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  • Best Possible Medication History in the Emergency Department: METHODS

This study was a prospective comparison of current medication histories obtained by pharmacy technicians and by pharmacists in the emergency department at The Moncton Hospital, a 400-bed community hospital. The emergency department at this institution is a combined adult and pediatric care facility that is designated as a level II trauma centre, with about 55 000 visits annually. During December 2008, patients presenting to the emergency department were enrolled to be interviewed 2 times, once by a pharmacist and once by a technician. Patient recruitment took place on weekdays during daytime hours (0830 to 1700). Patients were eligible for inclusion if they were being admitted to hospital from the emergency department or if a member of the health care team asked a pharmacist for a medication history. Patients were excluded if they had been transferred from a nursing home or other hospital or if a medication history had been initiated by a health care professional other than a pharmacist. Three pharmacists and 2 technicians participated in the study.
The pharmacy technicians were trained to obtain a BPMH by means of a 4-step process adapted from the medication reconciliation education and certification program described by Small and others. First, an interactive learning and education session was provided, during which background information was reviewed and tips for success when obtaining a BPMH were outlined. During this session, the technicians were given a BPMH interview guide, adapted with permission from an existing interview guide, which outlined appropriate probing questions. The technicians were expected to use this guide for each interview that they completed.  Third, each technician participated in several practice interviews, during which he or she interviewed a patient after a pharmacist had done so; the histories obtained by pharmacist and technician were compared, and discrepan­cies were reviewed and discussed. Finally, each technician underwent a competency assessment, during which he or she interviewed a standardized patient and received detailed feed­back from the assessor. This training program and related tools were also offered to the 3 pharmacists assigned to the emergency department.

Patients who met the inclusion criteria were randomly assigned, by means of sealed-envelope randomization, to participate or not participate in the study. As per usual practice, the technicians used multiple resources (e.g., medication list, prescription vials, community pharmacy profile) to prepare a preliminary medication list for patients. For patients assigned to not participate, this list was given to the pharmacist only, and no further data were collected for the study. For patients assigned to participate, this list was given to both the technician and the pharmacist for subsequent interviews with the patient. For each patient, the technician who prepared the preliminary list also conducted the interview. Because this procedure replicated those used for medication reconciliation audits in the Safer Healthcare Now! Campaign at the authors’ institution, patient consent was implied, and patients were simply informed that they would be interviewed twice as part of the study. A second sealed-envelope randomization was performed to determine the order of interviews by technician and pharmacist: half of the patients in the study were interviewed by the pharmacist first and the technician second, and the other half were interviewed by the technician first and the pharmacist second. The interviewers recorded the approximate start and stop times of the patient interviews on study log sheets. The randomized order of the interviews served as an experimental control, and all comparisons between pharmacists and techni­cians were carried out by contrasting data from interviews with the same patients (i.e., within-subject analysis). Apcalis Oral Jelly

After each set of interviews, the principal investigator (R.J.) reviewed both histories within 24 h. Each history was compared to the final BPMH, as determined by the principal investigator on the basis of a review of the patient’s prescription medication vials and community pharmacy medication profile, a call to the community pharmacist (if necessary), and the combined results of the interviews carried out by the pharma­cist and the technician. If the principal investigator found any discrepancies between a patient’s medication list as prepared by the pharmacist or the technician and the final BPMH, she clarified the issue with the patient. Patients who were no longer in the hospital were contacted at home. The following discrep­ancies were coded: omission of a prescription drug, omission of an over-the-counter drug, incorrect drug (prescription or over-the-counter), discrepant dose or frequency (for prescrip­tion or over-the-counter drug).

After the study was complete, 3 pharmacists who had not been involved with the study independently classified each discrepancy for its potential severity, according to the classifica­tion system of Cornish and others: a class 1 discrepancy was defined as unlikely to cause discomfort to the patient or clinical deterioration, a class 2 discrepancy had the potential to cause moderate discomfort or clinical deterioration, and a class 3 discrepancy had the potential to result in severe discomfort or clinical deterioration. Disagreements were resolved by group discussion, and consensus was reached for all discrepancies.

Descriptive and statistical analyses were completed with SPSS version 16.0 (SPSS Inc, Chicago, Illinois). Descriptive statistics were used to describe the sample in terms of age and numbers of prescription and over-the-counter medications and to describe the length of the interviews. Pearson correlations were performed to analyze relationships between discrepancies and variables of interest (e.g., age of patient, number of medications). Spearman correlations were also calculated for all relationships. cialis 10 mg

Exploratory analyses were performed using dependent group x2 tests and t tests. The data for pharmacists and techni­cians in this study were compared with national norms data for December 2008 (obtained from the March 2009 Safer Healthcare Now! quarterly report) using a series of 1-sample t tests for per-patient unintentional discrepancies and success index. For all x2 tests, effect size is reported using Cramer’s V. For all t tests, effect size is reported using eta squared (^2). The values for Cramer’s V and represent the proportion of the variance in the dependent variable accounted for by the independent variable. For Cramer’s V, values of 0.10 to 0.20 are considered weak, values of 0.20 to 0.30 are considered midrange, and values above 0.30 are considered large. For values in the range of 0.01 are usually considered small, values close to 0.06 are considered midrange, and values in the range of 0.14 are usually considered large.

The Horizon Health Network Research Ethics Board approved the protocol for this study.

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