Characteristics Associated With Postdischarge Medication Errors

doi:10.1016/j.mayocp.2014.04.023

Mayo Clinic Proceedings

Volume 89, Issue 8, August 2014, Pages 1042-1051

Data Previously Presented: The study was presented at the Society of General Internal Medicine 35th Annual Meeting; April 25, 2013; Denver, Colorado.

https://doi.org/10.1016/j.mayocp.2014.04.023 Get rights and content

Abstract

Objective

To examine the association of patient- and medication-related factors with postdischarge medication errors.

Patients and Methods

The Vanderbilt Inpatient Cohort Study includes adults hospitalized with acute coronary syndromes and/or acute decompensated heart failure. We measured health literacy, subjective numeracy, marital status, cognition, social support, educational attainment, income, depression, global health status, and medication adherence in patients enrolled from October 1, 2011, through August 31, 2012. We used binomial logistic regression to determine predictors of discordance between the discharge medication list and the patient-reported list during postdischarge medication review.

Results

Among 471 patients (mean age, 59 years), the mean total number of medications reported was 12, and 79 patients (16.8%) had inadequate or marginal health literacy. A total of 242 patients (51.4%) were taking 1 or more discordant medication (ie, appeared on either the discharge list or patient-reported list but not both), 129 (27.4%) failed to report a medication on their discharge list, and 168 (35.7%) reported a medication not on their discharge list. In addition, 279 participants (59.2%) had a misunderstanding in indication, dose, or frequency in a cardiac medication. In multivariable analyses, higher subjective numeracy (odds ratio [OR], 0.81; 95% CI, 0.67-0.98) was associated with lower odds of having discordant medications. For cardiac medications, participants with higher health literacy (OR, 0.84; 95% CI, 0.74-0.95), with higher subjective numeracy (OR, 0.77; 95% CI, 0.63-0.95), and who were female (OR, 0.60; 95% CI, 0.46-0.78) had lower odds of misunderstandings in indication, dose, or frequency.

Conclusion

Medication errors are present in approximately half of patients after hospital discharge and are more common among patients with lower numeracy or health literacy.

Section snippets

Study Setting and Design

The Vanderbilt Inpatient Cohort Study (VICS) is a prospective study of patients admitted with cardiovascular disease to Vanderbilt University Hospital. The purpose of VICS is to investigate the effect of patient and social factors on postdischarge health outcomes, such as medication safety, quality of life, unplanned hospital utilization, and mortality. The rationale and design of VICS are detailed elsewhere.²⁵ Briefly, participants completed a baseline interview while hospitalized, and

Results

Of the 680 eligible, we enrolled 587 patients from October 1, 2011, through August 31, 2012. Ninety-three eligible patients (13.7%) declined enrollment (Figure 1). Of the 587 enrolled, 471 patients (80.2%) completed the medication review portion of the postdischarge telephone interview and were included in these analyses. The remaining 116 patients did not complete the follow-up call (n=51), did not complete the medication review (n=49), withdrew (n=11), or died before discharge (n=5).

Table 3

Discussion

We identified at least one medication error or unintentional discrepancy between the discharge list and patient report in 51.4% of patients. As hypothesized, higher levels of health literacy and numeracy were associated with lower odds of medication errors. However, we did not observe significant associations between medication errors and other potential risk factors: medications changed during hospitalization, poor social support, or low preadmission medication adherence.

Our results must be

Conclusion

In summary, we determined that half of patients with ACS and/or ADHF had a medication error in the days after hospital discharge. These errors have the potential to harm patients; thus, we must understand which factors are associated with an increased risk of errors. We found that patients with low health literacy and numeracy are at increased risk of medication errors; therefore, identification of patients at risk can help clinicians provide appropriate discharge medication education.

Acknowledgments

We thank Joanna Lee for organizing and entering data and Dr Jesse Ehrenfeld for providing Elixhauser scores. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The funding agency was not involved in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript. Drs Mixon and Kripalani had full access to

References (48)

R.L. Rothman et al.
Patient understanding of food labels: the role of literacy and numeracy
Am J Prev Med
(Nov 2006)
N.L. Campbell et al.
Medication adherence in older adults with cognitive impairment: a systematic evidence-based review
Am J Geriatr Pharmacother
(2012)
W.F. Gellad et al.
A systematic review of barriers to medication adherence in the elderly: looking beyond cost and regimen complexity
Am J Geriatr Pharmacother
(2011)
S.I. Chaudhry et al.
Geriatric conditions and subsequent mortality in older patients with heart failure
J Am Coll Cardiol
(2010)
K.T. Unroe et al.
Inpatient medication reconciliation at admission and discharge: A retrospective cohort study of age and other risk factors for medication discrepancies
Am J Geriatr Pharmacother
(2010)
K. Kroenke et al.
The PHQ-8 as a measure of current depression in the general population
J Affect Disord
(2009)
S. Kripalani et al.
Development and evaluation of the Adherence to Refills and Medications Scale (ARMS) among low-literacy patients with chronic disease
Value Health
(2009)
M.J. Maniaci et al.
Functional health literacy and understanding of medications at discharge
Mayo Clinic Proc
(2008)
D.M. Stitt et al.
Medication discrepancies identified at time of hospital discharge in a geriatric population
Am J Geriatr Pharmacother
(2011)
A.J. Apter et al.
Linking numeracy and asthma-related quality of life
Patient Educ Couns
(2009)

Y.M. Cua et al.

Medication use in the transition from hospital to home

Ann Acad Med

(2008)

L.A. Lindquist et al.

Relationship of health literacy to intentional and unintentional non-adherence of hospital discharge medications

J Gen Intern Med

(2012)

K.T. Haynes et al.

Pharmacists' recommendations to improve care transitions

Ann Pharmacother

(2012)

P.J. Kaboli et al.

Clinical pharmacists and inpatient medical care: a systematic review

Arch Intern Med

(2006)

C.R. Selden et al.

Current Bibliographies in Medicine: Health Literacy

(2000)

Y.K. Loke et al.

Systematic review of consistency between adherence to cardiovascular or diabetes medication and health literacy in older adults

Ann Pharmacother

(2012)

L. Calvillo-King et al.

Impact of social factors on risk of readmission or mortality in pneumonia and heart failure: systematic review

J Gen Intern Med

(2013)

R.L. Reese et al.

Depression and rehospitalization following acute myocardial infarction

Circ Cardiovasc Qual Outcomes

(2011)

A.J. Forster et al.

The incidence and severity of adverse events affecting patients after discharge from the hospital

Ann Intern Med

(2003)

A.J. Forster et al.

Adverse events among medical patients after discharge from hospital

CMAJ

(2004)

A.J. Forster et al.

Adverse drug events occurring following hospital discharge

J GenIntern Med

(2005)

J.R. Pippins et al.

Classifying and predicting errors of inpatient medication reconciliation

J Gen Intern Med

(2008)

E.A. Coleman et al.

Posthospital medication discrepancies: prevalence and contributing factors

Arch Intern Med

(2005)

M. Mesteig et al.

Unwanted incidents during transition of geriatric patients from hospital to home: a prospective observational study

BMC Health Serv Res

(2010)

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: For editorial comment, see page 1027; for a related article, see page 1116

: Grant Support: This study was supported by grant R01 HL109388 from the National Heart, Lung, and Blood Institute (Dr Kripalani) and in part by grant UL1 RR024975-01 from the National Center for Research Resources and grant 2 UL1 TR000445-06 from the National Center for Advancing Translational Sciences.

: Potential Competing Interests: Dr Kripalani is a consultant to and holds equity in PictureRx, LLC. Dr Mixon is a Veterans Affairs Health Services Research and Development Service Career Development awardee at the Nashville Department of Veterans Affairs. No other authors report conflicts of interest or financial disclosures.

View full text

Original articleCharacteristics Associated With Postdischarge Medication Errors

Abstract

Objective

Patients and Methods

Results

Conclusion

Section snippets

Study Setting and Design

Results

Discussion

Conclusion

Acknowledgments

Am J Prev Med

Am J Geriatr Pharmacother

Am J Geriatr Pharmacother

J Am Coll Cardiol

Am J Geriatr Pharmacother

J Affect Disord

Value Health

Mayo Clinic Proc

Am J Geriatr Pharmacother

Patient Educ Couns

Medication use in the transition from hospital to home

Ann Acad Med

Relationship of health literacy to intentional and unintentional non-adherence of hospital discharge medications

J Gen Intern Med

Pharmacists' recommendations to improve care transitions

Ann Pharmacother

Clinical pharmacists and inpatient medical care: a systematic review

Arch Intern Med

Current Bibliographies in Medicine: Health Literacy

Systematic review of consistency between adherence to cardiovascular or diabetes medication and health literacy in older adults

Ann Pharmacother

Impact of social factors on risk of readmission or mortality in pneumonia and heart failure: systematic review

J Gen Intern Med

Depression and rehospitalization following acute myocardial infarction

Circ Cardiovasc Qual Outcomes

The incidence and severity of adverse events affecting patients after discharge from the hospital

Ann Intern Med

Adverse events among medical patients after discharge from hospital

CMAJ

Adverse drug events occurring following hospital discharge

J GenIntern Med

Classifying and predicting errors of inpatient medication reconciliation

J Gen Intern Med

Posthospital medication discrepancies: prevalence and contributing factors

Arch Intern Med

Unwanted incidents during transition of geriatric patients from hospital to home: a prospective observational study

BMC Health Serv Res

Original article
Characteristics Associated With Postdischarge Medication Errors