1222: QUANTIFYING MEDICATION ERRORS MITIGATED BY AN EFFECTIVE POST-SEPSIS TRANSITION PROGRAM

Introduction: Medication errors are a common cause of adverse events after hospital discharge. Sepsis survivors may be particularly vulnerable to medication errors because new medications are frequently started (e.g., antibiotics), home medications are frequently held during the acute phase, and physiologic changes may influence dose and tolerance of medications. In the IMPACTS randomized trial, a nurse navigator-led multicomponent transition and recovery (STAR) program improved 30-day outcomes for sepsis survivors. Medication optimization was a core component of the program, but the extent and characterization of medication errors addressed by STAR navigators is unknown. Methods: This was a secondary analysis of patients enrolled in the IMPACTS trial allocated to the intervention group. Six internal medicine physicians reviewed STAR navigator notes in study patients’ medical records and recorded whether interventions related to medications occurred and used granular EHR review to characterize the medication errors that were addressed. Results: Of 317 patients randomized to receive STAR and discharged alive without hospice care, 87 (27%) had medication errors addressed by STAR navigators in the 30 days after discharge. The most common medications involved were antibiotics (23%), heart failure medications (9%), antidepressants/psychotropics (7%), diabetes medications (7%), and anticoagulants (7%). Errors were of omission (patients not taking prescribed medication) in 56%, commission (patients taking medication that was deprescribed) in 19%, and errors in dose or duration in 25%. Navigators communicated with a complex network of clinicians (e.g., primary care providers. pharmacists, SNF physicians) to address errors. Conclusions: In the intervention arm of a clinical trial of a multicomponent sepsis transition program, nurse navigators addressed medication errors in over one-fourth of patients. Medication errors were most commonly related to antibiotics but also included medications for serious comorbidities.