Background: In medical care for older patients, the presence of potentially inappropriate medications (PIMs) is associated with increased adverse outcomes [1, 2]. A wide range of medications with anticholinergic properties affects cognitive states of older patients have been regarded as PIMs [1, 3]. We purposed to assess clinical impact of anticholinergic cognitive burden on clinical [...]

Background: People living with HIV (PLWH) are now anticipated to have near-normal life expectancies. With increased longevity comes the higher burden of non-infectious comorbidities related to the chronic immune activation and premature telomere shortening in PLWH, ranging from dyslipidemia to osteoporosis [1]. Increased comorbidity burden can lead to polypharmacy, defined as the concurrent use of [...]

Background: Heart failure is a deadly epidemic with over 37 million people affected worldwide with a multitude of physical, psychological and financial implications on patients and the healthcare system. The progression of heart failure can be prevented by appropriate and persistent medication therapy however previous research has estimated forty to sixty percent of patients with [...]

Background: Anticoagulants are among the highest-risk medications in hospitalized patients. Studies have demonstrated that a majority of in-hospital anticoagulant adverse drug events are not only preventable, but are the result of excessive dosing. This is especially true for warfarin dosing, which is complicated by a lack of consensus among validated initial dosing nomograms. As part [...]

Background: Medication errors occur frequently at transitions of care and lead to significant patient harm. Robust medication reconciliation practices can mitigate these errors, but this process is complex and time-consuming. One of the conclusions of the first Multi-center Medication Reconciliation Quality Improvement Study (MARQUIS1) was that pharmacist team involvement in medication reconciliation is a key [...]

Background: U.S. healthcare costs are rising due to the increase in polypharmacy, which is a potential risk factor for hospital readmission.1 In a cohort study of 5,507 patients with ≥10 discharge medications, more than 25% of them were readmitted.1 At one of the largest public county hospitals in the U.S., readmission rates for patients with high-volume home [...]

Background: Discharging patients in an efficient manner improves patient satisfaction and hospital throughput. In this project, we sought to improve patient throughput as well as benefit resident education. Prior to our project, 75% of patient discharges were delayed more than two hours after the patient was determined to be medically ready for discharge; 21% were [...]

Background: Electronic prescribing (eRx) at discharge enhances safety and quality of care transitions. It results in improved medication adherence and a decreased chance of readmission. Stage 3 Meaningful Use goals include discharge eRx rates of greater than 25%. As of September 2017, our large academic medical center had a year-to-date discharge eRx rate of 18.3%, [...]

Background: Medication errors harm 1.5 million patients yearly, designating medication reconciliation a National Patient Safety Goal. The average hospitalized patient is subject to at least 1 medication error per day (IOM,2007), with 70% of patients experiencing a medication discrepancy at either admission or discharge(Leapfrog,2018). Medication Reconciliation, creating the most accurate list of medications patients take [...]

Background: Obtaining the Best Possible Medication History (BPMH) is the protocolized gold standard in obtaining medication histories and well known to decrease the total number of medication errors during transitions in care. Trained technicians require an average of 15-30 minutes to collect a BPMH [2]. Our facility conducted a categorical analysis and within subject study [...]