Purpose: To help address this problem, interns in our program developed a standard process during their quality improvement (QI) curriculum to ensure that at least 95% of patients discharged from the medicine teaching service were able to obtain their prescriptions on the first attempt without barriers.
Description: In March 2015 over 20 weeks, two interns led an interdisciplinary team to test an improvement process designed during their intern QI curriculum to (1) identify patients age 18 and older with prescription coverage being discharged home with new prescriptions and (2) address and remove those barriers prior to discharge. A dedicated faculty mentor was assigned to facilitate to ensure continuity while residents were involved in their other required training activities. Scripts were considered new if (1) they were not listed on the admission medication history and/or (2) home medication doses were changed. Students and nonclinical administrative care team staff faxed new scripts to the pharmacy followed by a call to verify availability, formulary status, copay and/or prior authorization (PA) requirement.
We called all patients after discharge to ask about barriers encountered when obtaining medications. If unable to reach them, we contacted the their pharmacy to verify that medications were obtained.
Conclusions:
One hundred sixty-one patients had a total of 465 scripts included in the improvement process. Fifty-nine patients (59/161, 36.6%) had a total of 78 scripts (78/465, 16.8%) with barriers that would have caused delays continuing postdischarge treatment. Five scripts had multiple issues, totaling 83 discrete issues. Most commonly encountered barriers were unavailability at the time of discharge (29/83, 34.9%), PA (26/83, 31.3%), and nonformulary status (14/83, 16.9%). Top medication classes associated with barriers were antimicrobials (15 of 78 prescriptions, 19.2%), narcotics/sedatives (12/78, 15.4%), and proton pump inhibitors (10/78, 12.8%).
We contacted 43 of the 59 patients (72.9%) with scripts requiring intervention. Thirty-nine (39/43, 90.7%) had no issues on the first visit. Of the remaining four patients, two were non-adherent, one required prescription changes, and one had a PA delay. Adding medication education into future iterations would help increase medication safety for nearly all of our patients.
Housestaff are the frontline of patient care and invaluable in creating the future state. Numerous training responsibilities make sustainable QI a challenge. With dedicated and experienced faculty mentorship and support from leadership, we have shown that residents can successfully design, test and implement process improvement projects that greatly improve the quality and safety of patient care.