Medication error at the primary secondary care interface: costs, causes, consequences

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Walsh, Elaine K.
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University College Cork
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Background: Medication error is an important patient safety issue worldwide and results in morbidity, mortality and economic burden. The true cost of medication error is unclear from current evidence. Medication error is particularly common at the primary secondary care interface as patients move between hospital and the community. Developing interventions to reduce medication error (and in particular error at this interface in care) is currently an international priority. Existing interventions, such as medication reconciliation, are often resource intensive. Within healthcare systems, where resources are limited, measures to reduce costs and improve process efficiency are required in addition to optimising patient care. Aim: The overarching aim of this thesis is to examine medication error at the primary secondary care interface in terms of cost, causes and consequences in order to develop a pragmatic intervention to facilitate its reduction. Structure and methods: The Medical Research Council, UK (MRC) guidance on the development and evaluation of complex interventions in healthcare was employed. Existing evidence on the cost of medication error was systematically reviewed and synthesised in a narrative synthesis. A cost per error was extracted and expressed in Euro. A cross-sectional study was conducted. The study examined an existing process of medication reconciliation in terms of factors predicting time burden and associated financial cost. Logistic regression was used to investigate associations between patient characteristics and clinically significant errors and additional time. Cost for additional time was calculated in terms of hospital pharmacist salary. The new evidence generated was used, along with the existing evidence base, to develop a novel intervention aiming to reduce the occurrence of medication error at the primary secondary care interface. The intervention, the PHARMS (Patient Held Active Record of Medication Status) device, is a patient held electronic record used to transmit medication information between primary and secondary care. The intervention was evaluated by a mixed methods feasibility study (non-randomised controlled intervention and a process evaluation of qualitative interviews and non-participant observation). The study was informed by the Consolidated Framework for Implementation Research (CFIR). The occurrence of medication error was compared between groups and factors associated with medication error investigated using negative binomial regression. Thematic analysis of data from semi-structured interviews with key stakeholders was conducted. Results: Systematic review: 16 studies were included in the systematic review. The review identified that medication error is associated with significant economic impact with an associated cost of up to €111,727.08 per error. In view of the limited parameters used to establish economic impact, it was concluded that the true economic burden of medication error may have been underestimated to date. Cross-sectional study: 89 patients were included. Having a personal record of medication at admission (OR 3.30, 95% CI: (1.05 to 10.42), p=0.004) was a significant predictor of additional time. No significant associations were found between the occurrence of clinically significant error and additional time (p>0.05). The most common reason for additional time was clarifying issues pertaining to communication of medication information from primary care. Projected annual five year costs for the mean additional time of 3.75 minutes of the study were €1.8-1.9 million. Feasibility study: 102 patients were included (Intervention n=41, Control n=63). Total error number was lower in the intervention group Median=1 (0,3 IQR) than the control group Median=8 (4,13.5 IQR) p< 0.001, with the clinical significance score in the intervention group Median= 2 (IQR 0,4) also being lower than the control group Median=11 (IQR 5,20) p< 0.001. The device was found to be technically implementable using existing IT infrastructure and acceptable to all key stakeholders. Conclusion: Medication error is a costly problem, the true extent of which may have been underestimated. Issues pertaining to communication of medication information at the primary secondary care interface were identified as contributing to the economic burden associated with medication reconciliation. In addition, it was identified that increasing time for medication reconciliation may not necessarily result cost savings in terms of reducing medication error. The intervention developed as a result of this thesis may have the potential to facilitate more efficient medication reconciliation and reduce medication error at the interface of primary and secondary care. This may result in both clinical and economic benefit. Limitations: The overall numbers of patients included in the cross-sectional and feasibility studies in this thesis are small. In addition, these studies included only older adult patients in a single geographical location and involved a single hospital.
Medication error , Transitional care , Information technology , Cost
Walsh, E. K. 2019. Medication error at the primary secondary care interface: costs, causes, consequences. PhD Thesis, University College Cork.
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