Use of complete medication history to identify and correct transitions-of-care medication errors at psychiatric hospital admission

Victoria Vargas; Weston W. Blakeslee; Colin A. Banas; Christian Teter; Katherine Dupuis-Dobson; Carol Aboud

doi:10.1371/journal.pone.0279903

Peer Review History

Original SubmissionMay 5, 2022
5 Jul 2022 Decision Letter - Vijayaprakash Suppiah, Editor PONE-D-22-13219Use of Complete Medication History to Identify and Correct Transitions-of-Care Medication Errors at Psychiatric Hospital AdmissionPLOS ONE Dear Dr. Aboud, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Aug 19 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. 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Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. 8. Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Partly Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Thank you for submitting this well written and carefully considered study addressing a very pertinent research question. Introduction The introduction was well written and supported the need for the research. Methods The methods did not stipulate that the study was conducted at a psychiatric hospital/ward despite the introduction indicating so. I would like to see a sentence providing more background on the nature of the hospital – e.g number of beds, location (i.e rural vs metropolitan), staffing etc would provide context to the significance of these 82 identified errors in 6 months. The authors mentioned “identified, legitimate medication discrepancy (Lines 125-127)” – what would constitute to it being legitimate or illegitimate? Please elaborate. It would also be of value to the readers for the authors to briefly summarise the role of the pharmacist in this context. In particular, how do they usually identify these discrepancies in their daily practice? Is there an established process or is this what the research is trying to initiate? Results Table 1: I noted that in the row “Medication Error Type,” Other is listed in the middle of the list. It may be better for other to be listed at the bottom of the list given that the description is “any error that does not meet any of the above options.” Table 2d: I noted that one of the (2nd) most common medication error type is “Omission.” Does this suggest that a best possible medication history was not collected (in Australia, this is the role of the pharmacist). I would like to see this explored in the discussion. Discussion The discussion does not contain any references to the existing literature. I would like to see the findings be discussed in the context of the current body of literature. For example, “…adds quantification and clarity to the scale and severity of medication errors that has been previously difficult and cumbersome to measure and convey (Lines 212-215).” This would need a reference. I feel that the results can be explored/explained more in the discussion section. There is a brief discussion about formulation errors (line 231), however, I feel that other errors such as frequency and omission can also be further elaborated. Multiple uses for certain types of medications (Lines 240-245): would this be part of the methods? Lines 273-275: “potential follow up studies may include documenting medication non-adherence and potential barriers to first fill such as cost to the patient.” I cannot see the benefit of this or how this would add to the findings presented. Please further elaborate. Conclusion Repetition: Lines 285-287 and 287-289. The authors claim to “prove the value of pharmacist expertise while utilizing a medication history tool for TOC medication reconciliation.” Please elaborate how the authors were able to make this conclusion based on the results presented (i.e 82 medication errors in six months, how does this compare to the existing literature). Would other health professionals such as nurses be able to identify such errors? Maybe the skills and expertise of the pharmacists have been shown/proven in other studies. This could be discussed and referenced in the discussion if appropriate. Overall I find the manuscript well written and interesting, addressing a pivotal research question. I am concerned that the discussion is not supported by references. I would suggest some restructuring to the discussion, especially to include references to other relevant/similar research. For example, “oftentimes, patients have inaccurate accounts of their medication history, current medication list or refill history…” is this based on personal experience? Reviewer #2: It's an interesting study so in my opinion can publish it as it . It has a good point for the pharmacists role in our hospitals and has a good idea to protect patients from drug drug interaction or overlaps or ovser doses . ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0279903.r001
Revision 1
17 Aug 2022 Author Response To our reviewers and editors at PLOS One, thank you for your constructive comments. Please find our responses to each comment below: • We have included an Ethics Statement in the Methods section of our manuscript at the direction of the editor. • We have added additional clarification to our financial disclosure to our cover letter at the direction of the editor. • We have included our updated Data Availability Statement in our cover letter. Also, we have uploaded our Minimum Underlying Dataset as Supporting Information and will include the following statement in our manuscript: All data is included in the manuscript and/or Supporting Information. We added legends for all Supporting Information and named the files to be consistent with PLOS’ submission guidelines. • Instead of breaking out the Abstract into separate Objective, Methods, Results, and Conclusions, we have amended the manuscript to include the Abstract in one cohesive paragraph. • We double checked to ensure that none of the papers we cited have been retracted. All our citations correctly refer to the preceding statements. Reviewer Comments Addressed: • We have provided a sentence at the beginning of the methods section to provide more context on the nature of the hospital. • We have clarified what a “legitimate medication discrepancy” is in the methods section by removing the word “legitimate” and describing a medication discrepancy. • We have added a brief summary of the role of a TOC pharmacist in the context of transitions of care and supporting citations for the benefits of this clinical workflow. • We have moved the Medication Error Type of “Other” to the bottom of the list instead of the middle where it makes more sense to display. • We explored the 2nd most common medication error we found (Omission) in the discussion as requested. • We agree that the methodology for scoring medication that have multiple uses belongs in the methods section and has been moved there. • We have added references that support our claims of the difficulty to quantify the scale and severity of medication errors. • We deleted the second repetitive sentence identified in the conclusion. • In support of our claim that we “proved the value of pharmacist expertise while utilizing a medication history tool for TOC medication reconciliation,” we have added references and clarification adjacent this claim, changed the word ‘proved’ to ‘support’, and we also introduced this concept with this sentence earlier in the discussion “Pharmacists are more in tune to the miniscule differences between medication formulations and dosages” • We added the following clarifying sentence to address how a follow up study measuring medication cost may add to the omission findings presented “These were not directly addressed by TOC pharmacy staff during the time setting of this study and would be an interesting follow up analysis to measure the effect of prescription drug costs on omission medication errors in psychiatric patients.” • We have included citations to support the claim “oftentimes, patient have inaccurate accounts of their medication history, current medication list, or refill history” in the discussion. Font size • Standard font was used in the manuscript • Major heading were formatted In bold 18pt font • Sub heading were formatted in bold 16pt font Table formats • Table title and caption was inserted after paragraph of initial mention • Actual table itself was inserted after paragraph of initial mention • Tables were converted into editable cells • 1pt font was used for border • 3pt font was used for lever • Only black color font was used Any other changes, etc. • Figure title and caption was inserted after paragraph of initial mention • Figure is provided separately • Acknowledgements were added before references • Supporting files are added after references • References are recited into correct format • Retractable references checked (none noted) We hope that these revisions satisfy the reviews and eagerly await your decision. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0279903.r002
6 Oct 2022 Decision Letter - Vijayaprakash Suppiah, Editor PONE-D-22-13219R1Use of complete medication history to identify and correct transitions-of-care medication errors at psychiatric hospital admissionPLOS ONE Dear Dr. Aboud, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Nov 20 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols. We look forward to receiving your revised manuscript. Kind regards, Vijayaprakash Suppiah, PhD Academic Editor PLOS ONE Journal Requirements: Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: N/A ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Thank you for addressing the comments. I have some minor comments. Abstract The abstract could benefit from further editing, I noticed that there were frequent uses of long sentences which can reduce the readability of the paper. Introduction I do not feel that ‘feasibility’ is the appropriate terminology for what was achieved in this study. The study seems to do the following: 1. Design a tool to assess and quantify the risk of medication errors 2. Assess the benefit of TOC pharmacists in identifying medication errors If this is the case, authors should reconsider the wording to better reflected what was achieved in this study. The abstract mentions “Establishing a method for categorizing the scale and severity of medication errors…” which I think is a better reflection of the study’s aim. Methods: Inclusion criteria: This section would benefit from some minor editing. For example Lines 155-159 is long and cumbersome. Results Format – line 216-217, needs a space between the table and the next paragraph. Discussion I feel that the discussion will benefit from further editing. In particular, sentences could be shorten to improve readability. Figure: DrFirst Medication Reconciliation Intervention Study Timeline The figure I received was of poor quality and was difficult to read as a result. A better quality figure/image may be needed for publication. Unless this is managed by the journal? Overall The manuscript highlights the importance of the TOC pharmacists and addresses a key area. I would suggest some minor revision to the manuscript, especially the discussion, to improve readability. In particular, sentences should be shortened and made more concise. ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No ******** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0279903.r003
Revision 2
16 Nov 2022 Author Response To our reviewers and editors at PLOS One, thank you for your constructive comments. We are happy to accommodate your additional revisions to improve the readability of our manuscript. Please find our responses to each comment below: Reviewer Comments Addressed: Abstract • We have edited the abstract to eliminate long sentences to improve the readability of the paper. Introduction • We have removed the term feasible and feasibility from the manuscript and re-worded our explanations to reflect “assessing the benefit” of our methodology in response to our reviewer’s comments. Methods: • We edited the following sections to improve reading clarity: Inclusion Criteria, Medication Error Data Collection, and Medication Error Scoring Methodology. Results • We added a space between the table and the next paragraph for lines 216-217. Discussion • We significantly edited this section by shortening sentences and breaking out an additional section to improve readability. Figure: • We did a full re-design of the figure ‘DrFirst Medication Reconciliation Intervention Study Timeline’ per the reviewer’s suggestions. Thank you for the clarifying reviews. We believe they will greatly enhance the readability of our manuscript and eagerly await your response. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0279903.r004
19 Dec 2022 Decision Letter - Vijayaprakash Suppiah, Editor Use of complete medication history to identify and correct transitions-of-care medication errors at psychiatric hospital admission PONE-D-22-13219R2 Dear Dr. Aboud, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Vijayaprakash Suppiah, PhD Academic Editor PLOS ONE Additional Editor Comments (optional): Dear authors, Please note that the reviewer has highlighted that the figure was very blurry. Please submit the figure with better resolution. Thank you. Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: N/A ****** 4. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes ****** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Thank you for addressing the comments. I noted that figure 1 has been greatly improved since the first submission. However, my copy was very blurry, I think the figure may need to be resubmitted (with better resolution) for publication. ****** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No ******** https://doi.org/10.1371/journal.pone.0279903.r005
Formally Accepted
2 Jan 2023 Acceptance Letter - Vijayaprakash Suppiah, Editor PONE-D-22-13219R2 Use of complete medication history to identify and correct transitions-of-care medication errors at psychiatric hospital admission Dear Dr. Aboud: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Vijayaprakash Suppiah Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0279903.r006

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