Reconciling Medications in Mental Health Assessments Protects Patients

Medication errors result in 1.5 million adverse drug events annually, costing the health care system over $3.5 billion.¹ These can include administration and dosing errors, allergic adverse events, and drug-drug interactions.¹ Approximately 40% of medication errors occur during the transitions of care process because of ineffective or nonexistent medication reconciliation (MR).¹

MR compares the medications a patient is taking with newly ordered medications.² MR is enacted as a safeguard to prevent potentially life-threatening errors. Errors are often the result of poor communication among health care providers, time constraints, and unshared health information among multiple care sites. The Joint Commission has recognized the importance of MR and has established its presence and effective conduct as an accreditation standard for all hospitals.² The Joint Commission has outlined 5 steps to describe the MR process: obtain and update medication information; define which information needs to be collected from secondary sources; compare the new information with previous records; provide the patient or caregiver written information about the medications the patient should be taking upon discharge; and explain the importance of managing medications to the patient.² Initially, pharmacists took on the role of MR. However, with several of these steps not requiring clinical expertise, pharmacy technicians have been able to secure a role in the MR process, helping pharmacists and other professionals use their time more effectively.

Implementing MR is not without its challenges. Results of a survey of emergency department providers, including nurses and physicians, show that 77% of them spent 10 minutes or less to complete a MR, and 44% responded that lack of time was the biggest barrier to conducting a comprehensive one.³ Although these are relevant challenges in the delivery of health care, the study results suggest using support staff members, such as technicians, by involving them in the first 3 steps in MR outlined by the Joint Commission. This can maximize money, resources, and time to provide exceptional care to patients and minimize medication errors. A diverse sample of health care professionals shows that with technicians assisting in the medication management process, they had more time to perform direct patient care duties and felt gratification with the supplemental time and increased thoroughness of medication histories.³

MR is especially important in mental health, where patients with chronic disorders are at a higher risk for potential drug-drug interactions.⁴ These patients are likely to be on medications with a higher incidence of interactions with both OTC and prescription medications.⁴ They often have other comorbidities that add to the complexity of their medication regimens.⁴ Medication histories are further complicated in the transitions of care process to a secondary care unit, and any previous medication discrepancies have the potential to remain undetected. This compromises the consistency and quality of communication between patient care destination sites, and patients’ medical records are left with inconsistencies.

An evaluation of medication discrepancies on admission to a secondary inpatient mental health facility shows that 56.2% of admissions had at
least 1 medication discrepancy, with a mean of 1.5 medications per patient needing correction.⁵ In addition to investigating the rate of medication inconsistencies upon admission, this facility implemented specially trained technicians to perform the reconciliations.⁵ The technicians reconciled each patient admission over the course of 3 months, gathering information from the patient’s community pharmacy, patient interviews, and prior care notes. Any discordance identified by the technician was discussed with the clinical team. Over a period of 3 months, 377 patients participated in the MR process, with 212 having at least 1 discrepancy identified. The average time for the technician to conduct the patient interview process was 16 minutes. Technicians identified variabilities involving 569 medications, with the majority involving antidepressants (19.5%) and antipsychotics (13%).⁵ Other medications not specifically related to mental health contained discrepancies, such as cardiovascular (11.1%), endocrine (9.3%), and respiratory (9.3%).⁴ The most common discrepancy was omission (77.2%)⁵ (ie, a medication was not prescribed that should have been). Without the MR process, these errors would not have been identified and patient safety may have been compromised.

Increased medication discrepancies in the mental health setting were found to be more common with increasing age and number of medications on admission.⁵ The prevalence of cognitive impairment and dementia with increased age presents a barrier to MR in this population. It is therefore beneficial to have specially trained health care providers, such as technicians who know alternative avenues, to retrieve and reconcile medication information, including consulting with secondary sources, such as caregivers and community pharmacy records.

Another pilot study investigated the outcomes of a pharmacy team implementing MR for patients with severe mental illness in a primary care setting. Technicians were able to identify 23 patients on clozapine, which is frequently prescribed in secondary care settings. In 5 cases (22%), the clozapine was found to be omitted and therefore corrected.⁶ Depot antipsychotics were prescribed and administered to 37 patients while in a secondary care site, and tec nicians were able to determine that in 18 of these cases, the depot medication was not documented in patients’ primary care records, which were updated as needed.⁶ Technicians were also able to assist with obtaining allergy information, and the most up-to-date information was updated in the elec- tronic medical record.⁶

Technicians have proven their ability to contribute efficiently to the MR process and helped to prevent a wide range of medication errors, some of which were potentially fatal to patients. In doing so, they allow time for other health care professionals to cater to other necessary functions. Patients with a mental illness are often on multiple concomitant medications, having a complex regimen, which puts them at high risk of experiencing a medication error, especially when being transitioned across varied care settings. A lack of communication often occurs once patients are moved from one site to another, which contributes to inaccurate medication records. This leads to increased risk of error because of decisions that are not well informed.

Technicians can be trained within the scope of mental health medications to efficiently bridge the gaps between transitions of care. Precise and reliable MR allows providers to find resolutions for patients that promote safety, which is a vital feature of providing high-quality patient care.

Ashley Woodyard and Pareeksha Ramdeo are PharmD candidates at Touro University California’s College of Pharmacy in Vallejo.

Kristen Herzik, PharmD, BCPS, is an assistant professor of clinical sciences at Touro University California’s College of Pharmacy.

Shane P. Desselle, PhD, RPh, FAPhA, is a professor of social, behavioral pharmacy, and administrative sciences at Touro University California’s College of Pharmacy.

References

1. Champion HM, Loosen JA, Kennelty KA. Pharmacy students and pharmacy technicians in medication reconciliation: a review of the current literature. J Pharm Pract.2019;32(2):207-218. doi:10.1177/0897190017738916

2. National patient safety goals effective July 2020 for the hospital program. The Joint Commission. March 26, 2020. Accessed January 19, 2022. https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2020/npsg_chapter_hap_jul2020.pdf

3. Patel S, Mathis AS, Costello J, Ghin HL, Fahim G. Satisfaction with medication reconciliation completed by pharmacy techniciansin an emergency department. PT. 2018;43(7):423-428.

4. English BA, Dortch M, Ereshefsky L, Jhee S. Clinically significant psychotropic drug-drug interactions in the primary care setting. Curr Psychiatry Rep. 2012;14(4):376-390. doi:10.1007/s11920-012-0284-9

5.Brownlie K, Schneider C, Culliford R, et al. Medication reconciliation by a pharmacy technician in a mental health assessment unit. Int J Clin Pharm. 2014;36(2):303-309. doi:10.1007/s11096-013-9875-8

6.Raynsford J, Dada C, Stansfield D, Cullen T. Impact of a specialist mental health pharmacy team on medicines optimisation in primary care for patients on a severe mental illness register: a pilot study. Eur J Hosp Pharm. 2020;27(1):31-35. doi:10.1136/ejhpharm-2018-001514