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вторник, 22 декабря 2009 г.

Пациенты часто не знают, какие препараты им назначают в стационаре

Краткое резюме  интересной статьи на злободневную тему в дайджетсе Physician's First Watch.
С одной строны, доктора не считают необходимым сообщать пациентам, чем они их лечат в больнице, и какие препараты они рекомендуют принимать пациетам после выписки (мол, все будет указано в выписном эпикризе), с другой - сами пациенты тоже мало интересуются, чем их лечат или собираются лечить. В результате нередко нарушается преемственность в лечении пациентов на этапах стационар-поликлиника.


Результаты исследования грустные. В среднем один из 7 рекомендованных к приему препаратов пациенты не принимают вообще, чаще всего при этом выпадает анальгетик либо сердечно-сосудистый либо гастроинтестинальный препарат из рекомендованного перечня, половина пациентов были уверены в приеме препаратов, которые в действительности им не были назначены. Кто владеет english - читайте сами.

Patients Often Don't Know Which Drugs They're Prescribed in the Hospital
Patients are often unaware of which medications they're taking while in the hospital, according to a pilot study published online in the Journal of Hospital Medicine.
Fifty cognitively aware adults (mean age, 54) admitted to a teaching hospital compiled lists of the medications they believed they were prescribed during their admission. Their lists were then compared with the inpatient medication records. Among the findings:

  • Nearly all patients left at least one prescribed medication off their list (average number of medications omitted, 7).
  • The most commonly omitted medications included analgesics, gastrointestinal drugs, antibiotics, and cardiovascular drugs.
  • Almost half of patients thought they were receiving a medication they were not prescribed.
The researchers write: "These results are a call to reexamine how we educate and involve patients regarding hospital medications," with the potential benefits of patients catching medication errors and having greater satisfaction with their care.
[Editor's note: This study has been released from embargo but has not yet been posted. Our link is to the Journal of Hospital Medicine's early-release page, where the article will appear shortly.]

Journal of Hospital Medicine early-release page (Free)
А вот и Brief Report самой статьи в журнале Journal of Hospital Medicine


Ethan Cumbler, MD, Heidi Wald, MD, MSPH, Jean Kutner, MD, MSPH
Department of Medicine, University of Colorado Denver School of Medicine, Denver, Colorado
email: Ethan Cumbler (Ethan.Cumbler@ucdenver.edu)

*Correspondence to Ethan Cumbler, Mail Stop F782, 12401 East 17th Ave, Aurora, CO 80045
Disclosure: Dr. Cumbler, Dr. Kutner, and Dr. Wald have no relevant conflicts of interest for this manuscript.
Telephone: 720-848-4289; Fax: 720-848-4293
Dr. Cumbler has no commercial interest relevant to this manuscript, has full access to all of the data in the study, and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Funded by:
 University of Colorado Hospital Clinical Excellence Grant

KEYWORDS
medical error • medication reconciliation • patient education • patient safety
Received: 28 December 2008; Revised: 19 May 2009; Accepted: 26 May 2009

ARTICLE TEXT
Inpatient medication errors represent an important patient safety issue. The magnitude of the problem is staggering, with 1 review finding almost 1 in every 5 medication doses in error, with 7% having potential for adverse drug events.[1] While mistakes made at the ordering stage are frequently intercepted by pharmacist or nursing review, administration errors are particularly difficult to prevent.[2] The patient, as the last link in the medication administration chain, represents the final individual capable of preventing an incorrect medication administration. It is perhaps surprising then that patients generally lack a formal role in detecting and preventing adverse medication administration events.[3]
There have been some ambitious attempts to improve patient education regarding hospital medications and involve selected patients in the medication administration process. Such initiatives may result in increased patient participation and satisfaction.[4-7] There is also potential that increased patient knowledge of their hospital medications could promote the goal of medication safety, as the actively involved patient may be able to catch medication errors in the hospital.
Knowledge of prescribed medications is a prerequisite to patient involvement in prevention of inpatient medication errors and yet there is little research on patient knowledge of their hospital medications. Furthermore, as the experience of hospitalization may be disorienting and disempowering for patients, it remains to be seen if patient attitudes toward participation in inpatient medication safety are favorable. To that end, we conducted a pilot study in which we assessed current patient awareness of their in-hospital medications and surveyed attitudes toward increased patient knowledge of hospital medications.
After consenting to participate, study patients completed a structured list of their outpatient medications and a survey of attitudes about being shown their in-hospital medications, hospital medication errors, and patient involvement in hospital safety. They then completed a list of the medications they believed to be prescribed to them in the hospital.
The primary outcomes were the proportions of as needed (PRN), scheduled, and total hospital medications omitted by the patient, compared to the inpatient medication administration record (MAR) (patient errors of omission). Secondary outcomes included the number of in-hospital medications listed by the patient that did not appear on the inpatient MAR (patient errors of commission), as well as patient attitudes measured on a 5-point Likert scale (1 indicated strongly disagree and 5 indicated strongly agree). Descriptive data included age, race, gender, and number of inpatient medications prescribed. Separate analysis of variance (ANOVA) models provided mean estimates of the primary outcomes and tested differences according to each of the patient characteristics: age in years (<65 or 65), self-reported knowledge of hospital medications, and self-reported desire to be involved in medication safety. Similar ANOVA models adjusted for number of medications were also examined to determine whether the relationship between the primary outcomes according to patient characteristics were altered by the number of medications. The protocol was approved by the Colorado Multiple Institutional Review Board.
Participants averaged 54 years of age (standard deviation [SD] = 17, range = 21-89). Forty-six percent (23/50) were male, and 74% (37/50) were non-Hispanic white. Using a structured, patient-completed, outpatient medication list, patients in the study were on an average of 5.3 outpatient prescription medications (range = 0-17), 2.2 over-the-counter medications (range = 0-8), and 0.2 herbal medications (range = 0-7). The admitting physician's medication reconciliation list demonstrated similar number of outpatient prescription medications (average = 5.7) to the patient-generated list. Fifty-four percent of patient-completed home medication lists included all of the prescription medications on the physician's medication reconciliation at admission. According to the inpatient MAR, study patients were prescribed an average of 11.3 scheduled and PRN hospital medications (range = 2-26) at time of study enrollment.

Ninety-six percent (48/50) of study patients omitted 1 or more of their hospital medications. On average, patients omitted 6.8 medications (range = 0-22) (Table 1). Among scheduled medications, patients most commonly omitted antibiotics (17%), cardiovascular medications (16%), and antithrombotics (15%) (Figure 1). Among PRN medications, patients most commonly omitted analgesics (33%) and gastrointestinal medications (29%) (Figure 2).





Table 1. Patient Knowledge of Their Hospital Medications List


Total Medications
Scheduled Medications
PRN Medications

Percent of patients with at least 1 hospital medication they could not name (95% CI)
96% (90-100%)
94% (87-100%)
80% (69-92%)
Average number of hospital medications omitted by patient (range)
6.8 (0-22)
5.2 (0-15)
1.6 (0-7)
Percentage of hospital medications omitted by patient (95% CI)
60% (52-67%)
60% (52-67%)
68% (57-78%)







   NOTE: n = 50 patients.
   Abbreviations: CI, confidence interval; PRN, as needed.








Figure 1. From 260 omitted scheduled hospital medications by 50 study patients.
[Normal View 17K | Magnified View 43K]








Figure 2. From 78 omitted PRN hospital medications by 50 study patients.
[Normal View 12K | Magnified View 28K]






Patients less than 65 years omitted 60% of their PRN medications whereas patients greater than 65 years omitted 88% (P = 0.01). This difference remained even after adjustment for number of medications. There were no significant differences, based on age, in ability to name scheduled or total medications. Forty-four percent of patients (22/50) believed they were receiving a medication in the hospital that was not actually prescribed.

Only 28% (14/50) of patients reported having seen their hospital medication list, although 78% (39/50) favored being given such a list, and 81% (39/48) reported that this would improve their satisfaction with care. Ninety percent (45/50) wanted to review their hospital medication list for accuracy and 94% (47/50) felt patient participation in reviewing hospital medications had potential to reduce errors. No associations were found between self-reported knowledge of hospital medications or self-reported desire to be involved in medication safety and the proportion of PRN, scheduled, or total medications omitted.
We posit that without systematically educating patients about their hospital medications, significant deficits in patient knowledge are inevitable. Some might argue that patients should not be asked to know their hospital medications or identify medication errors while sick and vulnerable. Certainly with multiple medication changes, formulary substitutions, and frequent modifications based on changes in clinical status, inpatient medication education could be time consuming and potentially introduce patient confusion or anxiety. Incorrect patient feedback could have potential to introduce new errors. An educational program might use graded participation based on patient interest and ability. Models for this exist in the literature, even extending to patient medication self-administration.[5-7] In our sample of inpatients, the majority desired a more active role in learning about their hospital medications and believed that their involvement might prevent hospital medication errors from occurring.
Medication literacy, education, and active patient involvement in medication monitoring as a means to improve patient outcomes has received significant attention in the outpatient setting, with lessons applicable to the hospital.[8][9] More broadly, the Joint Commission has established a Hospital National Patient Safety Goal to encourage patients' active involvement in their own care as a patient safety strategy.[10] Examples set forth by the Joint Commission include involving patients in infection control measures, marking of procedural sites, and reporting of safety concerns relating to treatment.
While this study identifies patient knowledge deficit as a barrier to utilizing patients as part of the hospital medication safety process, it does not test whether reducing this knowledge deficit would actually reduce medication error. Our study population was limited to cognitively intact adult medicine patients at a single institution, limiting the generalizability of our conclusions. Our enrollment process may have resulted in a study population with less serious illness, greater knowledge of their hospital medications, and greater interest in participating in medication safety potentially overestimating patient knowledge of hospital medications. Finally, our small sample size limits the power to find differences in study comparisons.
Our findings are striking in that we found significant deficits in patient understanding of their hospital medications even among patients who believed they knew, or desired to know, what is being prescribed to them in the hospital. Without a system to incorporate the patient into hospital medication management, these patients will be disenfranchised from participating in inpatient medication safety. These results are a call to reexamine how we educate and involve patients regarding hospital medications. Mechanisms to allow patients to provide feedback to the medical team on their hospital medications might identify errors or improve patient satisfaction with their care. However, the systems and cultural changes needed to provide education on inpatient medications are considerable. Future research is needed to determine if increasing patient knowledge regarding their hospital medications would reduce medication errors in the inpatient setting and how this could be effectively implemented.

REFERENCES





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Phelan G, Kramer EJ, Grieco AJ, Glassman KS. Self-administration of medication by patients and family members during hospitalization. Patient Educ Couns . 1996; 27: 103-112.Links
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Joint Commission. 2009. Standards Improvement Initiative. Available at: http://www.jointcommission.org/NR/rdonlyres/31666E86-E7F4-423E-9BE8-F05BD1CB0AA8/0/HAP_NPSG.pdf. Accessed June 2009.

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