Keeping patients safe through medication review and management in the community

Patient safety is of paramount importance to good healthcare delivery. Numerous studies and reports have shown that health management errors caused almost half of the adverse hospital events (Brennan et al, 1991; Leape et al, 1991; Institute of Medicine (US) Committee on Quality of Health Care in America, 2000). However, the incidence of adverse events occurring after discharge was often under-reported. One study found that one in five patients experienced an adverse event during the transition from hospital to home (Forster et al, 2005). One-third of these adverse events were preventable, and adverse drug events accounted for most of these adverse events (Leape et al, 1991).

Many types of adverse events may occur after discharge from the hospital. Examples include nosocomial infection, diagnostic and medication errors (Forster et al, 2005). According to Forster et al (2003), adverse outcomes are defined as any of the following patient experiences after discharge:

• New or worsening symptoms
• Unanticipated visits to healthcare facilities for tests or treatments
• Death.

A preventable adverse event is an injury that could have been avoided due to an error or a system design flaw (Forster et al, 2003).

Medication error is an event that may cause or lead to inappropriate medication use or patient harm (National Coordinating Council for Medication Error Reporting and Prevention, 2024). It is a common type of adverse event following a hospital discharge and one of the leading causes of preventable harm within the healthcare system, including community settings worldwide (World Health Organization (WHO), 2005).

An emerging body of international literature reports on the high prevalence and nature of medication errors following hospital discharge (Forster et al, 2005; Ahmad et al, 2014; Meyer-Massetti et al, 2018; Parekh et al, 2018a; Alqenae et al, 2020). A systematic review of the burden and nature of medication errors post-hospital discharge found that the median rate of medication errors following hospital discharge was as high as 53% among adult patients (Alqenae et al, 2020).

According to a large-scale multicentre UK study, medication errors were found to be the third most prevalent form of medicines-related harm in older people following hospital discharge, with a prevalence of 3.4% (Yao et al, 2018). Another study estimated that almost 20% of adult patients experience an adverse drug event post-hospital discharge, and 50% experience medication errors or unintentional medication discrepancies (Parekh et al, 2018b; Alqenae et al, 2020).

In Singapore, very few studies report on the prevalence and nature of medication errors following hospital discharge. Most studies explored medication errors but focused on those during hospital admission (Choo et al, 2013; 2014; Foo et al, 2017). Only one study reported medication discrepancies as common and already happening at the point of discharge (Akran et al, 2015). More community-based studies exploring medication errors following hospital discharge are needed.

Transitions of care, such as discharge from the hospital, have been identified as critical points of increased risk for medication errors (Tong et al, 2017). This is due to the possibility of medication regime misunderstandings resulting from ineffective communication between physicians, patients and caregivers (Cheong et al, 2019).

The WHO's third global patient safety challenge has also identified the burden of risk associated with medication safety at the transfer of care (WHO, 2005).

Hospital-to-Home transitional care programme

In Singapore, the Hospital to Home (H2H) programme is one of the programmes that support transitions of care. Singapore General Hospital, one of the acute care hospitals in Singapore, screened for eligible patients who were admitted, to be enrolled into the H2H programme. The eligibility criteria include:

• Patient admitted to Singapore General Hospital
• Patient requiring support post-discharge for chronic disease and medication management
• Patient or caregiver requiring support or patient's care education
• Patient with high fall risk requiring home assessment for safety and equipment.

The H2H team—largely comprised of community nurses—conducts regular home visits, video and telephone consultations with patients and caregivers. Other than performing comprehensive care needs assessment, patient education and co-developing care plans with the patients, the nurses also perform medication review and consolidation.

The community nurses are trained to provide basic medication review and consolidation, and this includes checking if the patient is taking the right prescribed medications (from the hospital), at the right dose, right route and right time. The nurse will also examine if the patient is taking any other over-the-counter drugs, or traditional medicine, which may cause drug-drug interactions. All community nurses have to undergo training and competencies on administration and management of medications annually.

The H2H programme aims to deliver holistic patient-centric care to support patients' safe and timely transit from hospital to home and reduce unnecessary hospital utilisation, that is, inpatient admissions and emergency department attendance that are preventable through H2H interventions.

The error will be escalated and reported in the ‘good catch’ reporting system when the community nurse encounters any medication discrepancies. The supervisor and safety quality department will review and mitigate the ‘good catch’ incidents accordingly.

Good catch

A good catch, also known as a ‘near miss’, has been used to describe an event that can potentially cause patient harm but fails to do so because of chance or because it was intercepted (WHO, 2005). Tracking good catches can provide valuable resources for identifying care gaps and areas for improvement. Furthermore, studies and guidelines have emphasised the importance of examining the near misses of medication errors (WHO, 2005; Sheiktaheri, 2014).

The institution that the authors worked in developed an initiative, a reporting system called ‘good catch’, in 2017 to supplement and improve the risk management system (RMS). For good catch reporting, the user will document the medication error incident discovered during the home visit and interventions done to mitigate the situation. Details of the medication errors, such as wrong dosage, frequency, and time are included in the report.

In contrast, RMS is a system where workplace adverse events, including medication errors, are reported and stored for analysis. One limitation of RMS is that it does not report near misses/good catches.

Since the root causes of adverse events and near misses are often similar, analysing the root causes of near misses will also help to address these incidences and potentially prevent future adverse events.

Hence, it is necessary to analyse good catch/near-miss reports of medication errors in the community setting. Only then, targets can be identified for future work in preventing medication errors post discharge.

Aims

This article aims to describe and analyse the types of medication errors among community-dwelling patients following their discharge within 3 weeks from an acute care hospital.

Materials and methods

Study design

This is a descriptive, retrospective review of ‘good catch’ reports via a reporting system in a tertiary hospital.

Methods

Using the ‘good catch’ database, the authors extracted the data of all medication-related error incidents reported between December 2018 and March 2022.

From the data, the errors were categorised into:

• Incorrect dose
• Omission
• Taking the discontinued drug
• Medication belonging to another patient
• Incorrect method of preparation.

The reasons for the errors were further categorised into a poor understanding of medication usage, unawareness of medication changes, language barrier, physician-related (e.g. wrong prescribing and poor communication with the physician), pharmacy-related (e.g. pharmacy dispensing wrong medication, pharmacy writing wrong indication, pharmacy dispensing different patient's medication and poor communication with a pharmacist), and caregiver-related reasons (e.g. lack of medication, caregiver training not completed and wrong instruction given by caregivers) (Table 1).

Findings

Demographic

The community nurses reported 73 medication-related good catches between December 2018 and March 2022. Out of these, 46.6% (n=34) were female, 37% (n=27) were male, and the remaining 16.4% (n=12) of the patient's gender were unrecorded. The mean age of the patients was 78 years old (standard deviation (SD)=9) (Table 1).

Person managing medication

Most patients managed their medications independently (45.2%, n=33) or with help from their family members (32.9%, n=24). Others were managed by a domestic helper (16.4%, n=12) or a friend (1.4%, n=1). The remaining three samples did not report who managed the medications (Table 1).

Types of medication

Cardiovascular medication (51.5%, n=50), diabetes medication (15.4%, n=15), vitamin supplements (9.2%, n=9), antibiotics and antifungals (7.2%, n=7), and urologic medication (3.1%, n=3) were the most common types of medications involved in the error (Table 2).

Types of medication error

The majority of medication errors reported were incorrect dose (41.1%, n=39), followed by the omission of medications (23.1%, n=22), taking discontinued medication (16.8%, n=16), medication belonging to another patient (3.2%, n=3) and incorrect method of preparation (1.1%, n=2) (Table 2).

Out of the incorrect dose (n=39), most were taking more than the prescribed dose (n=23), followed by a lesser dosage (n=10). The remaining six samples did not specify (Table 2).

Reasons for the medication error

Multiple factors contributed to the medication error. Most were due to the patient's poor understanding of medication usage (35.6%, n=26). Other factors include unawareness of medication changes (24.7%, n=18) and language barrier (12.3%, n=9). There were also factors that were related to the physician (11%, n=8), pharmacist (8.2%, n=6) and caregiver (8.2%, n=6) (Table 2).

Discussion

The findings from the analysis of this research are consistent with the body of literature on post-discharge medication adverse events. Older people are at higher risk of medication errors following hospital discharge (Tomlinson et al, 2020a). This might be attributed to the many prescribed medicines due to their multiple chronic conditions (Maher et al, 2014) under the care of different medical disciplines (Oliver et al, 2014). Approximately 37% of older people over 65 years are at risk of medication-related harm in the 8th week following hospital discharge (Parekh et al, 2018a). This highlights the importance of ensuring that older people receive appropriate medication management and follow-up care post-discharge.

A local study conducted in Singapore also reported a non-adherence rate of 60% among the community-dwelling older population (Chew et al, 2021). This suggests that there is a need for interventions to improve medication adherence and reduce the risk of adverse events among older people.

In this study, it was found that there are many reasons for the cause of medication non-adherence. The main reasons are poor understanding of medication usage and unawareness of medication changes upon discharge. These reasons are aligned with another local study which explore the prevalence and predictors of medication adherence among community-dwelling older adults. It is reported that most of the community-dwelling older adults did not know the purpose of their medications and have experienced side effects, leading them to non-adherent to medications (Chew et al, 2021). Patients and families should be taught on the indications and the potential side effects when there is a new medication, change of medication, change of dosage and/or discontinuation of medications. However, understanding the medications and side effects are insufficient, patient and families should be involved in the de-prescribing process e.g. to address healthcare professionals if new medication and/or increase of dosage of a particular medication causes certain side effects.

Importance of education, communication and engagement

More efforts must be dedicated to discharge education and extend interventions beyond the hospital walls. Patients and their caregivers should be involved in communication during transitions of care to improve the transfer of clinical information and patient outcomes, and prevent adverse events during hospitalisation and following discharge (Manias et al, 2019). However, the patient and caregiver's willingness to participate also depends on their trust in the healthcare professionals. Therefore, careful exploration and explanation of medication management and administration at home should be part of the discharge planning process (Tomlinson et al, 2020a). Communication and engagement with patients during the transition, rather than just at discharge, are essential and contribute to a better understanding (Tomlinson et al, 2020b).

Healthcare provider's role

Nurses and pharmacists add value by identifying patients and caregivers who need help with medication management during dispensing upon discharge (Bethishou et al, 2020). By identifying patients and caregivers who need help with medication management during discharge, nurses and pharmacists can provide targeted support and education to improve medication adherence and reduce the risk of adverse events.

Giving more time and attention to these patients and caregivers needing help in medication management is essential. Using artefacts such as medication leaflets and labels, pill box reminders, de-prescribing and teach-back methods are useful tools and strategies for medication safety post-discharge.

Involving patient and family members

Community nurses play a crucial role in medication management at home, involving patients and their family members. Family members can support patients in decision-making about managing medications and negotiating communication with health professionals (Manias, 2015). Community nurses can provide education and skill-building for family caregivers, emphasising increasing knowledge and education regarding symptoms (Bethishou et al, 2020).

Involving family members in patient education improves the chances that instructions will be followed and increase medication adherence (Bucknall et al, 2016). Families play an important role in de-prescribing and reconciliation in all transitions, as they are the key players at home (Manias et al, 2019; Zhao et al, 2019).

In the hospital setting, nurses have the ability to monitor patient's medication administration throughout their hospital stay. In the event where the patient or family member has concern on the medications (e.g. does not want to take a particular medication due to a certain side effect), healthcare professionals are always ready to address them and provide medication review instantly. This is a challenge in the home setting as the ability for patients and/or family members to make unwise decisions regarding the medication is possible. Hence, it is vital that patient and family empowerment should be the ultimate goal, since medication administration depends on them to be effective and safe at home.

Teach-back method

The teach-back method is beneficial in reinforcing patient and caregiver education (Yen and Leasure, 2019). In the teach-back method, patients and caregivers explain health information in their own words after sharing it.

This teach-back method can potentially unscramble most of the main factors contributing to this study's medication errors, such as patients' poor medication literacy, unawareness of medication changes and language barrier.

Patients who received a standard discharge with the teach-back method scored higher on medication comprehension compared to patients who received only a standard discharge instruction (P<0.02) (Griffey et al, 2015).

Transitional care

It is crucial to look beyond patient and family education upon discharge. Project BOOST (Better Outcomes by Optimising Safe Transitions) is another resource developed to enhance the discharge transition from hospital to home. Although there is limited study targeting medication error, studies have found that Project BOOST was associated with decreased readmission rates (Hansen et al, 2013).

A mixed study systematic review revealed that BOOST has the potential to meet patient information and communication needs (Woods et al, 2019). Moreover, it is valuable since it represents continual care. Contrary to giving a discharge summary alone, the information in the discharge summary is retrospective and does not tell what patients and families need to do to maintain well in the community.

The suggested interventions, such as the teach-back method and nurse-led post-discharge follow-up, would need to be evaluated using a rigour study design that requires a long follow-up duration to assess its effectiveness.

Community nurses play a critical role in the safety of medication management since nurses are known to be key members of the transitional care team (Mardani et al, 2020). Through home visits and teleconsultations, community nurses have a better view of what is happening at the patient's home. They can recognise and resolve potential problems related to medication safety.

Limitations

Our study has several limitations. Firstly, it is conducted retrospectively where the good catch reporting system was not explicitly designed to collect research data. Therefore, the data could not be validated further to understand better what was reported.

Secondly, the reports are based on the nurses' narratives, not patients' and caregivers' perspectives on medication error occurrence. Patients and caregivers can provide unique perspectives on the medication error, including how it affected their health and well-being and what could have been done to prevent it. By including their narratives, healthcare providers can better understand the factors that contribute to the error and develop strategies to prevent them in the future (Yao et al, 2018).

Thirdly, the ‘good catch’ report is inadequate and considerably small as there are only 78 reported cases in a period of 39 months. Nevertheless, as the good catch reporting system was not explicitly designed for this study and as the reports were based on only nurse's narratives, there is a possibility of under-reporting. Despite the small number of ‘good catch’ reports, having community nurse-led follow up post-discharge is still necessary as nurses do not merely provide medication consolidation alone, they provide holistic care and look at other areas (e.g. chronic disease management, home assessment and coping after discharge).

Lastly, the study failed to report patients' and caregivers' health literacy and educational background. Health literacy and educational background significantly influence medication adherence and health outcomes. Patients with limited health literacy are more likely to misinterpret prescription labels, leading to medication errors (Parekh et al, 2018b).

Further review is needed to explore the burden and causes of medication safety challenges following discharge from hospital to home among older patients and the challenges within the healthcare system.

Summary

The findings from the good catches provided valuable information on the incidence and type of adverse events post-discharge and areas where healthcare professionals can further enhance and improve medication management processes to prevent medication errors during the transitions of care.

Key points

• The majority of medication-related error incidents occur among older people
• Effective education on medication self-management should be catered to the ones managing the medications at home
• Involving the patient and family members is crucial as medication administration depends on them to be effective and safe at home
• Medication management and administration education can be emphasised using the teach-back method
• A seamless transition from hospital to community is essential.

CPD reflective questions

• What were the factors that contributed to the medication error post-discharge at home?
• What steps could have been taken to prevent the medication error from occurring?
• How can the healthcare team improve communication during the admission or discharge process to reduce the risk of medication errors?
• How can patient education be improved to help prevent medication errors post-discharge?
• How can the healthcare team learn from the medication error and use it to improve the discharge care process?
• What role can patient and family engagement play in preventing medication errors post-discharge?