Study Finds Antimicrobial Prescribing at Discharge Rife With Errors
Pharmacists on a hospital's antimicrobial stewardship team say that medication errors at discharge that are related to antiinfective prescribing and use are surprisingly common and present an opportunity to improve transitional care.
At The Brooklyn Hospital Center in New York, a one-month retrospective pilot study of patients discharged from the family medicine service found that medication errors occurred among 27% of patients leaving the hospital with a prescription for an antimicrobial. A six-month follow-up study, this time conducted during the discharge process, found an even higher rate—47%—said Christy Su, who led the research as part of a postgraduate year 2 pharmacy residency project in infectious diseases (ID).
"With this project, we were able to highlight another high-risk population, which is those patients that are being discharged on antibiotics," Su said in December. She presented the team's findings last September at a poster session during the Interscience Conference on Antimicrobial Agents and Chemotherapy in Washington, D.C.
The stewardship team found that 65 antiinfective drugs were prescribed for 45 patients during the six-month study. The team documented a total of 33 medication errors affecting 19 patients and made recommendations to the prescribers to rectify those errors.
In all, the prescribers accepted 23 of these recommendations in 13 patients before discharge, thereby avoiding medication errors in 68% of the study population.
The project used the National Coordinating Council for Medication Error Reporting and Prevention's definition of a medication error: any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. The errors were subcategorized as problems related to safety, efficacy, or regimen simplification.
The team found that recommendations to resolve medication errors classified as safety-related were least likely to be accepted by the prescriber. Su said interventions to rectify such errors included the ordering of renal function testing, adjusting medication doses, or checking a patient's leukocyte count to assess the response to antimicrobial therapy.
In all, 6 of the 11 safety-related medication errors in this group pertained to the avoidance of unnecessary antimicrobials.
"It pretty much means that a lot of physicians overtreat or may not necessarily follow recommendations to the extent an ID specialist would," Su said of this finding.
Prescribers accepted 82% of the team's recommendations for regimen simplification, such as switching patients from i.v. to oral regimens, decreasing the frequency of dosing, and reducing the number of antiinfectives prescribed. The acceptance rate for efficacy-related interventions, such as optimizing the selection of a drug and the duration of therapy, was 73%.
Su said the 70% overall rate of physician acceptance of the stewardship team's recommendations leaves "room for improvement" but also attests to how well established and respected the team is at the hospital.
Veena Venugopalan, ID clinical pharmacist for the hospital at the time of the project, said the antimicrobial stewardship team was created about a decade ago and includes ID physicians, pharmacists, and first- and second-year pharmacy residents.
Venugopalan cautioned that the study was small, and its findings should be interpreted with caution.
Nevertheless, she said, "I think that this data is valuable and that it shows that we have a lot of headway to make on educating prescribers about modifying antibiotics and potentially identifying areas in which we could optimize therapy."
"When it comes to discharge, it's almost as if the onus for picking agents and modifying therapy is removed from the pharmacists' hands, and it's a decision that's made by the prescriber alone," she noted.
Educating physicians about improving their prescribing of antimicrobial drugs is one of the key elements of an antimicrobial stewardship program, according to recommendations from the Centers for Disease Control and Prevention.
Su, who now works as an emergency department pharmacist at Memorial Hermann Memorial City Medical Center in Houston, said the research generated a lot of interest among her colleagues in New York and during the poster session in Washington, D.C.
"The top question that I got when I presented this poster was how to do this, because a lot of times we are not able to catch patients at discharge," Su said. "The struggle right now is really just being able to find that multidisciplinary discharge team and finding that system that works in your hospital."
Venugopalan, who is currently an ID clinical pharmacy specialist at California's Scripps Green Hospital and Scripps Memorial Hospital Encinitas, said finding sufficient manpower to involve ID clinicians in discharge medication review can be a problem. But she said it can be done without dedicating a specific ID staff member for the job.
"Just as much as we get consults for the initiation of antibiotics, we could be consulted at the time of discharge," Venugopalan explained. She said she does this work informally as needed alongside a transitional care pharmacist.
"We are, in fact, doing the same thing, achieving the same goals" as those described in the study, Venugopalan said.
The 45 patients whose discharge prescriptions were analyzed for the study were 60 years of age, on average, and their diagnoses included pneumonia, bacteremia, osteomyelitis, skin and soft tissue infection, urinary tract infection, and Clostridium difficile infection.
Half of the medication errors reported during the study were related to the use of cephalosporins or macrolides. Cephalosporins and aminopenicillins were the most frequently prescribed antimicrobials at discharge.
The most common safety-related intervention was to avoid the use of unnecessary antiinfectives. Correcting inappropriate antimicrobial selection was the top efficacy-related recommendation, and reducing the number of antiinfectives prescribed was the top simplification-related recommendation.
Kasey Thompson, ASHP's vice president for policy, planning, and communications, noted that ASHP has for many years "led efforts in the area of antimicrobial stewardship," including the development of the 2010 Statement on the Pharmacist's Role in Antimicrobial Stewardship and Infection Prevention and Control.
The Centers for Medicare and Medicaid Services (CMS) has been urged by ID societies and other stakeholders to make hospitals' implementation of an antimicrobial stewardship program a condition of participation in Medicare and Medicaid.
A CMS spokesman stated that the agency is "looking at" this issue but cannot comment on it specifically during the rulemaking process.
ASHP's Thompson said that if antimicrobial stewardship does become a condition of participation for Medicare and Medicaid, this would present "a real opportunity for pharmacists to take a major leadership role in preparing their organizations and helping them lead in this important area."
[This news story appears in the Feb. 15, 2015, issue of AJHP.]