Ms Fiona Dunne ADON Practice Development – MSc 2016 RCSI

1. Gerontological Nursing: Promoting
Evidence Based Quality Care
Presenter: Fiona Dunne
MSc Advanced Leadership in Nursing,
ADoN Nurse Practice Development
email: fionam.dunne@hse.ie

2. Outline of presentation
• Title of systematic review
• Medication reconciliation explained
• Background for study
• Reasons for choosing a systematic review
• Aim
• Methods used
• Results
• MedRec interventions carried out by nurses
• Findings
• Secondary outcomes
• Challenges for healthcare professionals
• Conclusion & recommendations

3. Systematic review title
• “The impact of nurse-led medication
reconciliation on medication discrepancy
detection at older adult care transitions.”

4. Medication reconciliation?
• The process of creating & maintaining the most accurate list possible of all medications a person is taking in order
to identify any discrepancies & to ensure any changes are documented and communicated 1
• Ensures that the person has a complete list of accurate medication
• Aim: to provide service users with the correct medications at all care transitions. It can be considered effective
when all medication that a person has been consuming has been purposely continued, stopped , temporarily
held or amended at each point of transfer & importantly when this has been communicated effectively to the
next providers of care 2

6. Medrec… not med wreck!

7. Background
• Safe healthcare is a national & international priority with one of the most
worrying aspect of care being medication safety 17
• Increased challenges: an ageing population + associated increase in
chronic conditions = people consuming more medications
• Medication errors have been reported as the most common type of error
& can have detrimental outcomes for patients yet are often preventable
• Hospital transition is a stressful, complex and potentially dangerous
process for patients. 3,4,5,6
• Particularly vulnerable times for older adults who often have co-
morbidities with consequent complex medication regimens, frequently
amended by many different healthcare providers 18
• 71.2% of hospital discharges had at least one type of MedRec problem 8
• 40% medication errors due to inadequate MedRec at transition 9
• Although transition is complex, accurate and complete medication
reconciliation plays an integral role in securing safe transitions 3
•
Global
ageing
populati
on.

8. Background
• In 2004, The Joint
Commission recommended
that organisations must
carefully reconcile
medications to avoid
adverse drug events.
• Consequently, many
organisations developed
strategies for achieving a
complete patient
medication list at admission
& conveying this list
accurately to the next care
provider.

9. International &
national documents
advocating all
healthcare
providers should
ensure MR policies
are instigated at
admission

10. There is an urgent need for evidence-based research regarding
nurses’ role in medication reconciliation (MedRec).

11. Medication reconciliation
• Despite the focus on MedRec, the
most effective process of conducting
MedRec remains unclear 10
• Literature review shows variation of
standards of MedRec
• Questions have been posed such as
who is responsible for MedRec?
• Irish report highlighted lack of
policies & clarity around MedRec
and requested all services to review
MedRec practices 1
• Nurses should have a key role in
MedRec but majority of literature
refers to pharmacists and doctors.

12. Why a systematic review?
>The question of ‘what works’ in
international development policy & practice
is becoming ever more important against a
backdrop of accountability and austerity 11
>Enormous volume of research evidence for
clinicians to keep abreast of 12
>A method of identifying & synthesising
all the available high quality research
that has evidence on a particular topic
using transparent and specified in advance
explicit methods 13, 14
>Gold standard for comparison & synthesis
of evidence in healthcare due to the rigorous
methodology 15

13. Aim of this review
• To systematically review & evaluate research
studies which analysed medication
reconciliation interventions performed by
nurses in older patients at care transitions, in
order to assess the impact of the nursing role
in detecting medication discrepancies (MDs),
determine the validity and transferability of
the results.

14. Outcomes
• Primary outcome of interest: the rate of medication
discrepancies detected by nurses when performing MedRec.
• Secondary outcome of interest: factors which contribute to
MedRec and a comparison of nurse-led MedRec with other
healthcare professionals.

15. Methods
• Adhered strictly to PRISMA
• Protocol designed
• Well-framed question
• PICO framework
• Inclusion and exclusion criteria
(older adults over 50 years at
care transitions)
• Search strategy
• Data extraction
• Quality appraisal
• Data analysis and synthesis
• Results
• Conclusions
• Recommendations

16. Results
• Search identified 457
citations
• Additional records
identified from study
references totalled 2
• Full text of 53 articles
was retrieved and 8 met
the inclusion criteria
PRISMA 2009 Flow Diagram
Records identified through
database searching: Embase (132)
Pubmed (50) Cochrane (4) Cinahl
(189) Web of Science (82)
(n= 457)
(n =369 )
Studies included in
quantitative synthesis
(meta-analysis)
(n = 8)
Studies included in
qualitative synthesis
(n = 0)
Full-text articles assessed
for eligibility
(n = 53)
Records screened
(n = 360)
Records after duplicates removed
(n = 360)
Additional records identified
through other sources
(n = 2)
IdentificationEligibilityIncludedScreening
Records excluded
(n = 307)
See appendix 8 for
rationale
Full-text articles excluded, with
reasons (n=45)
Age criteria <50 (n=21)
No nurse detected MR (n= 20)
Thesis (n=1)
Pharmacy focus (n= 1)
Case study (n=1)
Protocol (n= 1)
See appendix 9

17. Location of studies

18. Quality of studies

20. Nurse-led interventions
• Specialist diabetes nurse.
• Carried out structured
nurse-patient interviews in
OPD (referred from GPs)
with a strong focus on
medication reviews

21. Nurse-led interventions
• Nurses performing
home visits post
hospital discharge
• Interviews patients in
their home and checks
medications

22. Nurse-led interventions
• Specially trained
transitional nurse.
• Identifies medication
discrepancies during
telephone calls made
within 2-3 days of
discharge

23. • Community hospital
nurses
• Used a structured
assessment tool to
obtain an accurate
medication history
Nurse-led interventions

24. • Advanced Nurse
Practitioner working in
the Emergency
Department.
• Assumed complete
responsibility for the
management of
MedRec
Nurse-led interventions

25. Findings
• In all of the studies medication reconciliation
carried out by nurses improved the rates of
medication detection discrepancy

26. Some interesting findings
• Over 80% GP letters contained 1 or more
discrepancy.
• Nurses detected 58.9% omissions in GP
letters.

27. Some interesting findings
• Nurses detected medication discrepancies in 45-53% patients at the
home visit within the first week post hospitalisation.
• Nurses detected medication discrepancies in 22% patients during a
first follow up phone call post discharge.

28. • Improved history taking by nurses led to a decrease in drug
omissions in the discharge summary (pre 0.43 (0.71) versus
post 0.18 (0,44) p=0.053
Some interesting findings

29. Electronic assessment tool versus no
tool
• Nurses’ use of a structured assessment tool produced an
improvement in the accuracy of history taking at admission & less
odds of having a medication discrepancy when an electronic
assessment tool is used (p=0.004).

30. • Percentage of patients with at least 1 discrepancy decreased from 94% to 81%
where an ANP carried out Medrec.
• ANP intervention led to a decrease of almost 50% in medication discrepancies
compared with nurses working in the ED.

31. Secondary outcomes
Patient contributing factors leading to
inaccurate medication lists
System-level contributory factors leading
to inaccurate medication lists

32. Patient-level contributory factors to inaccurate medication lists
• Patients unaware of the importance of having a clear understanding of their own medication & the
MedRec process.
• Levels of patient acuity (if unwell poor patient recall)
• Acute admission (medications left at home)
• Increased age
• Unrecognised cognitive deficits
• Polypharmacy (sometimes but not always)
• Increased patient anxiety - poor history giving
• Patients with limited English, low education level
• Financial burden of medication
• Poor tolerance of medication
• Failure to fill a prescription

33. System-level contributory factors to inaccurate
medication lists
• More system level discrepancies than patient level discrepancies
• Incomplete or inaccurate communication and/or documentation
• Incomplete discharge instructions
• Changes in formularies of medications (medication substitutions can lead to MDs)
• Handwritten GP letters increased errors
• Lack of standardised processes to enable nurse to collect accurate medication information from
patients
KEY POINT: Information technology is a central component to support the process of MedRec
• Positive impact of electronic assessments were proven

34. Challenges for other healthcare professionals
Importance of interviewing patients to
elucidate actual medication use.
Difficulties busy clinicians face
Need for interpreters with increased
globalisation
Mean time of telephone calls was 80 minutes
Staff workloads
Not all nurses have the benefit of ANP service

35. Conclusion
• Despite extensive searching…. limited number of studies evaluating nurse-led MedRec &
lack of available high quality quantitative research.
• There is an alarmingly high rate of medication discrepancies at care transitions.
•
• Timely follow-up post discharge very significant.
• Need for improvements in care that will potentiate effective communication regarding
medications throughout hospitalisation in addition to hospital to home discharge.
• Nurses can contribute to a substantial reduction in medications discrepancies in care
settings for older persons by performing MedRec.
• Nurses can deliver improved outcomes by reducing potential medication errors.
• Outcomes of this review have global relevance.

36. Recommendations
• Strategies that facilitate the
prevention of medication errors at
care transitions need urgent
consideration.
• Further research needed to
investigate how nurse-instigated
MedRec can reduce medication
discrepancies.
• Focus on developing randomised
designs to accurately evaluate
MedRec during care transitions.
• Include larger number of patients to
determine significance.

37. How to ensure good MedRec
• Use of a checklist to facilitate MR at transition
points is advisable, such as at the point of
transfer from a nursing home/social care
setting to an acute hospital, or at the time of
discharge from an acute hospital to a nursing
home/social care setting.
• The availability of pre-printed service or ward-
specific forms may facilitate the MR process.

39. Don’t nurses have enough to do
already?
https://www.youtube.com/watch?v=U3
qiZGB9yUg&t=124s

42. References
1.Health Information & Quality Authority (2014) Principles of good practice in medication reconciliation
2. Institute for Healthcare Improvement (2011) How to guide: Prevent adverse drug events by implementing medication
reconciliation. Cambridge: MA: Institute for Healthcare Improvement.
3. Ruggiero J., Smith, J., Copeland J. & Boxer B. (2015) Discharge time out: an innovative nurse-driven protocol for medication
reconciliation. Medsurg Nursing. 24(3), 165-172
4. Coleman, E. A, Smith, J. D., Raha, D., & Min, S. J. (2005). Posthospital medication discrepancies: prevalence and contributing
factors. Archives of Internal Medicine, 165(16), 1842–1847.
5. Chhabra, P. T., Rattinger, G. B., Dutcher, S. K., Hare, M. E., Parsons, K. L., & Zuckerman, I. H.
(2012). Medication reconciliation during the transition to and from long-term care settings: a
systematic review. Res Social Adm Pharm, 8(1), 60-75. doi:10.1016/j.sapharm.2010.12.002
7. Alper E. Greenwald JL. & O’ Malley (2015) Hospital discharge and readmission. http://www.uptodate.com/contents/hospital-
discharge-and-readmission#H10
8. Foust J., Naylor M., Bixby B., & Ratcliffe S. (2012) Medication problems occurring at hopital discharge among older adults with
heart failure. Journal of gerontological Nursing. 5(1), 25-33
9. Hughes RG (ed.). Patient safety and quality: An evidence-based handbook for nurses. (Prepared with support from the Robert
Wood Johnson Foundation). AHRQ Publication No. 08-0043. Rockville, MD: Agency for Healthcare Research and Quality; March
2008. http://www.ahrq.gov/professionals/clinicians-providers/resources/nursing/resources/nurseshdbk/nurseshdbk.pdf
(accessed 12th October 2015)

43. References
10. Redmond P, Grimes TC, McDonnell R, Boland F, Hughes C, Fahey T. (2013) Interventions for improving medication reconciliation across
transitions of care (Protocol). Cochrane Database of Systematic Reviews 2013, Issue 10. Art. No.: CD010791. DOI:
10.1002/14651858.CD010791.
11. Mallett, R. , Hagen-Zanker, J., Slater, J & Duvendack, M. (2012) The benefits and challenges of using systematic reviews in international
development research, Journal of Development Effectiveness, 4:3, 445-455, DOI: 10.1080/19439342.2012.711342
12. Gugiu, P.C. (2015). Hierarchy of evidence and appraisal of limitations. Evaluation and Program Planning. 48, 149-159.
13. Oxman, A. D., & Guyatt, G. H. (1993). The science of reviewing research. Annals of the New York Academy of Sciences, 703, 125-133.
14. Gough, D., Oliver, S. & Thomas J. (2012) An Introduction to Systematic Reviews. Sage p. 4
15. Moher, D., Shamseer, L., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., Shekelle P. & Stewart L. (2015). Preferred reporting items for
systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic Reviews 4(1).
16. National Institute for Clinical Excellence (2015). Medicines optimisation: the safe and effective use of medicines to enable the best
possible outcomes. Retrieved November 13, 2015, from https://www.nice.org.uk/guidance/ng5
17. Godfrey, C.M., Harrison, M.B., Lang, A., Macdonald, M., Leung, T., & Swab M. (2013). Homecare safety and medication management with
older adults: A scoping review of the quantitative and qualitative evidence. JBI Database of Systematic Reviews and Implementation Reports,
11(7), 82-110.
18. Wang, T., & Biederman, S. (2012). Enhance the accuracy of medication histories for the elderly by using an electronic medication checklist.
Perspectives in Health Information Management. 9(Fall), 1-15.