used the hospital‐supplied IRCMAC and discharge medications, and the incidence of missed or significantly delayed medication doses in the first 24 h post‐discharge. The number of locum doctor call‐outs was a secondary endpoint. Results: RCFs received IRCMACs for 71/73 (97.3%) patients and used them for 61/71 (85.9%). Hospital‐supplied medication, in original packaging, was received for 65/73 (89.0%) patients and used for 59/65 (90.8%). One or more doses were missed or significantly delayed for 2/73 (2.7%) patients and locum doctors were called for nine patients (12.3%), which was similar to the 2009 post‐intervention study (6/226, 2.7% and 25/226, 11.1%, respectively) and significantly lower than the 2009 pre‐intervention study (37/202, 18.3% and 66/202, 32.7%, respectively; P < 0.01 for both endpoints). Nearly 100% of RCF staff believed IRCMACs and hospital‐supplied medication improved continuity of care. Conclusion: Hospital pharmacy‐prepared IRCMACs and discharge medication in original packaging were highly used and valued by RCF staff, and associated with sustained low rates of missed and delayed doses and locum doctor call‐outs. [ABSTRACT FROM AUTHOR]

Objective: Patients present to EDs with various medication‐related problems (MRPs). MRPs are also associated with ED care, occurring during ED presentation or shortly afterwards. The aim of the present study is to describe the prevalence and nature of MRPs that occur prior to, during or shortly after leaving ED. Methods: We undertook a prospective, observational study in nine Australian EDs. Blocks of 10 consecutive adult patients who were not seen by a pharmacist in ED and who presented at pre‐specified times were identified. Within 1 week of ED discharge, a pharmacist interviewed patients and undertook a medical record review to determine their medication history, patients' understanding of treatment, potential MRP risk factors and manage any identified MRPs. Results: A total of 904 patients were recruited: 14.8% aged ≥80 years, 18.9% taking more than eight regular medications; 581 MRPs were identified; 287 (49.4%, 95% confidence interval [CI] 45.3–53.5%) of moderate‐high significance. Most highly significant MRPs involved high‐risk medications, particularly strong opioids, insulin and anti‐coagulants. The most common types of MRPs were prescribing errors (46.8%), patient adherence/knowledge issues (31.2%) and adverse drug reactions (7.4%). Of all patients, 381 (42.1%, 95% CI 38.9–45.5%) had at least one MRP; 31.4% (95% CI 28.4–34.6%) had MRPs that could be identified or managed by screening at ED presentation and 12.4% (95% CI 10.4–14.8%) had MRPs that could be identified or managed by screening at ED discharge. Conclusions: Patients experienced a range of MRPs throughout the ED continuum of care. From these data, screening tools will be developed so that ED clinicians may identify patients at greatest risk of MRPs. [ABSTRACT FROM AUTHOR]

Abstract: Objective: To assess the accuracy of medication information sources available for adult patients presenting to the ED, compared to a best possible medication history (BPMH). Methods: This prospective observational study was undertaken in the ED of a major tertiary‐referral teaching hospital. A convenience sample of consecutive adult patients taking one or more regular medications was included. A BPMH was ascertained using patient/carer interviews, where available, and confirmed with one or more other sources. For residential care facility (RCF) patients, the RCF medication chart and at least one other source were used. Information sources compared with the BPMH were community pharmacy dispensing history, patient's own medications, patient's medication list, general practitioner letter, medications stored in and labelled on dose administration aids (DAAs) and the RCF chart. Number of discrepancies per patient for each source was determined by comparing medications and dose regimens to those documented in the BPMH. Results: A total of 455 patients (median age 71 years) took a median of six ‘regular’ and two ‘as required’ medications. The median number (range) of discrepancies per patient for regular medication names and dosages were RCF chart 0 (0–3), DAA contents 2.0 (0–9), patient's medication list 2.5 (0–16), DAA medications label 3.0 (0–7), community pharmacy history 3.0 (0–19), general practitioner letter 3.0 (0–18) and patient's own medications 4.0 (0–16). Overall, 40.4% of discrepancies were deemed ‘moderate’ or ‘high’ clinical significance. Omission errors accounted for 55.6% of discrepancies. Conclusions: A combination of sources is essential to determine the BPMH. RCF charts provided the most accurate information. Other sources had two to four regular medication‐related discrepancies per patient. [ABSTRACT FROM AUTHOR]

Objectives The objective of this study was to evaluate the impact of an educational intervention on ED discharge opioid analgesic ( OA) prescribing. Methods A brief, one-on-one, educational intervention was delivered to ED OA prescribers by an ED clinical champion. The percentage of patients receiving (i) written advice regarding appropriate oxycodone use, (ii) written or verbal advice regarding appropriate post-discharge follow up and (iii) written general practitioner notification that oxycodone had been prescribed were determined pre- and post-intervention, through review of electronic patient records and structured patient telephone interviews conducted 3-7 days after ED attendance. Secondary outcomes included total amount prescribed and use of non- OA therapies. ED OA prescribers were surveyed to evaluate perceived effectiveness and intervention acceptability. Results A total of 30 ED OA prescribers received the 5-min intervention. Pre- and post-intervention, 80 and 81 patients were interviewed, respectively. Percentage of patients given written OA information increased from 10% to 22% ( P = 0.04) and those receiving follow-up advice increased from 61 to 94% ( P < 0.01). General practitioner notification of OA prescription increased from 15% to 88% ( P < 0.01). Risk ratio for achieving all three end-points was 7.5 (95% confidence interval 1.8-32, P = 0.01). Median total amount of oxycodone prescribed/patient decreased from 100mg to 50mg ( P = 0.04). Non- OA therapies were used by 49% of pre-intervention and 85% of post-intervention patients ( P = <0.01). All ED OA prescribers agreed the intervention would change their prescribing practices; 70% deemed the intervention appropriate for delivery in their work environment. Conclusion A brief, one-on-one educational intervention targeting ED OA prescribers was well received by clinicians and associated with improved quality of OA prescribing. [ABSTRACT FROM AUTHOR]

Aim: To assess continuity of medication management during transition from hospital to residential care facilities (RCFs). Method: Telephone interviews with RCF staff were performed 24 hours after patient transfer to determine the proportion of patients with: missed or significantly delayed doses; RCF medication chart not written/updated in time for the first dose; suitably packed medications not available for the first dose; and RCF medication chart written/updated by a locum doctor. Retrospective audit was used to identify discharge summary discrepancies. Results: Seventy-five doses for 37/202 (18.3%) patients were missed or significantly delayed in the 24 hours after discharge. One hundred and twenty-five (61.9%) patients did not have their medication chart written/updated and 77 (38.1%) did not have suitably packed medications available for the first dose. Locum doctors wrote RCF medication charts for 66 (32.7%) patients. One hundred and ninety-seven of 392 (50.3%) changes to regularly scheduled medications were communicated. Conclusions: Strategies are needed to address gaps in the continuity of medication management. [ABSTRACT FROM AUTHOR]

Background: An interim residential care medication administration chart (IRCMAC), usually handwritten by hospital medical officers, is provided by some hospitals to reduce the risk of medication administration delays and errors for patients discharged to residential care facilities (RCFs). Aim: To describe a novel method for IRCMAC preparation; and to determine the percentage of patients discharged from hospital to RCFs who received an IRCMAC, the accuracy of the IRCMAC, and the time IRCMAC preparation added to the pharmacy discharge process. Method: Software and processes were developed to enable integration of IRCMAC preparation into the pharmacy discharge process, with auto-population of the IRCMAC with patient, prescriber and medication data. The percentage of patients for whom RCF staff reported receiving an IRCMAC over a 3-month study period was determined by telephone interview 24 to 72 hours post-discharge. Accuracy was determined by retrospective comparison of a random sample of IRCMACs with pharmacist reviewed and reconciled discharge prescriptions to identify discrepancies. Time added to pharmacy discharge processes was recorded prospectively by pharmacy staff. Results: RCF staff reported receiving IRCMACs for 214/226 (95%) patients discharged to 84 RCFs. The medication discrepancy rate (excluding nutritional supplements) in 76 randomly selected IRCMACs was 9/877 (1%). The IRCMAC took a mean of 8.7 (SD 4.1) minutes to prepare. Conclusion: Accurate IRCMACs can be provided for a high percentage of patients discharged to RCFs by hospital pharmacists using a semi-automated process linked to dispensing software. [ABSTRACT FROM AUTHOR]