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Risk Management » Practice Tips

June 2008

Medication Reconciliation in the Hospital: A Risk Management Process for Avoiding Adverse Drug Events

An Institute of Medicine Report indicates there are 7000 patient deaths each year due to medication errors.  Chart review data indicates over 50% of medication error occurs at interfaces of care.  These interfaces of care include: patient admission to the hospital, patient transfer out of a specialty unit to another nursing unit, patient transfer to step-down care and patient discharge to home.  In 2005, the process of medication reconciliation became a National Patient Safety Goal: Accurately and completely reconcile medications across the continuum of care. This NPSG applies to ambulatory care, assisted living, behavioral health, home health and long-term care organizations as well as hospitals.  This goal requires facilities to communicate a complete list of the patient’s medications to the next care provider when a patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization.  The transfer of care is recognized as a potential critical failure point for patient safety.  The value of the medication reconciliation process is inherent in the independent validation of the patient’s current medications by a second care provider.

Medication Reconciliation

Medication reconciliation is a formal process of obtaining a complete and accurate list of each patient’s home medications including name, dosage, frequency, and route, and using this list to guide drug choice usage anywhere within the health care system. Medication reconciliation involves comparing the patient’s current list of medications against the physician’s medication orders for that patient at any subsequent interface of care, e.g., admission, unit transfer, step-down care transfer or discharge to home.

Suggested Implementation Steps for the Medication Reconciliation Process

  1. Develop policies and procedures for all disciplines.  Policies should cover the following:
    1. Generation of a patient home medication list.
    2. Comparison of the home medication list to the current list of physician orders.
    3. Prohibition of “blanket orders.”  “Blanket orders” are general prescriber directions that do not provide specific information about the medication therapy prescribed; e.g. ,  “continue previous medications,”   “resume postoperative orders,” “ resume orders from floor,” “discharge on current medications.”  Orders previously written must be written in their entirety.
    4. Identify timeframes for completing the medication reconciliation process.  It is suggested that reconciliation occurs before the next prescribed dose, within 24 hours of admission and within four hours of certain identified high risk medications.
    5. Identification and resolution of high-risk situations.
      • Patients on high-risk medications
      • Patients on greater than five medications
      • Specific interventions for elderly or compromised patients
      • Non-reconciled medications at shift change
      • Unavailability of ordering physician
      • Review of discrepancies in medication orders
      • Need for specialist consult
  2. Adopt a standardized form for reconciling medications.
    1. Patient Identification
    2. Allergy Verification
    3. Preparer/Verifier’s Signature
    4. Physician Signature
    5. List each medication
      • Dosage
      • Frequency
      • Date/Time of last dose
      • Compliance with prescribed dosages and frequency
    6. Other data
      • Person providing information
      • Patient weight
      • Pharmacy contact
      • Over the counter medications and herbals
      • Compromising conditions
      • Pregnancy/Breast feeding
  3. Assure primary responsibility for reconciling medications is assigned to a healthcare professional with sufficient expertise.  A shared accountability is recommended with the ordering physician, registered nurse and pharmacist working together to achieve accuracy.
  4. Assure the medication reconciliation form is placed in a consistent, highly visible location in the patient’s medical record; e.g., the form may be a specific recognizable color and placed as the first page of the patient medical record.
  5. Assure reconciliation occurs.
    1. Identify who is responsible for reconciling the medication list upon transfer; e.g.,  the sending unit or the receiving unit.
    2. All medication orders should be re-written at the time of transfer and discharge.
    3. Each medication list should be compared to the previous medication list and any discrepancies resolved.
    4. Patients should receive a document listing drugs and doses they are to take at home.  This list should be compared to the medication list on admission and the medication orders on discharge.  Any discrepancy should be resolved.
  6. Documentation Expectations.
    1. Assure the record reflects that the patient’s home drug list was compared to the admission drug orders.
    2. Assure the record reflects that the medication list was reviewed and any discrepancies resolved at each interface of patient care.
    3. Assure the record reflects that the discharge medication list was compared to the home drug list and any changes were detailed for the patient.
  7. Provide access to drug information.
    1. Specify conditions that require a consultation; e.g., greater than five medications, high risk medications.
    2. Ensure 24/7 access to a pharmacist.
  8. Provide orientation and ongoing education to all healthcare providers.
  9. Develop strategies to educate patients/families in monitoring medications and maintaining accurate medication lists.  Engage primary care practices and other living facilities.  An excellent resource document is available from the Massachusetts Coalition for the Prevention of Medical Error.  This document outlines safety tips for the patient and actions for improving medication safety for prescribers in the office practice setting. http://www.macoalition.org/Initiatives/docs/RAMEproviderInfo.pdf
  10. Review the process for quality improvement.
    1. Review a random sample of medical records each month.
    2. Encourage reporting of errors identified through the reconciliation process.
    3. Develop a strategy to share the results of the process.

Other considerations for successful implementation:

  1. After obtaining the patient’s consent, always involve the patient’s family members.
  2. Always involve the primary care provider and the facility where the patient resides, e.g., LTC, SNF, assisted living, independent living.
  3. Start with a pilot unit.
  4. Thoroughly test process before going hospital-wide.
  5. Thoroughly test process before automation.

 

Resources:

Excellent Resources are available at the below listed web sites including sample policies and forms, implementation strategies, staff education programs and tool kits.

ECRI, The Risk Management Reporter, October 2004. www.ecri.org
Health Services Advisory Group, Medication reconciliation.acute.hsag.com
Institute for Health Improvement. www.ihi.org/ihi
Institute for Safe Medication Practices, www.ismp.org
Massachusetts Coalition for the Prevention of Medical Errors. www.macoalition.org/
and http://www.macoalition.org/Initiatives/docs/RAMEproviderInfo.pdf
The Joint Commission Sentinel Event Alert, Issue 35, January 2006. http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_35.htm


Medical Mutual's "Practice Tips" are offered as reference information only and are not intended to establish practice standards or serve as legal advice. MMIC recommends you obtain a legal opinion from a qualified attorney for any specific application to your practice.