Medication Reconciliation: A Major Patient-Safety Tool

Medication errors have been shown to be the most common type of errors affecting patient safety.¹ These errors generally occur at transition points in the patient's care?during admission, at the time of transfer from one level of care to another (eg, from a critical care area to a general care area), and at discharge. Incomplete documentation of medications when a patient is admitted, transferred, or discharged can account for ~60% of potential medication errors.²

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) National Patient Safety Goal 8 states that hospitals must "accurately and completely reconcile medications across the continuum of care."³ This goal stresses the need to maintain and use a medication list whenever a patient transitions to a new setting, service, or level of care. All organizations seeking accreditation from JCAHO were required to have this program implemented by January 1, 2006.⁴

In addition to JCAHO's mandate, in December 2004, Donald Berwick, MD, president and chief executive officer of the Institute for Healthcare Improvement (IHI), called for saving 100,000 lives in 18 months by adopting measures known to prevent patient injuries.⁵ One of the goals of this campaign is patient safety through medication reconciliation.

The IHI defines reconciliation as "a process of identifying the most accurate list of all medications a patient is taking?including name, dosage, frequency, and route?and using this list to provide correct medications for patients anywhere within the health care system."⁶ Having a medication-reconciliation process at critical transitional care points reduces the incidence of medication errors significantly (Table).^1,7-9

The focus is not just on compiling a list, but the list must be used to reduce medication errors and provide quality patient care. Implementing a medication-reconciliation program is a complex task, but, when done effectively, it can lead to a decrease in injuries to hospitalized patients.

Also, JCAHO mandates that a complete list of current home medications must be obtained within the first 24 hours of admission. Although most nursing admission assessment forms have a section for documenting patients' medications, documentation usually does not include all the key components of a complete medication history (ie, name of medication, strength, route, and frequency). In implementing a medication-reconciliation program, most hospitals have modified their existing medication-history form to meet all the JCAHO requirements.

Another significant change seen in the process of medication reconciliation is the involvement of pharmacy. In a study conducted at Northwestern Memorial, the researchers concluded that pharmacists are in the best position to perform medication reconciliation because of their educational background, knowledge of medications, and patient-counseling skills.¹⁰

The medication-reconciliation process typically starts with the admitting nurse obtaining the names of all the home medications from either the patient or a family member who may be present. The nurse also completes the record of the dose, frequency, route, and time of last dose. The list is then reconciled with the ordered admission medications. If the patient and/or a family member is uncertain of home medications, pharmacy or physician-office records may be obtained to get this information. This record follows the patient throughout the hospital stay until discharge.

At discharge, some facilities have developed a computer-generated record of medications taken while the patient was in the hospital. The physician can check which medications the patient needs to continue at home. Some facilities have used this generated form as a discharge prescription form.¹¹ Medication reconciliation must be done when a patient transfers from one level of care to another. For example, when a patient transfers from an intensive care unit (ICU) to a general care area, the patient's list of medications must be reconciled. In a study conducted at the Johns Hopkins Medical Institute and School of Medicine, an electronic medication-reconciliation form was developed and was used when patients were transferred from the surgical ICU to a general care area. Over a 1-year period, 21% of medication orders were changed due to the implementation of a medication- reconciliation program. The researchers concluded that this tool helped decrease medical errors during transfers from a surgical ICU.

The IHI recommends that new orders be written when patients transfer from one patient care area to another. Once these transfer orders are written, a pharmacist or nurse must review the medications on the order and compare them with the medications the patient was receiving prior to the transfer. Any discrepancies should be resolved prior to the transfer.

Before discharging a patient, the IHI recommends comparing the discharge medication orders with the nurse's medication administration record. This check will help identify any medications that may have been omitted from the discharge orders. The discharging physician could be contacted if any orders are missing to verify whether or not the patient should continue those medications.

Due to the complexity of the medication- reconciliation process, the IHI provides various workshops to help medical organizations create an effective program. It also provides helpful tips to assist with reconciliation at various transition points (Table).⁶

The IHI stresses the need to provide the patient with a list of previously taken medications and any new medications and to clearly review the new medications (name, indication, and dosing instructions), as well as discontinued medications, prior to discharge.

In conclusion, medication reconciliation is a major patient safety tool. Although various barriers must be overcome in order to have an effective and efficient reconciliation process, the success stories from hospitals that have already implemented this program are encouraging. The involvement of pharmacists in reconciliation also is very important. In a study by Gleason et al, the investigators concluded that "reconciliation by pharmacists of discrepancies in admission medication histories and orders decreased opportunities for medication errors and the potential for patient harm."¹²

Finally, patients also can help in this process by keeping a complete list of all their medications, including herbal products, vitamins, and OTC medications. They can be encouraged to bring all their medications to every health care visit. Doing so will help shorten the time needed to reconcile their medications and will facilitate prompt continuity of care.

Dr. Badger is a pharmacy education coordinator at Piedmont Hospital Pharmacy, Atlanta, Ga.

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