Medication errors when transferring elderly patients between primary health care and hospital care

RESEARCH ARTICLE
116

sa Bondesson, Tommy Eriksson and Peter Ho Patrik Midlo v, Anna Bergkvist, A glund

Pharm World Sci (2005) 27: 116120

Springer 2005

v (correspondence, e-mail: Patrik Midlo belund Primary Health Care peter.hoglund@skane.se): Ta Centre, Eslo v, Sweden; Department of Clinical Pharmacology, Lund University Hospital, Lund, Sweden Anna Bergkvist: Hospital Pharmacy, Kristianstad Central Hospital, Kristianstad, Sweden sa Bondesson, Peter Ho glund: Department of Clinical A Pharmacology, Lund University Hospital, Lund, Sweden Tommy Eriksson: Hospital Pharmacy, Lund University Hospital, Lund, Sweden Key words Drug related problems Drug use Elderly Integrated care Medication errors Pharmaceutical care Sweden Abstract Objective: The aims were to evaluate the frequency and nature of errors in medication when patients are transferred between primary and secondary care. Method: Elderly primary health care patients (> 65 years) living in nursing homes or in their own homes with care provided by the community nursing system, had been admitted to one of two hospitals in southern Sweden, one university hospital and one local hospital. A total of 69 patient-transfers were included. Of these, 34 patients were admitted to hospital whereas 35 were discharged from hospital. Main outcome measure: Percentage medication errors of all medications i.e. any error in the process of prescribing, dispensing, or administering a drug, and whether these had adverse consequences or not. Results: There were 142 medication errors out of 758 transfers of medications. The patients in this study used on an average more than 10 drugs before, during and after hospital stay. On an average, there were two medication errors each time a patient was transferred between primary and secondary care. When patients were discharged from the hospital, the usage of a specic medication dispensing system constituted a signicant risk for medication errors. The most common error when patients were transferred to the hospital was inadvertent withdrawal of drugs. When patients left the hospital the most common error was that drugs were erroneously added. Conclusion: Medication errors are common when elderly patients are transferred between primary and secondary care. Improvement in documentation and transferring data about elderly patients medications could reduce these errors. The specic medication dispensing system that has been used in order to increase safety in medication dispensing does not seem to be a good instrument to reduce the number of errors in transferring data about medication. Accepted September 2004

residents5 and is associated with an increased risk of admission to hospital due to an adverse drug reaction (ADR)6. A known cause of ADRs is drugdrug interaction and the frequency of these interactions is related to the age of the patient, the number of drugs prescribed, the number of physicians involved in the patients care, and the presence of increasing frailty7,8. In a meta-analysis of prospective studies, it was shown that fatal ADRs are between the fourth and sixth leading cause of death9, and other studies show that these ADRs often are preventable10,11. Other studies have shown that 1114% of all hospital admissions are caused by drug-related problems1214. In a review of Australian studies, the authors concluded that drug-related hospital admissions were a signicant and expensive public health problem in Australia, and approximately half were considered possibly or probably preventable15. In a study at an American teaching hospital, 905 prescribing errors were detected during a 1-year period16. Despite these well-known problems, there are not many studies that describe medication errors originating from the process of transferring information between hospital and primary health care. In a Norwegian study, the authors found that 19 out of 20 patients, living in nursing homes or in their own homes with care from the community nursing system, who were admitted to and discharged from a hospital had a total of 100 discrepancies in their medication information17. In Sweden there is no unied system of information on medication shared between different units in the health care system. The patient is the only holder of all information on medication. When patients are admitted to a hospital, the physician does not have a direct access to information on the patients medication and when the patient is discharged from the hospital the general practitioner at the nursing home does not have a direct access to information on the patients medication. We wanted to investigate the nature and frequency of errors in medication when elderly patients are transferred between primary health care and hospital care, both at admission to and discharge from hospital. We chose a town where physicians and nurses in both the primary health care and the local hospital had shown an interest in these matters.

Introduction
Elderly people often use many drugs1. In Sweden, people older than 75 years use on an average 4.6 different drugs, and 44% use ve or more drugs2. Elderly patients in nursing homes in Sweden use on an average nine different drugs3. It is common that nursing home residents use medications that are deemed inappropriate. In a previous study on 157 nursing home residents in southern Sweden, with Parkinsons disease or epilepsy, 40% used drugs that were classied as inappropriate to geriatric nursing home residents4. The number of medications is a risk factor for adverse drug events among nursing home Study objectives The objectives were to evaluate the nature and frequency of errors in medication when patients are transferred between primary and secondary care.

Method
Study site Elderly primary health care patients (> 65 years) living in nursing homes or in their own homes with care

provided by the community nursing system in the town of Landskrona in southern Sweden were invited to participate. The town of Landskrona has approximately 38,000 inhabitants. The hospital there has a department of internal medicine, but patients from Landskrona are also treated at the university hospital in the nearby city of Lund. To be eligible as participant in this study the patients had to have been treated at the department of internal medicine in Landskrona or any of the departments of internal medicine, neurology or orthopaedics at Lund university hospital during the period September 1, 2000December 31, 2001. Due to lack of nurses and organisational changes in the community nursing system in the town of Landskrona, no patients were included after June 1, 2001. Prior to the start of the study, all nurses in the nursing homes or from the community nursing system in Landskrona were invited to receive information about the study. They were also offered education in the eld of drug-use in the elderly. The nurses in the community nursing system in Landskrona identied patients who had been treated in any of the above mentioned hospital departments. The patients then received written and oral information and decided whether to participate in the study or not. The ethics committee of the University of Lund approved the study. Approval was also given by each patient (or their relatives), by the heads of the primary care centres in Landskrona, and the heads of the participating hospital departments.

notied about all changes in drug treatment using fax or phone. A new paper prescription form is written at the regional pharmacy and sent to the patient, to the responsible physician and to the nurse responsible for administration to the patient. We then identied if there were any errors in the transfer of information i.e. if the drugs were not the same as before the transfer. We used the denition of medication error proposed by Leape18. According to this denition, medication error is any error in the process of prescribing, dispensing, or administering a drug, and whether there are adverse consequences or not. We checked if there were any changes in medication after the transfer of a patient. If such changes were mentioned in the medication notes, it was of course not regarded as an error. Incorrect dosage interval was not an error if the total dose/24 hours had not been changed. Change of medication to a synonymous drug (generics) or withdrawal of drugs with long dosage interval, e.g. once monthly, was not regarded as an error. If drugs were added, withdrawn or the dosage had changed without any documentation in charts or medication lists, it was considered an error. All medications were classied by therapeutic group based on the World Health Organizations Nordic Anatomical Therapeutic Chemical Classication Index (ATC) codes19. Two different persons (P.M. and A.B.) separately evaluated all information about the patients drugs and errors. Thereafter their evaluations were compared and agreed on. When necessary a third person Identication of errors (T.E.) was consulted. The third person was consulted All medication notes used for information transfer in only two cases out of 758 medication transfers. were collected. These included referral forms, admission notes, discharge notes, medication lists Statistics and data analysis from the hospitals and from the community. Also, The results are generally given as frequencies, means the prescription forms used in the specic medica- and 95% condence intervals (CIs). We tested if there tion dispensing system were collected. This form is a was a signicant inuence on the number of patients complete list of all medications used by the patient. that had at least one medication error from any of the This system is quite common in Sweden and is used following variables: living in nursing home, number of especially for elderly patients living in nursing homes drugs used, sex, hospital (university or town hospital) or in their own homes. It is used because it is sup- and use of medication dispensing system. The analyposed to reduce the risk of mistakes in medication ses were performed using logistic regression. SAS handling. In brief, the medication dispensing system software was used for all statistical analyses (SAS is a multi-dose system and, if possible, all medica- Institute, Cary, NC). tions that the patient should take at one time are machine-packed together in small, fully labelled plastic bags at a regional pharmacy-dispensing Results centre. This means that the pharmacy instead of the The baseline characteristics of included patients are nurse prepares the dosages. The pharmacy has to be described in Table 1.

Table 1

Baseline characteristics for patients included in the study At admission to hospital (n = 34) At discharge from hospital (n = 35) 14 21 85 (6996) 24 11 26 9 28 7 117

Men Women Age, mean (range) Living in nursing home Living in their own home Using the specic medication dispensing system Not using the specic medication dispensing system Hospital care at Department of Internal Medicine, Landskrona Hospital care at Lund University Hospital

13 21 85 (6996) 23 11 26 8 28 6

The number of drugs and errors in medication when transferring patients between primary health care and hospital care

Discussion
In our study, errors in medication were common, almost one in every ve medications, when patients were transferred between primary and secondary care. The specic medication dispensing system that is used with the intention of reducing the risk of mistakes in medication intakes actually led to an increased risk in medication errors. Medications were often inadvertently withdrawn when patients were transferred to hospital. This could be due to lack of information. The fact that medications were more often erroneously added when patients left the hospital could be due to the fact that they were treated with the same medications as prior to the hospital stay. In that case, the changes that the physicians at the hospital had decided were not carried out. The patients received on an average 10.5 drugs at discharge from the hospital but since it was common that medications were erroneously added, the patients on an average received 11.7 drugs when they were back in primary health care. The elderly patients may not know the names of their medications and sometimes they do not have any written information

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The numbers are presented as totals and (mean) per patient and [95% CI]. N = 34 at admission to hospital and n = 35 at discharge from hospital.

Number of drugs at discharge from hospital

Number of drugs at admission to hospital

Table 2

Continuous use drugs On-demand use drugs All drugs

306 (9.0) [7.810.2] 83 (2.4) [1.83.0] 389 (11.4) [10.012.9]

303 (8.7) [7.69.7] 66 (1.9) [1.32.5] 369 (10.5) [9.211.4]

The patients in this study used on an average 11 drugs (Table 2). When patients were transferred from primary health care to hospital, 29 of 34 patients had at least one medication error (85%, CI 6995) compared with 19 of 35 patients (54%, CI 3771) for the opposite transfer of patients. Of all data about medications on an average 19% were transferred erroneously (Table 2). Percentage errors were slightly higher when patients were transferred from primary health care to hospital, 21%, as compared with the opposite transfer of patients, 17% (Table 2). Errors in medications for on-demand use were more than twice as common as errors in drugs for continuous use (Table 2). The most common drugs were drugs belonging to group N (central nervous system), C (cardiovascular system) and A (alimentary tract and metabolism) according to ATC codes, as described in Table 3. The number of errors was largest for the most common drugs according to ATC codes (Table 3). The most common error when patients were transferred to a hospital was withdrawal of drug. When patients were discharged from hospital, the most common error was that a drug was erroneously added (Table 4). An example of medication errors in one patient is presented in Table 5. There was no signicant inuence of the variables such as living in nursing home, number of drugs used, sex, hospital (university or town hospital) or use of medication dispensing system, on the number of patients who had at least one medication error when patients were admitted to hospital care. When patients were discharged from the hospital, the usage of a specic medication dispensing system constituted a signicant risk for medication errors: odds ratio 18 (CI 1.9169). Of the 26 patients with medication dispensing system, 18 patients had at least one medication error, whereas of the nine patients without medication dispensing system, only one patient had at least one medication error. There was no inuence on the number of patients with at least one medication error from any of the other variables tested, when patients were discharged from hospital.

Percentage errors of medications at discharge from hospital

Percentage errors of medications at admission to hospital Number of errors at discharge from hospital Number of errors at admission to hospital

57 (1.7) [1.02.4] 23 (0.7) [0.31.0] 80 (2.4) [1.53.2]

34 (1.0) [0.61.4] 28 (0.8) [0.41.2] 62 (1.8) [1.12.5]

18.7 [14.423.4] 27.7 [18.438.6] 20.6 [16.724.9]

11.2 [7.915.3] 42.4 [30.355.2] 16.8 [13.121.0]

Table 3

The number of drugs used and the number of errors before admission to and at discharge from hospital care classied by therapeutic group based on the World Health Organisation Nordic Anatomical Therapeutic Chemical Classication Index (ATC) codes Before admission When leaving The number of to hospital hospital errors at admission (34 patients) (35 patients) to hospital (34 patients) 71 (2.1) 38 (1.1) 89 (2.6) 105 (3.1) 86 (2.5) 389 (11.4) 62 (1.8) 38 (1.1) 92 (2.6) 102 (2.9) 75 (2.1) 369 (10.5) 20 (0.6) 4 (0.1) 10 (0.3) 21 (0.6) 25 (0.8) 80 (2.4) The number of errors at discharge from hospital (35 patients) 19 (0.5) 1 (0.0) 8 (0.2) 14 (0.4) 20 (0.6) 62 (1.8)

ATC

A, Alimentary tract and metabolism B, Blood and blood forming organs C, Cardiovascular system N, Central nervous system Others Total

One patient may use more than one drug in each group. The numbers are presented as totals and (mean) per patient. The number of errors may exceed number of drugs.

Table 4

The nature of error in medication occurring when transferring from hospital care to primary health care and vice versa Medication erroneously added Medication erroneously withdrawn 53 (1.6) 6 (0.2) 59 (0.9) Erroneous change in dosage 22 (0.6) 9 (0.3) 31 (0.4)

Transfer to hospital care Transfer to primary health care Total

5 (0.1) 47 (1.3) 52 (0.8)

The numbers are presented as totals and (mean) per patient.

Table 5

An example of medication discrepancies between hospital and primary care Medications in primary care Movicol (Makrogol 3350) on demand Alvedon (Paracetamol) 1 g three times daily Duroferon (iron sulphate) 100 mg once daily Kalcipos D (calcium + vitamin D) twice daily Tradolan (Tramadol) 50 mg on demand

Medications in hospital care Movicol (Makrogol 3350) once daily Alvedon (Paracetamol) not mentioned Duroferon (iron sulphate) not mentioned Kalcipos D (calcium + vitamin D) not mentioned Tradolan (Tramadol) not mentioned
This 84-year-old woman was transferred from hospital to primary care.

when they are admitted to or discharged from hospital care. All the patients in this study received care from the community nursing system because they are more physically or mentally disabled than elderly patients in general. It is likely that the magnitude of the problem is higher among our study population than among elderly patients in general. Our results are in accordance with a Norwegian study on similar patient group in another Scandinavian country which has a similar health care system17. Since there are no studies in these matters that compare different hospitals, we do not know how representative the studied hospitals are. This study has not dealt with the clinical outcomes caused by medication errors. The clinical importance of medication errors occurring when elderly patients are transferred between hospital and primary health care still has to be evaluated. This is a topic of an ongoing study. In a Dutch study, it was shown that discrepancies in information about current medication between patients and their general practitioner

are common20. In southern Sweden, the medical records are not always available to the new caregiver when patients are transferred between different care units. There is also a chance of errors due to human mistakes since the prescriber has to renew the whole medication chart whenever a patient is transferred. A recent British study showed that common causes to prescribing errors in hospital inpatients were slips in attention or because the prescribers did not apply relevant rules21. It has further been shown that it is common with medication errors during the hospital stay21,22. A Canadian study showed that an integration of admission medications, in-hospital changes and discharge medications on a single form could be a useful tool in decreasing drug-related problems23. If the patients discharge notes included information about what drugs were used prior to hospital care and why changes have been made, the primary health care physician would know whether the hospital physicians were aware about all the patients medications or not. Our study shows that the procedures

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in use for transferring information on medication are not optimal. There are several risks of introducing errors in medication before, during and after hospital stay. Techniques to improve transfer of information of medication could reduce some of these errors.

Conclusion

Medication errors are common when elderly patients are transferred between primary and secondary care. 9 Improvement in documentation and transferring data about elderly patients medications could reduce these errors. The specic medication dispensing sys- 10 tem that has been used in order to increase safety in medication dispensing does not seem to be a good 11 instrument to reduce the number of errors in transferring data about medication. 12

Acknowledgements

13

The authors thank Dorothea Westerlund (MSc Pharm) for her help in collection of parts of the data. We also 14 wish to thank participating nurses for their help in nding eligible patients.
15

Financial support of the study

16

We thank the department of Primary Care Research ne, the Na- 17 and Development in the county of Ska tional Corporation of Swedish Pharmacies and the Faculty of Medicine, Lund University, for nancial 18 support.
19

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