Medication reconciliation process improves with grant-supported pharmacist
Assure patient gets right medications
Like many hospitals, Piedmont Hospital in Atlanta, made medication reconciliation a top priority four years ago when the Institute for Healthcare Improvement (IHI) campaign focused on how hospitals could save 100,000 lives through several initiatives including medication reconciliation.
"We jumped on it fairly early and have been trying to accomplish medication reconciliation ever since," says Sarah Mullis, RPh, pharmacy director.
"The more we work with it, the more I'm convinced of its importance, and the more I'm convinced that it's not easy to do," Mullis adds.
The Joint Commission of Oakbrook Terrace, IL, also has focused on medication reconciliation, and this has given pharmacy directors another good reason why their organizations should put resources into this area.
"They realize that across the country everyone still is struggling to get medication reconciliation done and to get it done correctly," Mullis says.
Piedmont Hospital's medication reconciliation documentation is electronic as are the physician orders and nursing documentation, Mullis says.
"We had one of our pharmacy residents do a project on medication reconciliation at the beginning, and that helped us get started," she adds.
Originally, the hospital's medication reconciliation process was in a paper format, says Kim Butler, PharmD, clinical coordinator in the pharmacy department at Piedmont Hospital.
"We felt it should be done by a pharmacist, but there were resource issues, so we partnered with nursing since they had been doing medication histories," Butler explains.
The nurses continued to take the initial medication history, but if they had any questions about which medication or dosage a patient was taking they could request a pharmacy consult, she adds.
"So the pharmacist would come and talk with the patient and clarify any medications they weren't sure about," Butler says.
When the hospital's medication reconciliation process switched to an electronic format, patients' medications were entered and reconciled on the computer, and the medication orders then came electronically to the pharmacy for processing.
The hospital has received a grant to assist with having a dedicated pharmacist to one 20-bed unit, working with nurses and other disciplines in patient care. The pharmacist's role includes medication reconciliation.
The pharmacist can be proactive, anticipating problems and preventing them, partly through a little pharmaceutical detective work, Mullis and Butler say.
The pharmacist knows the right questions to ask patients. For instance, there might be a case of a patient with atrial fibrillation, and the patient's medication list did not list an anticoagulant, Butler says.
So the pharmacist knows to call the patient's drug store and physician's office to dig a little deeper and find out which anticoagulant the patient had been taking, she explains.
"The pharmacist might ask the patient's family to bring in all of the patient's medication bottles the next time they visit, and then he/she can make sure the patient's medications are appropriate," Butler adds.
"If the patient's medical record lists asthma and there's no inhaler listed, the pharmacist will ask the patient, "Are you taking an inhaler,'" Mullis says. "And the patient might say, 'Oh yeah, I forgot to tell you about that.'"
The pharmacist dedicated to the unit works only weekdays and does other clinical work, as well, Mullis notes.
"The grant money is not enough to cover the position entirely, but anything helps," Mullis says.
The problem most hospitals have is that it's difficult to come up with the resources necessary to have a clinical pharmacist conducting medication reconciliations and medication histories, Mullis says.
"Very few, if any, hospitals across the country are having pharmacy totally do this," she says. "Would it be ideal? Yes. Is it practical? No."
Hospitals do the best they can, and this means having clinical pharmacists consult on medication reconciliation when questionable or complicated cases arise.
"Patients omit things and forget to tell you about medications, or their dosages have changed," Mullis says. "They might have quit taking a prescription, but they forget to tell you."
This is why some detective work is necessary, and pharmacists are in the best position to do this, she adds.
For example, at Piedmont Hospital there was a recent case where a patient had a history of epilepsy, but the patient had not listed any seizure medications, Butler says.
"So after talking with the patient, the pharmacist was able to determine that the patient was on an antiepileptic agent, but had forgotten to mention it," she adds.
"In another case, a transplant patient had typed up a list of medications and gave it to us," Butler says. "But the patient had been discharged from another facility, and the medications had changed."
No one had updated the list, so the patient was put on the medications from the old list until the pharmacist spoke with the patient and learned that some had been changed, Butler adds.
"Some anti-rejection doses had been lowered, and others were changed," she says.
Piedmont Hospital had 213 transplants in the last fiscal year with a total of 6,286 inpatient days and 6,979 clinic visits, says Noreen Carew, RN, CNN, MBA, administrative director of transplant services at Piedmont Hospital.
Because of the high volume, there is a clinical pharmacist dedicated to handling transplant patients, Mullis says.
"The medications transplant patient's need are as critical as any because you need to balance the dosages so the patient doesn't reject the transplanted organ," she explains. "Plus most of these drugs can be fairly toxic."
So a pharmacist is assigned to this group of patients, including both inpatient and outpatient, Mullis says.
The inpatients are seen once per week, but their medications are reviewed daily by the pharmacist. And about one-fourth of the outpatients are seen by a pharmacist, Carew says.
Ideally, hospitals like Piedmont would have clinical pharmacists dedicated to all patient care units, Mullis says.
"I'd love to say to nurses, 'You go nurse, and we'll do medication reconciliation,'" Mullis says. "I don't think in my lifetime that would occur."
But what is possible for many hospitals is medication reconciliation on a priority or consulting basis.
So patients who have high risk of medication errors because of their comorbidities or their high number of prescriptions could be reviewed by a clinical pharmacist, Mullis notes.
And if the pharmacist works only weekdays, then the medications of patients who were admitted over the weekend would be reviewed on Monday, she adds.
"Most hospitals have a process of medication reconciliation in which medicines are reconciled within 24 hours," she says.
Like many hospitals, Piedmont Hospital in Atlanta, made medication reconciliation a top priority four years ago when the Institute for Healthcare Improvement (IHI) campaign focused on how hospitals could save 100,000 lives through several initiatives including medication reconciliation.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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