A Closer Look at Medication Reconciliation

Checking for omissions, duplications, dosing errors, compliance, and drug interactions by an inpatient or outpatient pharmacy team can prevent errors and ensure that a patient's medications are accurate and safe.

In earlier entries, I have explained the many counseling opportunities available for community pharmacists. Pharmacists working in hospitals have similar counseling opportunities. For example, medication reconciliation is a form of brown bagging and medication therapy management (MTM). Both can be used to advance communication and prevent errors. As with an MTM session, medication reconciliation helps ensure that a patient’s medications are accurate and safe.

By relying on medication reconciliation, the hospital pharmacist can prevent errors that occur when a patient’s medications include prescription and OTC drugs, herbals, and dietary supplements. The process allows for the checking of omissions, duplications, dosing errors, compliance, and drug interactions. In all, the services provided by the inpatient or outpatient pharmacy team enhance communication between the provider and patient.

HW is a loyal customer to your pharmacy. HW also is a “frequent flyer” at the local community hospital. HW was diagnosed with prostate cancer about 8 months ago and is facing many ups and downs. HW presents to you a brand new list of medications and his current laboratory data. HW explains that he was discharged from the hospital and that these are his “new papers.”

You page through the papers and notice the medication reconciliation performed by the inpatient pharmacist. You review it against HW’s profile at your pharmacy and notice several changes. As you conduct your review, you see the concern and confusion in HW’s face. You explain the concept of pharmacy brown bag and MTM sessions and ask if he would be interested. HW is relieved and informs you that he will bring in all of his medications the following day. HW is looking forward to going over his entire history and current medication list. You suggest he come around 2 pm, which is a slower time in your pharmacy. This will allow you to provide him with the best service and care.

The next day, HW is waiting in your consultation area. Having done your homework, you have filled HW’s new medications, opened his medication profile, and have access to the hospital laboratory data and medication reconciliation. You compare what is in HW’s brown bag with your information.

The brown bag contains:

• Abiraterone acetate 1000 mg daily
• Aspirin enteric coated (EC), 81 mg daily
• Atorvastatin 40 mg daily
• Niacin dietary supplement
• Lipitor 40 mg daily
• OTC omeprazole 20 mg daily
• Ondansetron 4 mg as needed
• Lorazepam 0.5 mg as needed

Your pharmacy profile (after reviewing medication reconciliation and hospital discharge papers) contains:

• Abiraterone acetate 1000 mg daily
• Atorvastatin 40 mg daily
• Niaspan 500 mg daily at bedtime
• Aspirin EC 81 mg daily
• Atenolol 25 mg daily
• Prednisone 5 mg twice daily

The goal of a brown bag session is the discovery of discrepancies. Awareness can now allow you to make a number of short- and long-term suggestions. Your advice may improve communication between HW and his providers. Overall, this may improve HW’s quality of life and reduce his risk for hospital readmissions.

One cause for concern is the presence of both atorvastatin and Lipitor in HW’s brown bag. The session is an opportunity to educate patients like HW on generic versus brand drugs to avoid duplication. What are some other general suggestions you have that come up after reviewing HW’s brown bag medications? What laboratory data might have helped you with the review?

HW is willing to have you act as a community liaison between him and his providers. The next step is to follow up with his providers. Make them aware of your brown bag session discoveries and the suggestions you have regarding HW’s plan of care.

Time will be your most challenging piece and you will need to find a way to incorporate these clinical opportunities into work flow. Loyalty and patient satisfaction are priceless and worth the energy to help HW.

UPDATE:

In this month’s Brown Bag Review, we tried to help patient HW by offering a brown bag session.

HW is definitely someone who needs more counseling and follow-up care in the community pharmacy. Considering the time restrictions of a brown bag session, how can you help ensure HW doesn't fall off the track you have now helped him get on towards better health?

Here are a few ideas:

1.)

Remind HW to visit your pharmacy during non-peak hours or when you have overlap coverage. This will allow you to give greater attention to detail and HW more attention.

2.)

Remind HW to always carry a current medication list in his wallet. This way when a health care provider in any setting asks him what medications he is on, everyone will be on the same page.

3.)

Encourage HW to fill all of his medications at one pharmacy so they can help act as his “hub” of care. HW has a number of disease states and if he is interested, offer to provide follow-up education and evaluate his understanding during an extended counseling session.

4.)

You notice some discrepancies during your brown bag session. Follow up and let the appropriate providers know that:

a.

HW has been taking both generic and brand name atorvastatin (Lipitor). You may suggest his renal function and cholesterol levels be re-evaluated after discovering this error.

b.

HW tells you his Niaspan co-pay is too high and started taking dietary supplement niacin without telling anyone. He heard from a media source it “was the same thing.” Notify him of available co-pay assistance and that the two medications are not equals. Suggest a lipid panel be re-evaluated

c.

You discover HW is not taking his abiraterone acetate with prednisone. Suggest HW go in for his routine blood work and to take his prednisone along with the abiraterone acetate. Offer him any advice on supportive care related to his diagnosis. This can include advice on nutrition, nausea/vomiting, drowsiness, anxiety, etc.

d.

HW tells you he forgot about his blood pressure medication. You take 3/3 blood pressure readings and his blood pressure is well above the recommended range.

Dr. Drury works as a clinical pharmacy specialist in Chicago, Illinois, and Milwaukee, Wisconsin. She earned her doctor of pharmacy from Midwestern University College of Pharmacy in 2007. In addition to her current work, she is a blogger for PharmacyTimes.com and a speaker for Abbott Pharmaceuticals.