Medication reconciliation and adherence: a call for clinical pharmacist

Introduction and Objectives: With the population ageing, there is a growing number of people who have several comorbidities and make use of a variety of drugs. These factors lead to a greater predisposition to adverse drug events, as well as to medication errors. The clinical pharmacist is the most indicated health professional to target these issues. The aims of this study were to analyze the profile of medication reconciliation and assess the role of the clinical pharmacist regarding medication adherence. Material and Methods: Prospective observational cohort study conducted from Jan-Mar 2013 at the Surgical Clinic of the University Hospital of the University of Sao Paulo. 117 admitted patients - over the age of 18 years, under continuous medication use and with length of hospitalization up to 120h - were included. Discrepancies were classified as intentional/unintentional and according to their risk to cause harm, and interventions were divided into accepted/not accepted. Medication adherence was measured by Morisky questionnaire. Results and Conclusions: Only 30% of hospital prescriptions showed no discrepancies between the medications that the patient was using at home and those which were being prescribed at the hospital and more than one third of those had the potential to cause moderate discomfort or clinical deterioration. One third of total discrepancies were classified as unintentional. About 90% of the interventions were accepted by the medical staff. In addition, about 63% of patients had poor adherence to drug therapy. The study revealed the importance of the medication reconciliation at patient admission, ensuring greater safety and therapeutic efficacy of the treatment during hospitalization, and orienting the patient at discharge, assuring the therapy safety.

Witnessing reconciliation reduces arousal of bystanders in a baboon group (Papio hamadryas hamadryas)

Reconciliation is the occurrence of friendly behaviour between opponents shortly after an aggressive conflict. In primate groups, reconciliation reduces aggression and post-conflict arousal. Aggression within a group can also increase arousal of bystanders (e.g. increase bystanders’ rates of self-directed behaviour). Since reconciliation reduces aggression between opponents, we tested whether it also reduces self-directed behaviour in bystanders. Following aggression in a captive group of hamadryas baboons, one observer conducted a focal sample on one of the combatants to document reconciliation and a second observer simultaneously conducted a focal sample on a randomly selected bystander. Matched control observations were then collected on the same individuals in a nonaggressive context to obtain baseline levels of behaviour. The self-directed behaviour of bystanders was elevated after witnessing a fight compared to baseline levels. If combatants reconciled aggression, bystander rates of self-directed behaviour significantly decreased. If combatants did not reconcile aggression, bystander rates of self-directed behaviour remained at elevated levels, significantly higher than after reconciliation. If combatants affiliated with partners other than their original opponent, bystander rates of self-directed behaviour did not decrease. The rate of bystander self-directed behaviour after a combatant affiliated with its opponent was significantly lower than the rate after a combatant affiliated with other animals. Witnessing aggression increased arousal in bystanders, and reconciliation between the combatants was accompanied by reduced bystander arousal. The reduction was specific to contexts in which former opponents interacted. We suggest that bystanders recognized the functional significance of this conflict resolution mechanism when it occurred in their group.

Witnessing reconciliation reduces arousal of bystanders in a baboon group (Papio hamadryas hamadryas)

Reconciliation is the occurrence of friendly behaviour between opponents shortly after an aggressive conflict. In primate groups, reconciliation reduces aggression and postconflict arousal. Aggression within a group can also increase arousal of bystanders (e.g. increase bystanders' rates of self-directed behaviour). Since reconciliation reduces aggression between opponents, we tested whether it also reduces self-directed behaviour in bystanders. Following aggression in a captive group of hamadryas baboons, one observer conducted a focal sample on one of the combatants to document reconciliation and a second observer simultaneously conducted a focal sample on a randomly selected bystander. Matched control observations were then collected on the same individuals in a nonaggressive context to obtain baseline levels of behaviour. The self-directed behaviour of bystanders was elevated after witnessing a fight compared to baseline levels. If combatants reconciled aggression, bystander rates of self-directed behaviour significantly decreased. If combatants did not reconcile aggression, bystander rates of self-directed behaviour remained at elevated levels, significantly higher than after reconciliation. If combatants affiliated with partners other than their original opponent, bystander rates of self-directed behaviour did not decrease. The rate of bystander self-directed behaviour after a combatant affiliated with its opponent was significantly lower than the rate after a combatant affiliated with other animals. Witnessing aggression increased arousal in bystanders, and reconciliation between the combatants was accompanied by reduced bystander arousal. The reduction was specific to contexts in which former opponents interacted. We suggest that bystanders recognized the functional significance of this conflict-resolution mechanism when it occurred in their group. (c) 2013 The Association for the Study of Animal Behaviour. Published by Elsevier Ltd. All rights reserved.

Multimembership and Identity in Writing Centers and in Industry: Examining the Work of Reconciliation in the Michigan Tech Multiliteracies Center and at Kimberly-Clark Corporation

Writing center scholarship and practice have approached how issues of identity influence communication but have not fully considered ways of making identity a key feature of writing center research or practice. This dissertation suggests a new way to view identity -- through an experience of "multimembership" or the consideration that each identity is constructed based on the numerous community memberships that make up that identity. Etienne Wenger (1998) proposes that a fully formed identity is ultimately impossible, but it is through the work of reconciling memberships that important individual and community transformations can occur. Since Wenger also argues that reconciliation "is the most significant challenge" for those moving into new communities of practice (or, "engage in a process of collective learning in a shared domain of human endeavor" (4)), yet this challenge often remains tacit, this dissertation examines and makes explicit how this important work is done at two different research sites - a university writing center (the Michigan Tech Multiliteracies Center) and at a multinational corporation (Kimberly-Clark Corporation). Drawing extensively on qualitative ethnographic methods including interview transcriptions, observations, and case studies, as well as work from scholars in writing center studies (Grimm, Denney, Severino), literacy studies (New London Group, Street, Gee), composition (Horner and Trimbur, Canagarajah, Lu), rhetoric (Crowley), and identity studies (Anzaldua, Pratt), I argue that, based on evidence from the two sites, writing centers need to educate tutors to not only take identity into consideration, but to also make individuals' reconciliation work more visible, as it will continue once students and tutors leave the university. Further, as my research at the Michigan Tech Multiliteracies Center and Kimberly-Clark will show, communities can (and should) change their practices in ways that account for reconciliation work as identity, communication, and learning are inextricably bound up with one another.

From Truth to Justice: How Does Amnesty Factor In? A Comparative Analysis of South Africa and Sierra Leone's Truth and Reconciliation Commissions

Truth and Reconciliation Commissions (TRC) have emerged in the last few decades as a mechanism for a state to overcome widespread, grave, human rights violations. There are numerous approaches to a TRC all with an ultimate goal: that formerly warring factions, perpetrators, witnesses, and victims can move forward as a united people. I propose that the provision of amnesty is critical to the success of a TRC. I hypothesize that the form of amnesty chosen (i.e. blanket v. conditional amnesty) determines the revelation of truth and realization of justice, which in turn dictates whether a TRC can achieve reconciliation. To test this hypothesis, I use two case studies: South Africa, which has utilized conditional amnesty, and Sierra Leone which has employed blanket amnesty. I create a model for measuring reconciliation. I can then look at the implications of both types of amnesty and assess which, in the end, is more effective. My overarching conclusion is that the provision of conditional amnesty is more effective than blanket amnesty in achieving reconciliation. Ultimately, I hope that this conclusion can be generalized to other TRCs.

Costs and quality of medication reconciliation practice in primary care clinics

Medication reconciliation, with the aim to resolve medication discrepancy, is one of the Joint Commission patient safety goals. Medication errors and adverse drug events that could result from medication discrepancy affect a large population. At least 1.5 million adverse drug events and $3.5 billion of financial burden yearly associated with medication errors could be prevented by interventions such as medication reconciliation. This research was conducted to answer the following research questions: (1a) What are the frequency range and type of measures used to report outpatient medication discrepancy? (1b) Which effective and efficient strategies for medication reconciliation in the outpatient setting have been reported? (2) What are the costs associated with medication reconciliation practice in primary care clinics? (3) What is the quality of medication reconciliation practice in primary care clinics? (4) Is medication reconciliation practice in primary care clinics cost-effective from the clinic perspective? Study designs used to answer these questions included a systematic review, cost analysis, quality assessments, and cost-effectiveness analysis. Data sources were published articles in the medical literature and data from a prospective workflow study, which included 150 patients and 1,238 medications. The systematic review confirmed that the prevalence of medication discrepancy was high in ambulatory care and higher in primary care settings. Effective strategies for medication reconciliation included the use of pharmacists, letters, a standardized practice approach, and partnership between providers and patients. Our cost analysis showed that costs associated with medication reconciliation practice were not substantially different between primary care clinics using or not using electronic medical records (EMR) ($0.95 per patient per medication in EMR clinics vs. $0.96 per patient per medication in non-EMR clinics, p=0.78). Even though medication reconciliation was frequently practiced (97-98%), the quality of such practice was poor (0-33% of process completeness measured by concordance of medication numbers and 29-33% of accuracy measured by concordance of medication names) and negatively (though not significantly) associated with medication regimen complexity. The incremental cost-effectiveness ratios for concordance of medication number per patient per medication and concordance of medication names per patient per medication were both 0.08, favoring EMR. Future studies including potential cost-savings from medication features of the EMR and potential benefits to minimize severity of harm to patients from medication discrepancy are warranted. ^

Kenya after the 2007 "post-election violence" : constitutional reform and the National Accord and Reconciliation Act

Immediately after the announcement of the re-election of President Kibaki on the evening of 30 December 2007, Kenya was thrust into the worst civil unrest experienced by the country since independence – a development that became known as the "Post-Election Violence" (PEV). However, after a subsequent process of reconciliation, the PEV came to an end within a relatively short period. The present-day politics of Kenya are being conducted within the framework of a provisional Constitution that took shape through peaceful mediation. How did Kenya manage to put a lid on a period of turmoil that placed the country in unprecedented danger? This paper traces the sequence of events that led to mediation, explains the emergency measures that were needed to maintain law and order, and indicates the remaining problems that still need to be solved.