Inpatient topical glaucoma medication-ordering discrepancies: a study of frequency and risk factors for inaccurate reconciliation

To describe the frequency of topical glaucoma medication-ordering discrepancies (MOD) during transitions of care and to explore factors that may be associated with an increased risk of MOD. Retrospective cohort study. A random sample of adult patients with primary open-angle glaucoma (POAG) on at least 1 topical glaucoma medication admitted to any Cleveland Clinic facility between January 1, 2012, to January 1, 2023. Study patients must have had at least 1 visit with a Cole Eye Institute ophthalmologist—who diagnosed POAG and prescribed one or more topical glaucoma medications—within 12 months prior to admission. Charts were manually reviewed for discrepant prescriptions. Logistic regressions were employed to assess potential risk factors. MOD was noted in 288 of 944 (30.5%) encounters. Patient demographics, hospital site, provider type, admitting service, and pharmacy verification did not alter the odds of MOD. Patients on 3 medications experienced MOD most frequently (41.2%) followed by 1 medication (29.3%) and then 2 medications (26.8%) (P = 0.032). Omission was the most common MOD type across all reconciliations followed by substitution, addition, and wrong eye MOD (23.8%, 9.1%, 3.3%, and 0.53%, respectively). Medication discrepancy in a previous hospitalization increased the odds of discrepancy in the next (OR 5.1, 95% CI [3.2–8.4]; P < 0.001). A discrepancy on admission significantly increased MOD rates at transfer and discharge (P < 0.001). Glaucoma MOD occurred in approximately one-third of the inpatient encounters in this study, suggesting incongruence at transitions of care. Patients with inpatient MOD were significantly more likely to have an MOD in subsequent admissions.