Précis
Accurate medication reconciliations are critical for ensuring safe patient outcomes, and a correct medication list can help prevent drug-drug interactions, contraindications, and duplicate therapies. Pharmacy-assisted medication reconciliation has demonstrated benefit in the inpatient setting, but evidence is lacking in the primary care setting.
Abstract
Objectives
This study evaluated the effectiveness of pharmacist-provided education and competency skill checks on medication reconciliation accuracy in a federally qualified health center (FQHC).
Setting
FQHC with 6 primary care practices.
Participants
Patients who were 18 years or older were enrolled for care at the FQHC, and had at least 9 active medications were included.
Interventions
During phase 1, baseline data were collected on medication reconciliation accuracy. Patient interviews and prescription fill history were compared with the medication history obtained in the clinic. Pharmacy-guided education and staff competencies were incorporated across the organization after phase 1. Phase 2 utilized the same process of data collection as phase 1. Medication reconciliation accuracy between phases 1 and 2 was analyzed.
Results
In the analysis, 120 patients were included (61 in phase 1 and 59 in phase 2). The number of medication discrepancies improved significantly following pharmacy-led interventions (4.61 vs 2.4 per patient; P < .05). The number of patients with a completely accurate reconciliation improved from 9.8% to 20.1% between phases. The discriminant analysis showed no demographic factors contributed to the observed medication discrepancies.
Conclusion
Pharmacist-led education and competency-based interventions reduced the incidence of discrepancies in medication reconciliation in a primary care setting. Additional interventions are warranted to further improve medication reconciliation accuracy.
Introduction
Annually in the United States, the FDA receives over 100,000 reports of suspected medication errors, with 7000 attributable deaths estimated.1,2 The population of older adults in the US is growing, with anticipation that by 2034 there will be over 77 million people 65 years or older.3,4 As the US population ages, the medication burden may rise, leading to greater potential for medication errors. Roosal et al reported the occurrence of medication errors increased by 30% in patients taking 5 or more medications.5 Medication reconciliation is an imperative step in the intake process that should be prioritized in all settings.
Evidence suggests that despite completion of medication reconciliations, errors still occur. A meta-analysis from Tam et al found that at least 1 medication error was present in 83% of physician-obtained medication histories, with 59% of the errors having potential to cause harm.6 The Joint Commission (TJC) defines duties to be completed during medication reconciliations as comparing “medications a patient should be (and is actually) using [with] the new medications ordered for the patient and resolving any discrepancies.”7
In an effort to improve patient safety, the World Health Organization (WHO) and TJC have established best practice guidelines for medication reconciliations, recommending an interdisciplinary team.8,9 The WHO and the American Society of Health-System Pharmacists (ASHP) recognize that pharmacists are ideal candidates for medication reconciliation.10 Findings from many studies have shown the benefit of pharmacy-led or pharmacist-incorporated medication reconciliation during hospitalization or transitions of care; however, there are fewer studies in the outpatient setting.11-14
Results from one study completed by Varkey et al in the outpatient setting found that by employing a number of measures, the accuracy of medication lists was significantly improved.15 These interventions included phone calls to patients prior to their appointments to bring in medication lists and/or bottles, follow-up phone calls after the patient appointment to confirm medications again, and frequent personnel audits and feedback. Although the investigators gathered information on nonprescription medications, they were excluded from the results, limiting the generalizability of the study. In a second study, Nassaralla et al employed a similar approach in asking patients to bring in medication bottles for the appointment that included a medication reconciliation.16
In this study, the authors assessed the impact of pharmacist-led education and training on the accuracy of medication reconciliations in a federally qualified health center (FQHC) using both patient-supplied information and objective pharmacy refill histories.
Methods
The objective of this study was to evaluate the accuracy of medication reconciliations following pharmacy-led education and staff competency intervention in a FQHC. ASHP details an appropriate medication reconciliation to consist of 3 parts: verification, clarification, and reconciliation.17 In the FQHC setting, the medication reconciliation parts are split among care team members. The verification and reconciliation of medications start with triage by the medical assistant (MA). During this time, the MA inquires about medications (ie, names, doses, frequencies) against the patient’s active medication list. Any changes in medications are updated in the active medication list in the progress note. During the consultation, the prescribers (ie, MD, DO, PharmD, PA-C, FNP-C) complete the clarification step, which accounts for appropriateness. Additionally, prescribers complete verification and reconciliation as necessary if the MA was unable to complete them. The medication list is marked as reconciled, and the progress note is locked.
The primary end point of this study was the mean number of medication discrepancies per patient between phase 1 and phase 2. A medication reconciliation discrepancy was defined as an active medication missing, nonactive medication included, incorrect dose, or incorrect frequency.
Patients 18 years or older with at least 9 active medications were included in the study. Nine medications were selected as the high end of polypharmacy (ie, 5 to 9 medications), with 10 or more medications considered extreme polypharmacy. Prior to intervention, baseline data on the accuracy of medication reconciliations were collected by contacting the patient’s pharmacy for 90-day refill history following an in-office consultation that included a completed medication reconciliation.
Following phase 1, data were compiled and presented by a clinical pharmacist practitioner to the entire organization, including administrators and clinical staff. Medication safety, with an emphasis on medication reconciliation, was reviewed separately with prescribing and nonprescribing staff members in a 1-hour educational session. The education provided to the prescribers included the importance of sending stop orders to the dispensing pharmacies, updating dosage changes, and providing clear, written instructions on each individual medication. The education to nonprescribing staff included consequences of inaccurate medication reconciliations, look-alike and soundalike medications, and differences between dosage forms. Staff were encouraged to retrieve refill histories from dispensing pharmacies when patients were unable to supply thorough and accurate information. Additionally, all staff who completed medication reconciliations were required to demonstrate competency of an accurate medication reconciliation on 2 separate occasions in front of a supervisor.
Phase 2 utilized the same process as phase 1 of assessing the accuracy of the medication reconciliation following in-office consultation with a unique set of patients. Medication reconciliation accuracy of phase 2 was compared with phase 1. Participants were not matched between the phases.
Descriptive statistics were utilized to report demographic characteristics, and a 1-sample student’s t test was utilized to determine differences in medication reconciliation discrepancies between the 2 phases. Discriminant analysis with χ2 estimation was utilized to identify factors that might have influenced the outcome.
Given the retrospective nature of the study, informed consent and patient notification were not performed. However, practices within the organization have changed subsequent to the findings of this study, directly affecting the patient experience in the practices.
The study received exempt approval from the affiliated university’s research review board. Informed consent was not required.
Results
A total of 120 patients met inclusion criteria and were included (baseline characteristics in Table). The mean number of medication discrepancies improved significantly from phase 1 to phase 2 (4.61 [SD, 3.8] to 2.3 [SD, 2.0]; P < .0001). The number of patients with at least 1 medication discrepancy decreased from 87% to 73% between phases. The most common types of medication discrepancies included an active medication missing or a nonactive medication listed for both phases (Figure). Discriminant analysis with a χ2 test showed that none of the collected demographic factors (ie, number of pharmacies, number of prescribers, number of diagnoses, patient age) contributed to the observed discrepancies (phase 1, P = .0660; phase 2, P = .0675).
Discussion
Implementation of pharmacist-led education and competency checks significantly improved the accuracy of medication reconciliation in this primary care setting. Although small in scale, the study findings demonstrated at baseline that most patients had an inaccurate medication list. The 2 previously referenced outpatient medication reconciliation studies lacked obtainment of objective medication records.15,16 In this study, however, not only were patients asked about their active medications during the interview, but objective pharmacy refill histories were obtained and utilized. Additionally, OTC and herbal medications have not consistently been included in former studies. Recognizing the adverse reactions and drug-drug interaction potential, it is imperative to capture both prescription and nonprescription medication histories in a thorough medication reconciliation, as was done in this study.
Although there was a significant improvement in the rate of medication reconciliation discrepancies, any discrepancies at all may lead to patient harm. There are many possible contributors for the inaccurate medication reconciliations. In a mixed methods evaluation conducted by Gionfriddo et al across 15 primary care clinics, lack of standardized workflow, variable staff knowledge, and sentiment of importance were noted to be the biggest barriers of completing medication reconciliations.18 Through observation of 170 staff-patient encounters, the authors identified questions regarding OTC medications, and new medications were rarely included (36% and 17%, respectively). Further interviews with patients in the practices revealed the majority felt the provider’s knowledge of their medications to be important or very important, yet 63% of patients never brought medications with them to appointments.
Other supported approaches to improve medication reconciliation accuracy include incorporation of probing open-ended questions (ie, What medication do you take if you have a headache? to capture OTC use), inclusion of 2 sources to gather data (ie, patient interview and refill history), review of prescription drug monitoring databases, and inclusion of specialist notes. This approach is recommended to be utilized regardless of visit type (ie, telehealth vs in person).19,20
Additionally, given that there is a higher rate of discrepancies between transitions of care, timely follow-up is paramount. In a study by Liu et al, nearly 300 older patients were contacted via phone by a pharmacy team member following discharge from the inpatient hospital, emergency department (ED), or observation unit to reconcile medications.14 Two-thirds of the patients had at least 1 medication discrepancy. Patients who did not receive a phone call about medication reconciliation were significantly more likely to have a repeat hospital, ED, or observation unit admission within 30 days post discharge compared with the patients who had received the phone call on medication reconciliation. The authors concluded that telephonic follow-up post discharge has the potential to decrease readmissions.
About the Authors
Aidan Walser, PharmD, is a PGY-1 ambulatory care resident at Billings Clinic in Billings, Montana.
Jessi Layne Edwards, PharmD, is a PGY-1 resident at Novant Health Rowan Medical Center in Salisbury, North Carolina.
Laurie Pennell, PharmD, is a PGY-2 ambulatory care pharmacy resident at Atrium Health in Charlotte, North Carolina.
Antoine Al-Achi, PhD, MPharm, MS, BS, CT (ASCP), is a professor of pharmaceutics and biomedical sciences at Campbell University College of Pharmacy & Health Sciences in Buies Creek, North Carolina.
Shawn Riser Taylor, PharmD, CPP, CDCES, is a professor and chair in the Department of Social Sciences and Outpatient Practice at the Wingate University School of Pharmacy in Hendersonville, North Carolina, and a clinical pharmacist at Appalachian Mountain Health in Asheville, North Carolina.
The primary limitation of this study was the small sample size. Second, only patients with at least 9 active medications were included, making it difficult to extrapolate to patients without such a high medication burden. Finally, a single educational event is not likely to yield sustainable improvement. It is recommended that educational efforts be continuous and repetitive.
Obtaining an accurate list of medications is paramount for preventing adverse drug events and medication errors. Given the increased likelihood of medication errors in patients who take multiple medications, paired with the prevalence of polypharmacy in older adults, the potential for medication errors may increase. Despite significant improvement in the rate of medication discrepancies, further improvement is warranted. Currently, in the FQHC, education regarding medication reconciliation is provided at new employee orientation as well as annually to all employees. Additionally, 3 competency checks are completed before any member of staff is allowed to complete medication reconciliations alone. When discrepancies are noted with a particular staff member, they receive referral to their supervisor for performance improvement plans. Transitions of care management are in place to ensure timely consultation with patients following discharge from inpatient hospitalizations. Additional programming to consult with patients following interactions with outside health care facilities (eg, ED, specialty clinics) for medication reconciliation is a priority in the future.
Conclusion
Pharmacist-led education and competency-based interventions reduced the incidence of discrepancies in medication reconciliation in a primary care setting.
References
Working to reduce medication errors. FDA. Updated August 23, 2019. Accessed June 22, 2023. https://www.fda.gov/drugs/information-consumers-and-patients-drugs/working-reduce-medication-errors
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Older people projected to outnumber children for first time in U.S. history. US Census Bureau. March 13, 2018. Accessed June 22, 2023. https://www.census.gov/newsroom/press-releases/2018/cb18-41-population-projections.html#:~:text=%E2%80%9CBy%202034%20(previously%202035)
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The authors have no disclosures.
