Session Date & Time: None. Available on demand.
*Purpose: Medication errors are of great concern due to the risk for patient and allograft injury. The aim of this study was to evaluate the effectiveness of a novel multidisciplinary discharge medication reconciliation process.
*Methods: Consecutive transplant recipients were retrospectively analyzed following the implementation of a multidisciplinary, quality improvement project targeting an efficient, effective discharge workflow. This project improved multidisciplinary communication and the discharge medication review process by including transplant pharmacist review prior to specialty pharmacy dispensing and nurse review after medication delivery. Data collected focused on quantifying the impact of the reduction of medication errors at discharge.
*Results: Seven-hundred twenty-three total medication errors were captured, among all adult abdominal organ recipients transplanted between Jun 1, 2019 and Sep 1, 2020 (N=389). The majority of errors were identified prior to medication dispensing (96%), with a median of 1.8 errors per patient (IQR 1.5-2.1). Types of error are described in Figure 1. The highest errors per patient identified were in March (3.2) and April (2.5), 2020 (Figure 2). Adherence to novel discharge workflow improved from 59% to 100% throughout the study period by pharmacy and nursing staff.
*Conclusions: A novel discharge workflow incorporating transplant pharmacists, nursing, and specialty pharmacy staff was effective in detecting and mitigating medication errors at each step in discharge process, improving discharge efficiency and de novo abdominal transplant recipients transitions of care.
To cite this abstract in AMA style:Norris M, Witek S, Whritenour C, Sigafus K, Chiang C, Sammons C, Naveiro D, Paredes A, Perez-Ngai E, Kaminski M, Westmoreland R, Malat G. Reduction in Medication Errors at Discharge in the Transplant Population via Use of Novel Pharmacist / Nursing Dual Check System [abstract]. Am J Transplant. 2021; 21 (suppl 3). https://atcmeetingabstracts.com/abstract/reduction-in-medication-errors-at-discharge-in-the-transplant-population-via-use-of-novel-pharmacist-nursing-dual-check-system/. Accessed June 20, 2021.
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