SHM Converge Scientific Abstract ePoster Gallery-Location, Location: Geographic Patient/Team Alignment Decreases Discharge Medication Errors

Pdf Summary

This poster reports on a quality improvement and research project at UVA Health focused on reducing medication reconciliation errors for patients discharged to skilled nursing facilities (SNFs), a group especially vulnerable to harm from discharge medication mistakes. In Fall 2019, the team found that 59% of such discharges had medication errors, and 20% of those errors had the potential to cause severe harm. After implementing multipronged quality improvement changes, severe errors were nearly eliminated, though the overall error rate remained around 35%.<br /><br />The researchers then studied whether “geographic” alignment between patients and their medicine team affected error rates. A geographic discharge meant the patient was discharged from the team’s home unit; a non-geographic discharge meant discharge from another unit. They found that geographic discharges had significantly fewer medication reconciliation errors than non-geographic discharges (p < 0.0001). Geographic teams also had lower severe error rates, although this difference was not statistically significant, likely because severe errors were rare (p = 0.74).<br /><br />The authors conclude that geographic patient-team alignment is associated with fewer discharge medication reconciliation errors and may improve patient safety, possibly by making it easier to use countermeasures such as interprofessional safety huddles to review discharge medications. They suggest further research to identify which specific geographic factors drive the improvement and note that the findings support expanding geographic care team models in hospital settings.

Asset Subtitle

Isabelle Z. Ciaverelli

Meta Tag

Author List Amber Inofuentes, Isabelle Z. Ciaverelli, Jessica J. Dreicer

Category Research

Concept Medication Reconciliation Error

Concept Transitional Care

Concept Quality Improvement

Concept Patient Safety

Concept Skilled Nursing Facility

Distinguished Non-Finalist

Presenter Organization University of Virginia School of Medicine

Presenting Author Isabelle Z. Ciaverelli

Track Quality Improvement

Keywords

medication reconciliation

skilled nursing facilities

quality improvement

discharge errors

patient safety

geographic alignment

hospital discharge

UVA Health

severe harm

interprofessional safety huddles

Medication Reconciliation Error

Transitional Care

Quality Improvement

Patient Safety

Skilled Nursing Facility