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Prevalence of medication transfer errors in nephrology patients and potential risk factors
M M Ebbens1, H Errami2, D J A R Moes2
1Leiden University Medical Center, Department of Clinical Pharmacy and Toxicology, Albinusdreef 2, 2333, ZA, Leiden, The Netherlands; Erasmus University Medical Center Rotterdam, Department of Hospital Pharmacy, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands; St Jansdal Hospital, Department of Pharmacy, Wethouder Jansenlaan 90, 3844, DG, Harderwijk, The Netherlands.
Background:
Medication reconciliation in transitions of care can prevent medication transfer errors (MTE). MTE can cause patient harm. Since performing medication reconciliation for every patient is not always feasible, identification of potential risk factors of MTE could aid in targeting this intervention to the right patients.
Objective:
To establish the proportion of patients with one or more MTE in the outpatient nephrology setting. Secondary patient characteristics associated with MTE, type and potential harm, and medication groups were investigated.
Methods:
This retrospective observational cohort study was conducted in the Leiden University Medical Center, the Netherlands, between November 2017 and April 2018. The cohort involved patients in whom medication reconciliation was performed by a medical attendant using the electronic tool 'Medical Dashboard' prior to visiting the nephrologist. MTE were defined as unintended discrepancies between the medication in the hospital system and the result of the medication reconciliation. The proportion of patients with one or more MTE was calculated and the association of patient characteristics (age, sex, number of medications and kidney function (CKD-EPI)) with MTE was analyzed using multivariate logistic regression.
Results:
Of 380 patients, 235 patients (61.8%) had at least one MTE. On average patients used 10.3 medications. The number of medications per patient was significantly associated with MTE; OR 1.11 (95%CI 1.05-1.16). No association was found for age, sex, and kidney function.
Conclusion:
In ambulatory nephrology patients 61.8% had at least one MTE. Nephrology patients using a higher number of drugs are more prone to MTE.
Insights
Medication transfer errors (MTE) are common in nephrology outpatient settings, affecting over 60% of patients. Patients taking more medications are at higher risk for these potentially harmful errors.
Area of Science:
- Nephrology
- Patient Safety
- Pharmacology
Background:
- Medication reconciliation is crucial during care transitions to prevent medication transfer errors (MTE).
- MTE can lead to significant patient harm.
- Identifying MTE risk factors can optimize targeted interventions.
Purpose of the Study:
- Determine the prevalence of MTE in outpatient nephrology.
- Investigate patient characteristics associated with MTE.
- Analyze MTE types, potential harm, and involved medication classes.
Main Methods:
- Retrospective observational cohort study at Leiden University Medical Center (Nov 2017-Apr 2018).
- Medication reconciliation performed using the 'Medical Dashboard' electronic tool.
- MTE defined as discrepancies between hospital system and reconciled medication lists. Multivariate logistic regression analyzed patient characteristics (age, sex, medication count, CKD-EPI).
Main Results:
- 235 out of 380 patients (61.8%) experienced at least one MTE.
- Average medication use was 10.3 per patient.
- Increased number of medications significantly associated with MTE (OR 1.11; 95% CI 1.05-1.16). Age, sex, and kidney function showed no association.
Conclusions:
- A high proportion (61.8%) of ambulatory nephrology patients experience MTE.
- Higher medication burden in nephrology patients increases susceptibility to MTE.
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