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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. The transfer of care is recognized as a potential critical failure point for patient safety.

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. The list is then used to guide drug choice throughout 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 all transitions in care, e.g., admission, unit transfer or inter-hospital transfer, step-down care transfer, or discharge to home.

Suggested Implementation Steps for the Medication Reconciliation Process

  1. Develop policies, protocols, and procedures which address the following:
    1. Development 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 out in their entirety.
    4. Identification of 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 format 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. Assess the appropriateness of each prescribed drug, on the basis of clinical status and patient report.
    1. Is the medication still indicated?
    2. Can the patient afford it?
    3. Does the patient take the medication as prescribed or recommended?
    4. Does the patient want to continue taking it?
  4. Assure primary responsibility for reconciling medications is assigned to a healthcare professional with sufficient expertise.
    1. Individual roles and responsibilities need to be clearly defined and understood by all disciplines participating on the medication reconciliation team.
  5. Assure the medication reconciliation list is easily accessible within the patient's EHR, or paper chart and that reconciliation of medications occur.
    1. Identify who is responsible for reconciling the medication list upon transfer, e.g., the sending unit or the receiving unit.
    2. Rewrite or re-enter all medication orders at the time of transfer and discharge.
    3. Compare each medication list with the previous medication list and resolve any discrepancies with the provider.
    4. Provide patients with 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 reviewed with the provider and 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 transition in patient care.
    3. Assure the record reflects that the discharge medication list was compared to the home drug list and any changes were reviewed in detail with the patient.
    4. Educate the patient when new and unfamiliar medications are prescribed. Encourage feedback from the patient and require a return demonstration of instructions to assure patient understanding. Document the elements of this encounter in the record.
  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.
  10. Engage primary care practices and other living facilities.
  11. 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. Involve the primary care provider, pharmacy and the facility where the patient resides, e.g., LTC, SNF, assisted living, independent living.
  3. Integrate medication reconciliation into existing workflows.
  4. Start with a pilot unit.
  5. Test process before going hospital-wide.

Resources:

Breakdowns in the Medication Reconciliation Process, Pennsylvania Patient Safety Advisory, http://patientsafety.pa.gov/ADVISORIES/Pages/201312_125.aspx

A Pocket Guide to the AGS 2015 Beers Criteria, American Geriatrics Society, http://www.ospdocs.com/resources/uploads/files/Pocket%20Guide%20to%202015%20Beers%20Criteria.pdf

How-to guide: prevent drug adverse events (medication reconciliation), http://www.ihi.org/resources/Pages/Tools/HowtoGuidePreventAdverseDrugEvents.aspx

Introduction to Reconciling Medication Information, NPSG.03.06.01 National Patient Safety Goals effective January 2018, https://www.jointcommission.org/assets/1/6/NPSG_Chapter_AHC_Jan2018.pdf

Massachusetts Coalition for the Prevention of Medical Errors, www.macoalition.org/ and http://www.macoalition.org/Initiatives/docs/RAMEproviderInfo.pdf

Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation, Agency for Healthcare Research and Quality, http://www.ahrq.gov/professionals/quality-patient-safety/patient-safety-resources/resources/match/match.pdf