CommentaryChallenges of managing medications for older people at transition points of care
Introduction
Older people aged 65 years and over are a vulnerable group who commonly have complex medication regimens and multiple co-morbidities.1 Due to their intricate health care needs, it is very likely that older people need to move across transition points of care in order to receive treatment by different health professionals. Transitions of care are “a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same location.”2 These transfers include movements between home and the hospital, and movements within and across various health care facilities.
As older people move across transition points of care, it is highly likely that their medication regimens change from one point to the next and that medication discrepancies occur.3 Medication discrepancies are differences in the medication regimens across different transition points of care.4, 5 Such discrepancies can involve omission or addition of a medication, substitution of an agent within the same pharmacologic class, and change in dose, frequency, or route of administration. Medication concerns related to transitions of care are complex.6 In addressing these complexities, pharmacists have placed heavy emphasis on the outcome – that is, identifying medication discrepancies and correcting them. What we do know is that many medication discrepancies are preventable1 and that miscommunication between health professionals or between health professionals and patients is a major cause of medication discrepancies.7, 8, 9 Another major cause of medication discrepancies involves problems with organizational systems, which include the local working culture, heavy workloads, staff and skill mix of health professionals, and compliance with policies and procedures.10, 11 Attempting to improve how communication occurs across transition points of care and how health professionals work through organizational systems, will help to address problems leading to medication discrepancies.
Section snippets
Tensions between proactively improving communication processes and rectifying medication discrepancies
The dominant strategy used in clinical practice in managing medications across transition points of care, is for pharmacists to perform detailed medication assessments. By performing these assessments, pharmacists detect, report and correct medication discrepancies.12 In isolation of considering the complexities of communication processes confronting older people moving across transition points, this strategy is unlikely to be sufficient on its own to ensure sustained and beneficial effects.
Overemphasis on identifying and rectifying medication discrepancies
Many studies have alerted to the problems associated with merely identifying and rectifying medication discrepancies. In the prospective observational study involving 375 older patients conducted by Coleman et al,19 14% experienced at least 1 medication discrepancy, defined as a lack of agreement between prescribed medication therapy indicated on the hospital discharge record and the therapy actually received by the patient. Of the 124 discrepancies identified, 49% occurred from
Possible solutions in managing medications across transition points of care
What are possible solutions to improving how medications are managed as older people move across transitions of care? Health professionals should focus on reducing the impact associated with the causes of medication discrepancies otherwise medication discrepancies will continue to perpetuate. As already mentioned, these causes relate to miscommunication about medication management activities and systems problems associated with the health care institutions.18 A three-pronged approach is needed.
Conclusion
Currently, extensive emphasis is placed on addressing medication reconciliation as a retrospective problem – that is, dealing with medication discrepancies after they have occurred. Pharmacists have claimed ownership of this problem as they attempt to identify medication discrepancies across many transitions of care and correct them. A more proactive stance should be taken whereby doctors, nurses and pharmacists collectively work together to prevent medication discrepancies from happening in
References (29)
- et al.
Inpatient medication reconciliation at admission and discharge: a retrospective cohort study of age and other risk factors for medication discrepancies
Am J Geriatr Pharmacother
(2010) - et al.
Medication reconciliation during the transition to and from long-term care settings: a systematic review
Res Soc Adm Pharm
(2012) - et al.
Medication communication between nurses and patients during nursing handovers on medical wards: a critical ethnographic study
Int J Nurs Stud
(2012) - et al.
Person-centred interactions between nurses and patients during medication activities in an acute hospital setting: qualitative observation and interview study
Int J Nurs Stud
(2010) - et al.
Reducing medication errors and improving systems reliability using an electronic medication reconciliation system
Jt Comm J Qual Patient Saf
(2009) - et al.
Literature Review: Medication Safety in Australia
(2013) - et al.
Improving the quality of transitional care for persons with complex care needs
J Am Geriatr Soc
(2003) - et al.
Effects of patient, environment and medication-related factors on high-alert medication incidents
Int J Qual Health Care
(2014) - et al.
Medication discrepancies upon hospital to skilled nursing facility transitions
J Gen Intern Med
(2009) - et al.
Tackling transitions in patient care: the process of medication reconciliation
Fam Pract
(2013)
Communication and information deficits in patients discharged to rehabilitation facilities: an evaluation of five acute care hospitals
J Hosp Med
Insufficient communication about medication use at the interface between hospital and primary care
Qual Saf Health Care
Communication gaps and readmissions to hospital for patients aged 75 years and older: observational study
Qual Saf Health Care
Complexities of medicines safety: communicating about managing medicines at transition points of care across emergency departments and medical wards
J Clin Nurs
Cited by (6)
A systematic review of older patients’ experiences and perceptions of communication about managing medication across transitions of care
2021, Research in Social and Administrative PharmacyCitation Excerpt :Unintentional discrepancies stem from unplanned medication changes, whereas intentional medication discrepancies happen where health professionals make the changes to the medication regimens depending on alterations in patients' clinical manifestations.6 Medication discrepancies can involve omission of medication, additional medication, or change in dose, route or administration of a medication.7,8 An incomplete or inaccurate medication history at any point during a patient's care can lead to medication discrepancies.9–12
An observational study of the cause and frequency of prescription rework in community pharmacies
2023, International Journal of Clinical PharmacyA shared medication scheme for community dwelling older patients with polypharmacy receiving home health care: role of the community pharmacist
2019, Acta Clinica Belgica: International Journal of Clinical and Laboratory MedicineGeriatrics care team perceptions of pharmacists caring for older adults across health care settings
2017, Annals of Long-Term Care