Robert G. Wahler

Objectives: This observational study examines challenges and opportunities in the medication reconciliation process within the emergency department (ED). Through a human factors approach, we look to identify barriers and potential improvements for enhancing patient safety during transitions of care for older adults. Methods: An observational study was conducted in the ED of a large teaching hospital, comprising 32 hours of observation across 12 sessions. Researchers followed pharmacists, nurses, and triage staff, documenting workflows, communication practices, and medication reconciliation processes. Recurring patterns, challenges, and opportunities for improvement were identified through a qualitative analysis. Results: Systemic barriers to effective medication reconciliation were identified, including fragmented workflows, inconsistent documentation, and usability issues in electronic health records. Challenges were exacerbated by the fast-paced ED environment and frequent interruptions. Pharmacists played a pivotal role in synthesizing diverse information sources to construct accurate medication histories, but their workload often limited their capacity to address broader medication safety concerns. Opportunities for improvement include delegating specific tasks to trained support staff, optimizing electronic health record functionalities, and fostering interdisciplinary collaboration to streamline workflows and reduce errors. Conclusions: Medication reconciliation in the ED is critical for patient safety but faces significant systemic and environmental challenges. Addressing these barriers through enhanced system integration, task delegation, and improved communication protocols could increase efficiency and reduce errors. Further research is needed to evaluate these interventions across diverse ED settings to optimize medication reconciliation processes and improve safety outcomes.

Background: Polypharmacy contributes to medication‐related harm in older adults. Deprescribing interventions are often employed in the outpatient setting, potentially missing patients with limited healthcare access. Hospitalization represents a unique touch point to address polypharmacy in older adults with a multidisciplinary team. Methods: This retrospective cohort study examined the feasibility and effectiveness of a polypharmacy intervention in hospitalized older adults. The intervention was developed by a multidisciplinary team with a quality improvement framework and implemented by clinical pharmacists on an academic teaching service. Adults aged 65 years and older were included. Pharmacists completed a comprehensive medication review with the identification of medication therapy problems (MTPs), with additional evaluation for polypharmacy (five or more chronic medications) and potentially inappropriate medications (PIMs) using validated tools (Beers and STOPP/START criteria), with recommendations implemented during hospitalization. Descriptive statistics were used to describe the intervention and its outcomes. Reporting followed the SQUIRE statement. Results: The polypharmacy intervention was provided to 155 patients. Polypharmacy occurred in 98.7% of older adults, whereas 82.6% received at least one PIM (261 total). This demonstrates a significant need for an intervention to address polypharmacy and PIMs during hospitalization. A median of two MTPs was identified per patient (total 287), the most common being adverse drug reaction (present in 52.3% of patients), medication without indication (47.7%), and indication without medication (31%). Opioids were the most common PIM (present in 36.1% of patients), followed by benzodiazepines (10.3%) and skeletal muscle relaxants (8.4%). A total of 40.6% of PIMs were successfully deprescribed at discharge. Conclusion: Polypharmacy is ubiquitous in hospitalized older adults. A multidisciplinary approach to deprescribing can reduce PIMs during hospitalization.

Deprescription is the process by which a physician supervises a patient’s withdrawal or dose reduction of a given medication due to side effects or diminishing efficacy. Prior studies on the process of deprescription have resulted in a number of models, two of which are used in this pilot study alongside the decision ladder to construct a novel analytic method. Initial findings indicate that this approach can offer unique insight into the deprescription process, particularly regarding the paths physicians take through the decision making process and when certain factors are most important. These early results are limited but lay the foundation for a rich variety of future work.

Objective: To assess the impact of a flipped-classroom approach to teach safe medication use and deprescribing for older adults on student academic performance and perceptions of deprescribing. Methods: This was a pre-post evaluation following implementation of the flipped-classroom approach in a third-year pharmacotherapy course. The primary endpoint was the difference in exam performance on 10 related assessment items. An electronic survey was distributed to students in both cohorts to assess their attitudes, perceived ability, and confidence in deprescribing (5-point Likert-scale). Results: The average score on covered exam items was 74.6% in the lecture group and 75.6% in the flipped-classroom group (p = 0.62). Students in the flipped-classroom group were more likely to endorse confidence in their ability to recommend appropriate deprescribing strategies for potentially inappropriate medications (p = 0.02). Conclusions: Learners reported increased self-confidence with deprescribing in practice when taught using the flipped-classroom approach, but exam scores were not significantly improved.

Background: Global prevalence of xerostomia has been reported at 22% (range 0.01%-45%), negatively impacting oral health, nutrition intake, and quality of life. The causal relationship between xerostomia and medications remains uncertain but greater understanding could guide interventions. Objective: To describe the demographic characteristics and medication regimens in patients with xerostomia of an academic dental clinic. Method: This is a retrospective academic dental clinic record review from July 1, 2018 to October 27, 2020. Patient records were obtained from the University at Buffalo, School of Dental Medicine. Xerostomia status was determined via query of electronic health records and validated by manual review. Pharmacologic class and xerostomic potential of medications were identified by the Veterans Affairs Drug Classification System and drug compendia, respectively. Predictors of medication use were assessed using a multiple logistic regression model. Results: Of 37 403 examined records, 366 (0.98%) were identified as xerostomic. After excluding confounding factors (Sjogren’s and radiation), 275 of 317 patients received at least one xerostomic medication, majority were female (240, 66%) versus male (126, 34%). Mean ± (SD) age was 64.9 ± 15.11 years. A total of 208 (57%) patients were aged ≥65. The median number of total and xerostomic medications were 8 (interquartile range [IQR], 4-12) and 4 (IQR, 2-7), respectively. The 3 most prevalent xerostomic pharmacologic classes were antidepressants (131, 35%), gastric medications (101, 28%), and vitamin D (87, 24%). Conclusion: Despite observed prevalence of xerostomia lower than global prevalence, xerostomic medication burden for patients experiencing xerostomia was high. Pharmacist-led interprofessional collaborations should be investigated to reduce xerostomic burden.

Context: Deprescribing is a term used to describe the identification and elimination of inappropriate medications to reduce harm and polypharmacy. While this activity has been common in elder care for decades, polypharmacy and inappropriate medication use remains common. Education has been identified as a key strategy to improve providers’ abilities to deprescribe, yet there is a paucity of literature studying this area. Objective: Describe medical students’ experience with and attitudes toward medication safety concepts and deprescribing training in medical education. Study Design: Setting or Dataset: Population studied: As part of a curricular improvement project, an online survey was designed and administered to fourth year medical students at the University at Buffalo (UB) Jacobs School of Medicine and Biomedical Sciences. All medical students in the 4th medical year were invited to participate in the survey. Outcome Measures: A novel survey instrument was developed to assess students’ experience with and attitudes toward medication safety concepts and deprescribing training in medical education. Results: The overall response rate was 25.6% (46/180). Of 4 medication safety terms (medication reconciliation, polypharmacy, potentially inappropriate medications and deprescribing), deprescribing was least familiar with 10 (21.7%) disagreeing that they understood the term. The majority (95.7%) endorsed learning concepts related to potentially inappropriate medications and deprescribing during their third and fourth-year clinical clerkships and 15 (32.6%) in their didactic coursework within the first 2 years. Of those who responded to the item on future educational needs in deprescribing (n=39), 87.2% desired it to be delivered during their clerkships and 30.2% in the didactic curriculum. Conclusions: This study identifies an opportunity to improve medical students’ knowledge on deprescribing at our institution. The concept of deprescribing should be targeted as an experiential medical education goal. Students have indicated their desire for further education to be delivered during their clinical clerkship years versus their didactic curriculum. Future studies are needed to correlate students’ attitudes with performance in related tasks.

Prescription opioid analgesics contribute to serious, preventable adverse drug events (ADEs) and despite efforts ranging from regulatory changes to quality improvement initiatives, national studies indicate that opioid‐related emergency department visits and hospitalizations are increasing amid the coronavirus disease 2019 (COVID‐19) pandemic. Effective pain management is challenging during care transitions, and system imperfections make patients vulnerable to ADEs as they leave one care setting and move to another. Therefore, the Island Peer Review Organization (IPRO) pain management coalition convened a task force to develop resources to guide improvements in opioid‐related communication during patient care transitions. Create a consensus list of requisite communication elements (RCEs) that should accompany all patients prescribed opioids as they undergo care transitions. An interprofessional task force of pain management experts was convened and completed a blinded, iterative Delphi process. After four Delphi rounds, the panel reached consensus on a pain management discharge communication (PMDC) List of 24 RCEs across the domains of opioid dosing and pain management (nine elements), factors associated with adverse drug events (nine elements), and patient education and caregiver support (six elements). During transitions of care providers need detailed information on opioid dosing, pain characteristics, risk factors for adverse events, and patient/caregiver capacity to adequately manage symptoms while avoiding potentially fatal ADEs. The PMDC list may guide the development of new clinical tools, quality measures, accreditation standards, and checklists for pharmacists involved in the delivery of opioid stewardship during a care transition. Additional work is needed to design comprehensive, interprofessional opioid stewardship programs to ensure that the requisite communication elements are consistently available at the time of a care transition.

Introduction: In response to the opioid crisis, New York State (NYS) mandated training for all licensed professionals authorized to prescribe controlled substances. Content included state and federal requirements for prescribing controlled substances, pain management, appropriate prescribing, managing acute pain, palliative care, prevention, screening and signs of addiction; responses to abuse and addiction; and end‐of‐life care. Training was required to be completed by 1 July 2017.Objectives: The primary aim of this analysis was to answer the question: Would a large‐scale, enduring, online training program administered in an academic environment be feasible?Methods: An interdisciplinary team from the University at Buffalo developed a 4‐hour accredited enduring training program which was launched on 15 March 2017. Pre‐ and posttests were required, with a score of ≥70% on the posttest set as successful completion of the course.Results: As of 1 July 2017, 31 909 participants had completed Module 1, with 26 511 (83.1%) originating from NYS. For Module 2, 29 450 participants completed the training, with 24 460 (83.1%) originating from NYS. A participant survey found that the overwhelming majority of participants were satisfied with the course. Prescribers (physicians, residents, dentists, nurse practitioners, midwives, and physician assistants) all demonstrated significant improvement for both course modules. Aggregate Module 1 scores improved from (mean ± SD) 79.88 (14.67) at baseline to 93.18 (7.45) postcourse (P < .0001). Aggregate Module 2 scores improved from 67.21 (14.8) to 89.13 (8.09; P < .0001).Conclusions: Our experience demonstrates the feasibility of deploying a credible, enduring, multiprofessional online educational program. The program has been well‐accepted, with a demonstration of increased knowledge across disciplines through pre‐ and posttraining assessment. Further study is needed to address the impact of this training on patterns of opioid prescribing.

Pharmacists play a key role in deprescribing medications. Incorporation of this concept into pharmacy school curricula is important in ensuring that graduates can address the complex needs of an aging population. The aims of this study were to assess if and how student pharmacists were exposed to deprescribing within their curriculum, to assess students’ perceptions regarding their attitudes, ability and confidence in deprescribing, and to assess if reported curricular exposure to this topic resulted in improved perceptions or objective knowledge assessment scores. An electronic survey was distributed to third- and fourth-year pharmacy students at 132 schools of pharmacy. The survey included three sections including: (i) demographics and questions on their exposure to deprescribing and other experiences within their curriculum; (ii) questions regarding their attitudes, ability, and confidence regarding deprescribing on a 5-point Likert-scale; (iii) a knowledge assessment on polypharmacy and deprescribing in the form of 12 multiple-choice questions. Likert-scale questions were analyzed as scales utilizing the mean score for items measuring student perceptions regarding deprescribing attitudes, ability, and confidence. Comparisons were made on each variable between students with and without curricular exposure to deprescribing using t-tests. Ninety-one responses were included in the analysis. Only 59.3% of respondents reported exposure to deprescribing in their didactic coursework. The mean scores on the polypharmacy and deprescribing knowledge assessments were 61.0% and 64.5%, respectively. Those with exposure to deprescribing concepts within their curriculum were more likely to agree that their school’s curriculum prepared them to deprescribe in clinical practice (t(89) = −2.26, p = 0.03). Pharmacy schools should evaluate their curricula and consider the addition of specific deprescribing objectives and outcome measures for didactic and experiential training.

Background: Despite making great strides in improving the treatment of diseases, the minimization of unintended harm by medication therapy continues to be a major hurdle facing the health care system. Medication error and prescription of potentially inappropriate medications (PIMs) represent a prevalent source of harm to patients and are associated with increased rates of adverse events, hospitalizations, and increased health care costs. Attempts to improve medication management systems in primary care have had mixed results. Implementation of new interventions is difficult because of complex contextual factors within the health care system. Abstraction hierarchy (AH), the first step in cognitive work analysis (CWA), is used by human factors practitioners to describe complex sociotechnical systems. Although initially intended for the nuclear power domain and interface design, AH has been used successfully to aid the redesign of numerous health care systems such as the design of decision support tools, mobile patient monitoring apps, and a telephone triage system. Objective: This paper aims to refine our understanding of the primary care office in relation to a patient’s medication through the development of an AH. Emphasis was placed on the elements related to medication safety to provide guidance for the design of a safer medication management system in primary care. Methods: The AH development was guided by the methodology used by seminal CWA literature. It was initially developed by 2 authors and later fine-tuned by an expert panel of clinicians, social scientists, and a human factors engineer. It was subsequently refined until an agreement was reached. A means-ends analysis was performed and described for the nodes of interest. The model represents the primary care office space through functional purposes, values and priorities, function-related purposes, object-related processes, and physical objects. Results: This model depicts the medication management system at various levels of abstraction. The resulting components must be balanced and coordinated to provide medical treatment with limited health care resources. Understanding the physical and informational constraints on activities that occur in a primary care office depicted in the AH defines areas in which medication safety can be improved. Conclusions: Numerous means-ends relationships were identified and analyzed. These can be further evaluated depending on the specific needs of the user. Recommendations for optimizing a medication management system in a primary care facility were made. Individual practices can use AH for clinical redesign to improve prescribing and deprescribing practices.