Medication safety following hospital discharge: understanding epidemiology, aetiology, and the impact of an improvement intervention

Abstract

Background: Improving medication safety during transition between care settings is one of three international priorities for the World Health Organization's Global Patient Safety Challenge: Medication Without Harm. An expansion in published literature has supported our understanding of the epidemiology and aetiology of medication errors (MEs) and medication related harm (adverse drug events (ADEs)) on admission and at the point of discharge from hospital, with efforts now turning to the development, evaluation, and integration of remedial interventions. However, medication safety following hospital discharge has received limited attention despite emerging evidence of significant risk to patients and overall vulnerability during this stage of their care journey. In addition, whilst remedial interventions such as Transfer of Care Around Medicines (TCAM) are now being introduced to improve medication safety following hospital discharge, further evidence of impact is required alongside a need for a greater understanding of the nature and contributory factors to generate intervention theory. The aim of this thesis is, therefore, to understand the epidemiology and aetiology of medication safety challenges post hospital discharge alongside the evaluation of a TCAM intervention in order to generate learning designed to drive an improvement action agenda. Method: The thesis presents three studies conducted during the programme of research. The first was a systematic review of international literature to synthesise knowledge of the prevalence and nature of MEs and ADEs following hospital discharge. The search was conducted on literature published between 1990 and 2019, using 10 databases and the grey literature. A second multi-method study was then conducted to identify the nature and contributory factors of medication incidents following hospital discharge by analysing patient safety incident reports submitted to the National Reporting and Learning System (NRLS) in England and Wales over a 5-year period. This included descriptive analysis of 1,121 incidents alongside content analysis of 408 incidents’ free text data with coding following the Patient-safety Incidents in Primary Care (PISA) framework. The third study was a multi-method study to evaluate the 'service utilisation' and 'service impact' of the nationally adopted TCAM service launched by one English NHS Trust in February 2019, with this local TCAM service initially focusing on patients with new or existing Monitored Dosage Systems (MDS). The TCAM service is designed to enable the prompt transfer of medication information, with referrals made by hospitals at discharge to a named community pharmacy for follow up. The 'service utilisation' study included a descriptive analysis of 3,033 anonymised patient referrals to 71 community pharmacies over one year period. The 'service impact' study assessed the impact of the TCAM service on unintentional medication discrepancies (UMD) and ADEs using a retrospective before and after study (6 months before and 6 months after implementation). Data were collected across 18 general practices by 16 trained practice pharmacists using general practice electronic record systems. Results: The first systematic review study identified 54 studies for inclusion. The median rate of MEs, UMDs and ADEs following discharge in adult patients was found to be 53% [Inter Quartile Range IQR 33–60.5] (n=5 studies), 50% [IQR 39–76] (n = 11), and 19% [IQR 16–24] (n=7) respectively. In the second study, the majority of NRLS medication incidents following discharge involved patients aged above 65 years (56%, n=626/1,121), and the prescribing stage (42%, n=479/1,121). Almost one eighth (12.6%, n=142/1,121) of incidents were associated with patient harm. The total number of identified contributory factors were 467 from 408 incidents, with organisation factors most common (82%, n=383/467) and specifically continuity of care issues (n=377/383, especially bet

Date of Award	1 Aug 2022
Original language	English
Awarding Institution	The University of Manchester
Supervisor	Richard Keers (Supervisor) & Douglas Steinke (Supervisor)