Reducing Risk Through Medication Reconciliation

In 2006, the Joint Commission onAccreditation of Healthcare Organizations(JCAHO) started the newyear with a mandate for accreditedorganizations to implement an innovativeinitiative: Medication Reconciliation.The mandate attempted to addressthe ~1.3 million iatrogenic adverseevents that occur annually, manyof which are related to medication.

Medication reconciliation is an effectiveprocess to reduce errors and harmassociated with loss of medicationinformation, as patients transfer amongcommunity-based and hospital providers.It may prevent up to 70% of allpotential errors and 15% of all adversedrug events.¹

Medication reconciliation involvingthe patient should occur at all interfacesof care (handoffs) and on admissionto and discharge from ambulatory,emergency and urgent care, long-termcare, home, or inpatient services. It isnot entirely a new requirement?it hasbeen a less prominent component ofJCAHO's Medication Managementstandard.²

The process of comparing a patient'smedication orders with all the medicationsthe patient has been taking oftenhas surprising results. Reconciliationcan prevent medication errors (omissions,duplications, dosing errors, ordrug interactions; see sidebar^3,4).

JCAHO mandates the process atevery care transition if new medicationsare ordered or existing orders arerewritten. The commission definescare transitions as changes in setting,service, practitioner, or level of care.The specific steps are presented in theFigure.

Certain types of orders are renownedfor their propensity to causeerrors and associations with adversedrug events.⁵ For this reason, the JointCommission's Medication Managementstandard (MM.3.20) specificallyforbids "blanket" orders, such as"Resume preop medications."

Rationale for Reconciliation

JCAHO's sentinel-event databaseincludes >350 medication errors resultingin death or major injury. Root causeanalysis identified breakdowns in communicationas significant factors, completelyor in part, in 63% of those errors.Clinicians could have preventedapproximately half of them using effectivemedication reconciliation.

The Institute for Safe MedicationPractices (ISMP) has published samplesof errors reported pursuant to failedcommunication.⁴ ISMP included thefollowing:

?Duplicate orders for insulin andother medications being givenwhen the patient's medication historyor medication administrationrecord followed the patient onlyhours later

?Poor handwriting leading to lookalike-name drugs being prescribed

?Infusions ordered by flow rate, witha higher concentration of medicationadministered and consequentoverdose

?Patients cutting tablets inappropriatelywhen doses were halved bymistake

Identifying Causes of MedicationErrors

The interfaces of care (admission to,transfer within, or discharge from ahealth care facility) are replete withopportunities for error.^3,6 Up to 77% ofall patients may be discharged withinadequate medication instructions.⁷

The US Pharmacopeia's (USP) MEDMARXreporting program captureserrors involving medication-reconciliationfailures. Examining the 2011 reconciliationerrors reported betweenSeptember 2004 and July 2005 revealsthat 66% occurred during transition ortransfer to another level of care, 22%occurred during admission to a facility,and 12% occurred at discharge.⁸ MEDMARXtracks types of errors and indicates that the majority involve improperdose or quantity, followed by omissionerror and prescribing error.Usually, analysis finds that performancefalling short of expectations,transcription errors, documentationdeficits, communication failures, andwork-flow disruption are involved.

Reducing Risk

All health care facilities must createa process for reconciling medicationsat all care interfaces. The process mustinclude reasonable time frames forcompleting reconciliation. Experts recommendusing standardized forms forthe patient's list and the reconciliationstep. Every party in this process shouldemploy reconciliation tracking toolsand medication-reconciliation flowsheets.^9,10 Patients and responsiblephysicians, nurses, and pharmacists allhave roles, which should be defined inpolicies and procedures.

Pharmacy technicians also can help.One hospital reduced potential adversedrug events by 80% over 3 months byhaving pharmacy technicians obtainpatients' medication histories beforescheduled surgeries.⁵

When health care extenders such astechnicians areinvited into theprocess, thekey is providingthe training andexperience necessaryfor themto become competentin theprocess, andthen assessingtheir competencyperiodically.In fact, all health care providersneed continuing training and competenceassessment.¹⁰ Some facilitiesalso involve case managers, dependingon the case management model theyuse.^11,12 The reasoning is that casemanagers can be a safety net forpatients, especially if they round withclinical pharmacists, because theyoften follow the patient's entire stay.

Pharmacists involved in this processmay find that some hurdles continuedespite a year's experience. Somefacilities have failed to define the interfacesin which reconciliation is necessaryand may need to redefine when apatient handoff occurs.^13,14

At admission, collaborating withpatients to create an acceptable listcan be undermined by poor staffinglevels, lack of focused attention, andpatients who are unable to explainwhat they take.¹⁵ Some tactics canhelp, such as linking medications withthe conditions they are prescribed for,and prompting patients with questionssuch as, "Does that medication have aCR or an XL after its name?" Providersalso can ask for the name of thepatient's outside pharmacy or pharmacies.¹⁶ In addition, some physiciansmay be uncomfortable reconcilingmedications prescribed by specialists,especially if they lack knowledge in thespecialty area.¹³

The lists may become lost in thejumble of the clinical record unless thefacility or practice designates a visibleand readily retrievable location forthem in the paper or electronic record.¹⁴ Names of medications may becollected successfully, but the informationmay lack the drug frequency,route, and time the patient took thelast dose. Standardized forms can helpstaff members remember to solicit thisinformation.²

Shared Accountability

Medication reconciliation is an ongoingresponsibility, and it cannot beassigned to one specific point in thehealth care continuum. When providersreceive a list of discharge medicationsfrom a facility, they mustinvoke the reconciliation process?despite the fact that the originatoralready should have performed medicationreconciliation.

Although the patient has reconciledthe list he or she sent against the list ofmedications he or she received duringhis or her tenure there and against theoriginal medication provided at patiententry to the organization, it must bechecked at the receiving organization.¹⁰ Medication reconciliation is onearea where the goal is to increaserather than decrease redundancy.

JCAHO reports high levels of compliancewith this requirement amongfacilities, but it indicates that noncomplianceis most likely at discharge.² Ondischarge from the facility, in additionto communicating an updated list tothe next provider of care, each clinicianor care provider must give the patientthe complete list of medications thathe or she will be taking after dischargefrom the facility, as well as instructionson how and how long to continue takingany newly prescribed medications.The patient should be encouraged tocarry the list with him or her and toshare the list with any providers ofcare, including primary care and specialistphysicians, nurses, pharmacists,and other caregivers.

Ms. Wick is a senior clinical researchpharmacist at the National CancerInstitute, National Institutes ofHealth, Bethesda, Md. The viewsexpressed are those of the authorand not those of any governmentagency.

References

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3. Rozich JD, Howard RJ, Justeson JM, Macken PD, Lindsay ME, Resar RK.Standardization as a mechanism to improve safety in health care. Jt Comm J Qual Saf.2004;30:5-14.

4. Institute for Safe Medication Practices. Building a case for medication reconciliation.Medication Safety Alert. April 21, 2005. Available at:www.ismp.org/MSAarticles/20050421.htm. Accessed December 24, 2006.

5. Michels RD, Meisel SB. Program using pharmacy technicians to obtain medicationhistories. Am J Health-Syst Pharm. 2003;60:1982-1986.

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8. USP Patient Safety CAPSLink. October 2005. US Pharmacopeia. Available at:www.usp.org/patientSafety/newsletters/capsLink.

9. Institute for Healthcare Improvement Web site, section on Medication ReconciliationReview, samples of a reconciliation tracking tool and a medication-reconciliation flowsheet. Available at: www.ihi.org.

10. Massachusetts Coalition for the Prevention of Medical Errors Web site. Available at:www.macoalition.org.

11. Help your hospital meet the new medication reconciliation requirements. Hosp CaseManag. 2006;14:161-164.

12. Stover PA, Somers P. An approach to medication reconciliation. Am J Med Qual.2006;21:307-310.

13. Varkey P, Resar RK. Medication reconciliation implementation in an academiccenter. Am J Med Qual. 2006;21:293-295.

14. JCAHO looking closely at medication reconciliation. Hosp Peer Rev. 2006;31:65-67.

15. Haig K. Medication reconciliation. Am J Med Qual. 2006;21:299-303.

16. Sullivan C, Gleason KM, Rooney D, Groszek JM, Barnard C. Medicationreconciliation in the acute care setting: opportunity and challenge for nursing. J NursCare Qual. 2005;20:95-98.