Medication Reconciliation

Most errors are attributable to poor communication rather than poor care.

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Learning Scope #408
1 contact hour
Expires Nov. 19, 2014

You can earn 1 contact hour of continuing education credit in three ways: 1) Grade and certificate are available immediately after taking the online test. 2) Send the answer sheet (or a photocopy) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the answer sheet to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.

Merion Matters is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 221-3-O-09), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation.

Merion Matters is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).

The goal of this continuing education article is to review the latest information on medication reconciliation. After reading this article, you will be able to:

1. Define the concept of medication reconciliation.

2. Discuss the gravity and importance of medication reconciliation and its effect on patient outcomes.

3. Explain how nurses play a critical and "fail-safe" role in the medication reconciliations process.

The author has completed a disclosure form and reports no relationships relevant to the content of this article.

 

Over the past decade, reporting regulations for hospitals have become significantly more comprehensive. The resulting depth of data has been, in many cases, eye-opening.

Medication errors have emerged as one of the most significant causes of patient harm. The Joint Commission and the Institute for Healthcare Improvement (IHI) realized this was a major patient safety issue. Many factors contribute to the problem: unreliability of patient data, multiple physicians writing multiple prescriptions, numerous transitions from one clinical setting to another and more.

IHI looked at the data and realized how many errors were occurring on a daily basis. However, developing a process to effectively combat the problem and achieving buy-in from the many clinical professionals treating the patient proved significantly more elusive.

Medication Reconciliation: The Ideal

Ideally, a medical home or a single provider coordinates the entirety of a patient's care. However, the reality is healthcare in our country is fragmented. Patients may see multiple providers during a single healthcare experience. They may receive new medication orders from each of these providers as they move through a variety of inpatient and outpatient settings, or they may have existing orders changed.

Reconciling the medications prescribed along the way may be one of the most significant challenges faced by hospitals today. Medication reconciliation, or "med rec," is a process intended to simplify, codify and document the patient's medication regimen, but medication reconciliation is at heart a patient safety philosophy.

Medication reconciliation is the process of creating the most accurate list possible of all medications a patient is taking, according to IHI.1 That includes the drug name, dosage, frequency, route and last time each medication was taken. It is then compared against the physician's admission, transfer and/or discharge orders. The goal is to provide the correct medications to the patient at all transition points within the hospital.

Transitions in Care

The term "transitions in care" is one becoming increasingly familiar to nurses. It is used to describe patient movement from one level of care to another. The transition may be from the operating room to the unit, from the floor to the ICU, or from inpatient to outpatient status. Even a routine discharge to the home setting is considered a transition.

Today, healthcare organizations must initiate and document a medication reconciliation process, which begins at the patient's first portal of entry. The patient's current medications are listed in the chart upon admission. More than half of patients have more than one unintended medication discrepancy at hospital admission, according to the Agency for Healthcare Research and Quality (AHRQ).2

This documented list must follow the patient throughout the continuum of care and be provided to the next clinician as the setting changes. Every change to the medication regimen must be noted and accompanied by the appropriate signature. "Studies have shown that unintended medication discrepancies occur in nearly one-third of patients at admission, a similar portion at the time of transfer from one site of care within a hospital, and in 14 percent of patients at hospital discharge," AHRQ states.2

The consequences are grim. Experience from hundreds of organizations has shown that poor communication at transition points is responsible for as many as 50 percent of all medication errors and up to 20 percent of adverse drug events in the hospital.3

Regulatory Environment

Medication reconciliation was a National Patient Safety Goal as far back as 2005. The scarcity of successful peer-reviewed strategies, however, led the Joint Commission to suspend scoring for it on surveys. The policy change was made in recognition of the lack of proven strategies for accomplishing medication reconciliation.2

The Joint Commission renewed its emphasis on the topic in July 2011 by enacting Hospital National Patient Safety Goal #3 (NPSG.03.06.01), titled "Use Medications Safely." It mandated facilities to: "Record and pass along correct information about a patient's medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor."4

Challenges for Clinicians

Although the need for a discrepancy-free medication regimen is self-evident, the method of obtaining and implementing the complete picture is neither straightforward nor effortless. All caregivers know they face formidable barriers.

When patients are admitted to a hospital, they frequently receive new medication. They are often assigned different doses of existing medication as well. As the transition from one clinical setting to another occurs, it is not unusual for clinicians to:

• be unable to access a previous complete list of patient medications;

• be unaware of recent medication changes;

• have insufficient time to properly note the details;

• encounter cultural and language barriers which inhibit effective communication; and

• come across patients who are poor historians and/or cognitively impaired.

In addition, physician understanding plays a role in medication reconciliation. Doctors may be well-informed in their field, with exceptional knowledge about the type and dosage of medications prescribed in that specialty, but less familiar with other medications the patient may be taking. How these medications interact with one another during any change in the medication status quo can have significant outcome changes for the patient.

Medication reconciliation is not merely a provider responsibility. The patient's input forms the basis of the process. However, as every clinical provider knows, this is not as clear cut as one might expect. Patients do not always provide accurate detail of the names, dosages and frequency of the medications they are taking. Sometimes they cannot name the medication, calling it "a blue pill" or "a square pill," thus putting the provider in an unenviable position of having to guess at the name.

Patients who do not wish to appear non-compliant might under-report the prescribed dosage of their medication. Patients may take the correct drug, dose and frequency when they have the medication in hand, but economic circumstances may dictate that this occurs on an irregular schedule.

Health literacy is an issue as well. "Within the realm of medication reconciliation, patients with limited health literacy may have problems adhering to a medication regimen and may be unable to provide an accurate medication history," according to one facility's medication reconciliation toolkit.5 "When these patients are discharged from the inpatient setting, instruction on changes to their prior medications and/or a new medication may require more targeted efforts on the part of the providers."

Dangers

Myriad dangers of incorrect medication reconciliation exist. The necessary medication may not be prescribed or the necessary medication may be duplicated. An incorrect dosage may be delivered. Inadvertent conflicts may negate necessary therapeutic effects. The potential for an adverse drug event is real and significant.

Studies have shown between one-quarter and one-third of patients have a discrepancy in their medication at the point of admission, discharge or transfer from one setting to another. This percentage would be unacceptable in any other aspect of healthcare. However, identifying the problem is not the same as finding practical and feasible solutions.

Who Should Take the Lead?

The question of who should take the lead in medication reconciliation has been perplexing healthcare organizations for nearly a decade. With no clear best-practices guidelines available, hospital and healthcare facilities have looked to different specialists within the organization.

The Patient

Clearly, effective communication with the patient at admission or the first point of care is paramount. If patients' knowledge of their current medication is complete and has been communicated effectively, it is still only a starting point. Patients may not even be aware new medication or different dosages of existing medication have been prescribed during transitions from one level of care to another.

Clinicians know this is not easily accomplished. Patients who take multiple medications may forget to mention one or two upon intake. Not all patients have the language skills to articulate their medication regimen. Patients sometimes claim they take their medication when in fact, blood tests and other diagnostic tools prove they do not. Much information may be lost in this way.

Information Technology

Some organizations have considered medication reconciliation an information technology (IT) issue. If a patient's former and current medications are all listed in electronic format, they explain, every clinician in the spectrum will have access to the information and make appropriate clinical decisions. Computer systems can be programmed to flag entries for unusual dosage orders, thus reducing medical errors.

However, this view is not widely held. As IT experts are not clinicians, they cannot be the ultimate bearers of responsibility, both legally and morally.

The Pharmacist

Others have considered putting pharmacists at the forefront, reasoning pharmacists are the clinicians most likely to spot dangerous adverse drug events when different medications are prescribed. Computers cannot spot nuances in prescriptions, but a pharmacist can.

With their broad scope of knowledge of medications treating the spectrum of disease, pharmacists are uniquely trained to notice, point out and correct discrepancies in patients' prescriptions as they move through levels of care. However, this is only feasible if pharmacists have access to a universal electronic record. If they do not, as is largely the case in hospitals today, the pharmacist cannot be asked to bear complete responsibility for medication reconciliation.

The Physician

Under the healthcare system in the U.S., it is generally accepted physicians bear the ultimate responsibility for the care delivered to a patient. They are compensated for this role, and they bear the accompanying legal liability. The question, though, is which doctor?

The medication reconciliation process acknowledges the reality that many physicians can be involved in a patient's care and prescribe or discontinue medication. In everyday clinical practice, it is possible a physician may assume another provider in the process will provide the information required to complete the med rec process.

However, the American Medical Association has stated it is a physician responsibility, albeit as part of a partnership: "The AMA's medication reconciliation panel strongly believes that improving medication reconciliation is the responsibility of physicians, requires effective partnership and collaboration with all members of the health care team, and is best accomplished through effective partnerships with patients," they write.6

The Nurse

As is often the case, the responsibility for patient safety circles back to the nursing staff. Still, there was no mention of medication reconciliation in the nursing literature until 2004.7 In general, the healthcare team tending to a sick individual has only episodic one-on-one contact with the patient. IT personnel never meet the patients; pharmacists may not dispense medication to the floors personally; physicians round periodically and are often not present when the transfer from one care site to another occurs. Nurses, however, are on site at all times.

The role of a nurse is to fulfill medication regimens written by the physician, nurse practitioner or physician assistant. They cannot independently override or circumvent medication orders. Although their proximity to the patient enables them to view the care plan in its entirety, many nurses and nursing associations do not want nurses to bear ultimate responsibility for the medication reconciliation process. It's a multidisciplined approach, they claim, and everyone has to play their part.

Still, there are many ways nurses can take a leadership role in the medication reconciliation process. They can "own" the home medication portion of the patient's admission intake. They can become knowledgeable about smartphone apps patients can use to list their medications, such as My Life Record for Android or MyMedRec for Apple products, and explain to patients how it can help them.

Medication reconciliation may well be the medical process touchstone of the decade. It therefore behooves nurses, who traditionally have been the strongest advocates for patients in the healthcare system, to be at the forefront in developing best practices.

One of the keys of successful medication reconciliation is providing nurse with opportunities and resources to create a relationship of trust with the patient that will shape and inform the patient's entire encounter in the healthcare setting. It is often said that "doctors and nurses hear different truths." A level of comfort between the nurse and the patient at the first level of care can ascertain the correct truth and establish a safe baseline of medications that all other caregivers can employ.

Controversy

Today, there is consensus that safety is best maintained with active collaboration between physicians, nurses, pharmacists, and importantly, the patients themselves. This was not the norm a generation ago, when a less multidisciplinary, more paternalistic approach all but excluded the patient from the equation and minimized the role of the nurse.

In many states, a tacit process has evolved in which the nurse is responsible for collecting the medication information at each level of care visited by the patient. The physician, nurse practitioner or physician assistant is responsible for updating and signing off on the required medication.

Not all nursing associations are pleased with this development. Nurses are not providers - they are neither licensed nor insured to act as such. At the point of entry, nurses only can record information given to them by the patient. The information may or may not be complete. There is a concern this unfairly increases a nurse's liability. There is a perceived notion among nurses physicians are attempting to deflect the responsibility regarding medication reconciliation to the nurse. There often is a communication gap, even among providers.

"Different styles of communication also come into play," one expert writes.8 "Nurses have been trained to be narrative and descriptive, whereas physicians want to cut to the chase."

Strong Leadership

Medication reconciliation is too important, difficult and complex a topic to be enacted halfheartedly. A firm and determined leadership commitment is the only way to ensure its success.

A healthcare organization's leadership must attempt to make medication reconciliation a top priority - a process that must be followed every time, with no tolerance of laxness and a good deal of accountability according to the institutions own policies. Hospital leaders should join the movement advocating for a nationalized, universal, electronic patient record.

Most errors that occur in a hospital are attributable to poor communication rather than poor care. Ultimately, medication reconciliation is not about satisfaction scores - it's about good, safe patient care.

References
1. Institute for Healthcare Improvement. (2012). Prevent adverse drug events with medication reconciliation. Retrieved Oct. 31, 2012 from the World Wide Web: http://www.ihi.org/explore/ADEsMedicationReconciliation/Pages/default.aspx  
2. Agency for Healthcare Research and Quality Patient Safety Network. Patient safety primer: Medical reconciliation. Retrieved Oct. 31, 2012 from the World Wide Web: http://www.psnet.ahrq.gov/printviewPrimer.aspx?primerID=1
3. Institute for Healthcare Improvement. (2011). Reconcile medications at all transition points. Retrieved Oct. 31, 2012 from the World Wide Web: http://www.ihi.org/knowledge/Pages/Changes/ReconcileMedicationsatAllTransitionPoints.aspx
4. The Joint Commission. 2012 hospital national patient safety goals. Retrieved Oct. 31, 2012 from the World Wide Web: http://www.jointcommission.org/assets/1/6/2012_NPSG_HAP.pdf
5. Northwestern Memorial Hospital. Education & training curriculum on medication reconciliation. Retrieved Oct. 31, 2012 from the World Wide Web: http://www.nmh.org/nm/medication-reconciliation-toolkit-education-training
6. American Medical Association. (2007). The physician's role in medication reconciliation. Retrieved Oct. 31, 2012 from the World Wide Web: http://www.ama-assn.org/resources/doc/cqi/med-rec-monograph.pdf
7. Barnsteiner, J.H. (2005). Medication reconciliation: Transfer of medication information across settings - keeping it free from error.  American Journal of Nurses, 105(3), 31-36.
8. Sutker, W.L. (2008). The physician's role in patient safety: What's in it for me? Proceedings (Baylor University Medical Center), 21(1), 9-14.

Online Resources
Agency for Healthcare Research and Quality Patient Safety Network: http://www.psnet.ahrq.gov/
American Medical Association: http://www.ama-assn.org/
Institute for Healthcare Improvement: http://www.ihi.org/
The Joint Commission: http://www.jointcommission.org/

Catherine Gallogly-Simon is chief nursing officer, Downstate Long Island College Hospital, Brooklyn, New York.




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