Medication error study wins MJA, MDA National Prize for Excellence in Medical Research

Cate Swannell
Med J Aust
Published online: 28 May 2018

A STUDY designed to recognise and reduce medication errors in hospital discharge summaries is the winner of the 2017 MJA, MDA National Prize for Excellence in Medical Research, for the best research article published in the Medical Journal of Australia in the previous calendar year.

The winning article, “Reducing medication errors in hospital discharge summaries: a randomised controlled trial” was authored by a large group from Alfred Health in Melbourne: Ms Erica Tong, lead clinical pharmacist (General Medicine); Ms Cristina Roman, senior pharmacist (Emergency); Associate Professor Biswadev Mitra, emergency physician; Dr Gary Yip, general physician; Associate Professor Harry Gibbs, Deputy Director of General Medicine; Associate Professor Harry Newnham, Clinical Program Director of Emergency and Acute Medicine, and Director of General Medicine; Associate Professor De Villiers Smit, Director of the Emergency and Trauma Centre; Professor Michael Dooley, Director of Pharmacy; and, from Monash University, Associate Professor Kirsten Galbraith, Director of the Postgraduate Studies and Professional Development Unit.

The winning study analysed discharge summaries from patients discharged from the Alfred Hospital for the period 16 March 2015 to 27 July 2015. Patients randomised to the intervention arm received medication management plans completed by a pharmacist; those in the control arm received standard medical discharge summaries (control).

The main outcome measure was a discharge summary including a medication error identified by an independent assessor.

During the study period, 1745 patients were discharged from the general medical unit (GMU). Of these, 832 patients were included in the study. No patients were lost to follow-up. Patient demographics and clinical characteristics were similar in the two groups. The total number of medications documented in the discharge summaries was 4363 in the intervention arm and 4116 in the control arm. Of the 431 patients who received standard medical discharge summaries during the study period, 265 (61.5%) received summaries in which at least one medication error was identified, compared with 60 patients (15%) who received discharge summaries completed by pharmacists that included at least one error (P< 0.01). The absolute risk reduction was 46.5% (95% confidence interval [CI], 40.7-52.3%), yielding an NNT of 2.2 (95% CI, 1.9-2.5) to prevent one discharge summary containing at least one medication error. The absolute risk reduction for a discharge summary containing a high or extreme risk error was 9.6% (95% CI, 6.4-12.8%), with an NNT of 10.4 (95% CI, 7.8-15.5). In the standard medical discharge summary arm, 54 patients (12.5%) had summaries with two identified medication errors, compared with 13 patients (3.2%) in the intervention arm. In the control arm, 40 patients (9.3%) had summaries including three errors, 21 patients (4.9%) summaries with four errors, and 57 patients (13.2%) summaries with five or more errors, compared with one patient (0.2%), one patient (0.2%) and four patients (1%) respectively in the intervention arm. In both arms, the most commonly identified errors were omitted drugs and incorrect dosing frequencies.

“The process of pharmacists completing the medication plan in the electronic medical discharge summary has now been implemented as routine care across the majority of clinical units in the Alfred Hospital,” the researchers concluded.

“The results of our study indicate that pharmacist input into the discharge plan should be more widely adopted. However, to be maximally effective, this requires integrating clinical pharmacists into the team structure of all medical units, and this is not currently standard in all Australian hospitals.”

Sponsored by MDA National, this prize awards the authors $10 000 in cash.

  • Cate Swannell



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