Still at It

February 2018 Vol 11, No 1 - Editorial
David B. Nash, MD, MBA
Editor-in-Chief, American Health & Drug Benefits Founding Dean, Jefferson College of Population Health, Philadelphia, PA
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As readers of my editorials know, I have been a member of the Thomas Jefferson University Hospital Pharmacy & Therapeutics (P&T) Committee for more than 25 years, and have chaired a P&T subcommittee focused exclusively on medication safety. Improving the overall quality and safety of medical care has been a central part of my entire career here at Jefferson. Our College of Population Health is a recognized leader in this arena, especially exemplified by our online master’s degree and graduate certificate program in healthcare quality and safety.

I remind readers of this context, because I recently came across a very important report that essentially says we are “still at it” with regard to measuring and improving the quality and safety of medical care, especially when it comes to medications. The report, “Advances in Patient Safety and Medical Liability,” is periodically updated and published by the Agency for Healthcare Research and Quality (AHRQ).1 This particular report was published at the very end of the summer of 2017, and is therefore timely and relevant.1 I learned a lot from this recent report, and I’d like to focus on some of my learnings, with a special emphasis on 2 of the chapters that concern the quality and safety of medications.

The Massachusetts Medical Society (MMS) and various prestigious delivery systems within Massachusetts are among the leaders of reforming the medical liability system in the nation. Some of the key new communication tools and processes have been promulgated by the MMS in an attempt to reduce harm to patients from adverse drug events and related medication administration errors. For example, for 2 decades, Massachusetts has been a recognized leader in implementing the Disclosure, Apology, and Offer (DA&O) program.

In the AHRQ report, the DA&O model emerges as one of the most promising strategies to improve medical liability.1 Further evolution of the DA&O model has led to the Communication Apology and Resolution (CARe) model. A statewide demonstration evaluation of the CARe model is currently underway, with a report expected in 2018.

The DA&O and CARe models fall under the umbrella of communication and resolution programs (CRPs). In a nutshell, I did not grasp the rich research that underpins these CRP-like models, the direct connection between the implementation of CRPs and a reduction in liability, and an eventual improvement in medication safety through full disclosure.

The remaining barriers to the implementation of the DA&O model include physician discomfort with disclosure, and a lack of training on the model’s proper use, poor coordination across health insurers, and the force of inertia in adopting a new practice paradigm. The researchers also point out that there is concern among stakeholders that DA&O models may not work in some medical settings, and many healthcare practitioners believe that there is simply insufficient evidence to support the widespread training, dissemination, and mandated implementation of such models.1 Personally, sign me up! To me, transparency and accountability are the central pillars that support a just culture and an overarching reduction in medication error and related liability.

Let’s turn then to the 2 chapters of the AHRQ report that focus on medication-related error and liability.1 In the next to last chapter, “Transitional Care Medication Safety: Stakeholders’ Perspectives,” Corbett and colleagues conducted a series of stakeholder focus groups to identify the common barriers and solutions to medication safety during patients’ transition from hospital to home.1 The focus group interviews were then assessed using a qualitative descriptive study design.

Corbett and her team found that, “Patients at high risk to experience medication discrepancies and errors include older adults, those with polypharmacy,…drug interactions, multiple comorbidities, altered drug pharmacokinetic profiles and/or pharmacodynamic responses as a result of aging, and altered medication adherence caused by depression or cognitive impairment.”1

I do not think that our readers will consider any aspect of this finding very surprising, but what was surprising, as the authors point out, is that the National Priorities Partnership declared patient safety from potentially preventable adverse events, including medication discrepancies, as a national priority.1 In other words, getting that medication list right the first time, every time, remains an important priority, and in the hospital-to-home transitional care period, there is an important opportunity to review the medication list. Although this may seem a mundane activity, this report further emphasized for me, even after 25 years of active participation in evaluating this process, just how important it still remains.

Finally, via the focus groups, Corbett and her team created a classification scheme of the barriers to medication safety in the transitional care period.1 These barriers include poor communication and the coordination of care between physicians, lengthy and confusing discharge processes, and staffing and time constraints. Again, this is not a surprising list of barriers, but it is a reinforcement of the difficulties in smoothing out the transition in care.

The final chapter of the report, which was written by Neumiller and his team and is titled “Medication Discrepancies and Potential Adverse Drug Events During Transfer Care from Hospital to Home,” reinforces the findings by Corbett and colleagues.1 Specifically, instead of a qualitative focus group–derived study, Neumiller and his team evaluated nearly 1400 medication discrepancies among 212 patients, to determine which specific drugs are on the list of drugs that cause potentially harmful adverse drug events. They found that the serious potential adverse drug events came from drugs such as enoxaparin, warfarin, and sublingual nitroglycerin. Other categories that were ascribed significant risk ratings include opioids, antihypertensives, diuretics, antiarrhythmics, antipsychotics, and antiepileptic medications.1

Once again, I do not think our readers will be surprised by this drug list, but they may appreciate the depth of this research: a deep-dive review of the involved charts creates an opportunity to reflect on the importance of the transitional care period from the hospital to home care. For me, Corbett and Neumiller reinforce the notion that medication discrepancies frequently occur during the transition from hospital care to home care, and these seemingly innocuous discrepancies often lead to a very specific adverse drug event that can cause harm.

Kudos to the editors at AHRQ and to the authors of the specific chapters I cited for creating this important report. We need to support research such as this in the public sector and widely disseminate the results. Every hospital has a P&T committee, and a deeper understanding of the discrepancies involved in the transitions of care will improve safety and reduce harm. We are “still at it”!

As always, I am interested in your views, and you may reach me at This email address is being protected from spambots. You need JavaScript enabled to view it..

David B. Nash, MD, MBA is Editor-in-Chief, American Health & Drug Benefits Founding Dean, Jefferson College of Population Health, Philadelphia, PA

1. Battles J, Azam I, Grady M, Reback K, eds. Advances in Patient Safety and Medical Liability. AHRQ Publication No 17-0017-EF. Rockville MD: Agency for Healthcare Research and Quality; August 2017.

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