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Prevalence of medication transfer errors in nephrology patients and potential risk factors

  • M.M. Ebbens
    Correspondence
    Corresponding author at: Ziekenhuis St Jansdal, Wethouder Jansenlaan 90, 3844, DG, Harderwijk, The Netherlands.
    Affiliations
    Leiden University Medical Center, Department of Clinical Pharmacy and Toxicology, Albinusdreef 2, 2333, ZA, Leiden, The Netherlands

    Erasmus University Medical Center Rotterdam, Department of Hospital Pharmacy, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands

    St Jansdal Hospital, Department of Pharmacy, Wethouder Jansenlaan 90, 3844, DG, Harderwijk, The Netherlands
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  • H. Errami
    Affiliations
    Leiden University Medical Center, Department of Clinical Pharmacy and Toxicology, Albinusdreef 2, 2333, ZA, Leiden, The Netherlands
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  • D.J.A.R. Moes
    Affiliations
    Leiden University Medical Center, Department of Clinical Pharmacy and Toxicology, Albinusdreef 2, 2333, ZA, Leiden, The Netherlands
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  • P.M.L.A. van den Bemt
    Affiliations
    Erasmus University Medical Center Rotterdam, Department of Hospital Pharmacy, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
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  • P.J.M. van der Boog
    Affiliations
    Leiden University Medical Center, Department of Nephrology, Albinusdreef 2, 2333, ZA, Leiden, The Netherlands
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  • K.B. Gombert-Handoko
    Affiliations
    Leiden University Medical Center, Department of Clinical Pharmacy and Toxicology, Albinusdreef 2, 2333, ZA, Leiden, The Netherlands
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Published:October 09, 2019DOI:https://doi.org/10.1016/j.ejim.2019.09.003

      Highlights

      • Nephrology transplant outpatients use on average ten medications
      • Medication transfer errors are found in 62% of nephology outpatients.
      • The number of medications in use is associated with the occurrence of errors.
      • 71% of the medication transfer errors have the potential to cause harm.

      Abstract

      Background

      Medication reconciliation in transitions of care can prevent medication transfer errors (MTE). MTE can cause patient harm. Since performing medication reconciliation for every patient is not always feasible, identification of potential risk factors of MTE could aid in targeting this intervention to the right patients.

      Objective

      To establish the proportion of patients with one or more MTE in the outpatient nephrology setting. Secondary patient characteristics associated with MTE, type and potential harm, and medication groups were investigated.

      Methods

      This retrospective observational cohort study was conducted in the Leiden University Medical Center, the Netherlands, between November 2017 and April 2018. The cohort involved patients in whom medication reconciliation was performed by a medical attendant using the electronic tool ‘Medical Dashboard’ prior to visiting the nephrologist. MTE were defined as unintended discrepancies between the medication in the hospital system and the result of the medication reconciliation. The proportion of patients with one or more MTE was calculated and the association of patient characteristics (age, sex, number of medications and kidney function (CKD-EPI)) with MTE was analyzed using multivariate logistic regression.

      Results

      Of 380 patients, 235 patients (61.8%) had at least one MTE. On average patients used 10.3 medications. The number of medications per patient was significantly associated with MTE; OR 1.11 (95%CI 1.05–1.16). No association was found for age, sex, and kidney function.

      Conclusion

      In ambulatory nephrology patients 61.8% had at least one MTE. Nephrology patients using a higher number of drugs are more prone to MTE.

      Keywords

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