Unintended Medication Discrepancies Associated with Reliance: METHODS
Patients admitted from the emergency department to a general internal medicine ward by 1 of 2 preselected medical teams were identified the morning after admission by means of a computerized admission roster. Patients were considered for inclusion if their medication history indicated use of at least 4 regular prescription medications before admission. Patients were excluded if they had been transferred from a long-term care or nursing facility or from another acute care facility (since PharmaNet consistently records only outpatient prescriptions), if they were discharged within 24 h after admission, or if they were unable to consent to participate in the study. Because PharmaNet records prescription filling histories only for pharmacies located in British Columbia, patients from outside the province were also excluded. The study investigator (K.K.) approached all other patients, seeking their enrolment in the study, until a total of 20 patients had been recruited. Those who agreed were asked to provide informed consent. Patients who were not available to the study investigator because of obligations pertaining to their care and/or time constraints were not approached.
Medical staff ordered medications for their patients as per routine care, independent of this study. PharmaNet data were readily accessible to medical staff at the time of admission. The PharmaNet profile for each patient provides an electronic record of medications dispensed by provincial pharmacies within the previous 14 months. Information in the profile includes medication name, dose, and quantity dispensed, as well as the dates upon which the transactions occurred. Prescription medications are routinely recorded, but the profile excludes antiretroviral medications (for reasons of confidentiality), medications filled in long-term care facilities, and a small proportion of medications not subsidized under provincial drug benefit plans. Nonprescription medications may occasionally appear on the profile at the discretion of the dispensing pharmacist.The study investigator prepared a best possible medication history (BPMH) no sooner than 48 h after admission; the 2-day delay allowed for clarification of orders as appropriate and normal provision of pharmaceutical care by ward pharmacists. The study investigator first reviewed both the medical chart and the PharmaNet record and then conducted a patient interview, including examination of prescription vials if available. This process was assumed to provide the most accurate medication history, as it represented a combination of all sources of medication information typically available to the hospital practitioner at the time of patient admission.
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This comprehensive history was then compared with the physician’s admission orders to identify any discrepancies. Discrepancies were classified as “intended” or “unintended”, the latter referring to any discrepancy that was inadvertent or could not be justified by the medical team involved. Where the classification was unclear from the admitting or progress notes, the medical team or ward pharmacist was asked to clarify.
Three attending physicians (N.K., I.M., and G.H.) independently classified each unintended discrepancy for its potential to cause harm. As described by Cornish and others, class 1 discrepancies were those unlikely to cause patient discomfort or clinical deterioration. Class 2 discrepancies were those with the potential to cause moderate discomfort or clinical deterioration, and class 3 discrepancies were those with the potential to cause severe discomfort or clinical deterioration. Inter-rater reliability was assessed (as described below) on the basis of these initial, independent classifications. The final score assigned to each discrepancy was based on agreement between at least 2 of the physician auditors. For situations where the auditors did not agree, they were asked to rescore the specific discrepancies, in consultation with each other, to attain agreement. The physician auditors were not involved in caring for any of the study participants and were blinded to the patients’ identity.
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Calculation of descriptive statistics and other analyses were performed with Excel 2000 (Microsoft, Redmond, Washington) and SPSS for Windows (version 12; SPSS Inc. Chicago, Illinois). The mean discrepancy rates per patient among selected subgroups from the overall sample were compared with t tests for independent samples. Inter-rater reliability among the auditors who rated the potential severity of each unintended discrepancy was calculated using the Fleiss kappa (к) score for multiple observers, where scores of less than 0.40 indicate poor agreement, scores of 0.4 to 0.75 indicate fair to good agreement, and scores above 0.75 indicate excellent agreement.
The study protocol was approved by the University of British Columbia—Providence Health Care Research Ethics Board.