Multidisciplinary team leads reconciliation efforts
Proactive approach addresses challenges
At El Camino Hospital in Mountain View, CA, medication reconciliation is an essential part of the admissions process that needs to continue at discharge or transfer of care, reports Michael Fitzgerald, MS, RN, CS, clinical nurse specialist, who chairs the hospital's medication reconciliation committee.
The medication reconciliation committee is a multidisciplinary group that includes physicians, nurses, pharmacists, a representative from quality management and clinical effectiveness, the emergency department, clinical nurse specialists, and the education staff.
The hospital already was addressing medication reconciliation through its clinical documentation system when the Joint Commission issued its requirement, Fitzgerald says.
Medication reconciliation is an ongoing process that begins at admission, he says.
In the emergency department, the triage nurse, the physician, and the primary nurse are responsible for collecting information on the medications a patient is taking. The ultimate responsibility for medication reconciliation lies with the physician.
Patients who come into the hospital with a complete list of the medications they are taking are definitely the minority, he says.
"We can't always trust the bottles they bring in. Some patients bring in prescription bottles that contain pills that are not the medication listed on the bottle," he says.
Figuring out what the patient is taking can be like solving a puzzle, Fitzgerald says.
The staff gather what information they can from the patient and family, sometimes sending family members home to gather all the medication bottles and bring them back.
The emergency department staff have the option of calling the provider or the pharmacy for information.
"There's not an easy way for us to get information from their databases because of HIPAA and other security measures. It's also hard to get an answer from a doctor or pharmacist at 1 a.m.," Fitzgerald says.
The staff ask about alternative remedies, herbal medicines, vitamins and other supplements, and over-the-counter medications the patients may be taking.
"When we set up our medication reconciliation process, we identified potential failures before they became a problem. We broadened what we ask patients and don't limit it just to prescribed medications," he says.
The staff approach patients in a friendly, nonconfrontational manner when they talk about medications and use the term "medication adherence" rather than "compliance" because it sounds less negative.
"We do not make a judgment about what the patient is taking or about medication compliance. We tell them that we can help them better if we know whatever medications, drugs, supplements, or alcohol they are using," he says.
Very few people are compliant about taking their medication as prescribed, and many don't know what they are taking, Fitzgerald says.
"A lot of time, patients come into the emergency department and tell the nurse that they are taking a little blue pill or that they used to take one medicine and don't know the name of what they are taking now," he says.
The hospital's electronic medical record is set up so that physicians can view all medications a patient is taking and can compare side-by-side the medications ordered and what patients are taking prior to coming to the hospital.
If the patient wasn't sure of the name of the medication or just had a description, the staff can enter "little blue pill" in the record.
As a patient moves between floors of the hospital, a side-by-side review of medications is required.
"The challenge is keeping the surgeons involved in the process. For instance, if a patient is admitted to the hospital for a procedure, the surgeon may not be comfortable prescribing the patient's insulin. It takes a lot of advocacy on the part of the nurses to make sure the list of home medications is accurate and that it is addressed while the patient is in the hospital," he says.
Some patients bring their own medications and want to direct their own care, partly because of the expense of medications issued by the hospital and partly because they believe a certain combination of medications, including herbal medicines, has worked for them.
"We address these issues through the pharmacy and therapeutics committee, and if a medication isn't in our formulary, we do what we can to get it added," he says.
The hospital pharmacist reviews any medications ordered to make sure they do not have a negative interaction with other medications.
"We have educated the staff about the importance of getting the medication that patients bring with them to the pharmacy and making sure what is on the bottle is what is inside and that there are no contraindications with what else has been prescribed," he says.
Following admission, the hospital's primary care nurses are involved in the medication reconciliation process at the bedside.
"Their responsibility is to make sure that continuity of care is addressed when the patient is discharged. If there are issues with medication, they are involved," he says.
"The primary care physician needs to know what medications have been prescribed, and the patient needs to have clear instructions. The goal is to educate them about the medications they are taking and give them a list to take to the next provider of care," he says.
The hospital plans to develop a fax server that works in conjunction with the electronic medical record that will allow staff to fax the information to the next provider, rather than relying on the patient to be the link.
At present, the discharge nurse and the physician sit down and talk to patients about the importance of following the discharge instructions and letting their physician know what medications they are taking.
A newly implemented computerized discharge form, which includes discharge instructions and medications, is to be printed, and then signed by the patient.
The hospital has a facility transfer form that includes very specific information about medications. It is filled out by the care coordinator and reviewed by the physician.
The team looks at the receiving facility's formulary to make sure the medications will reconcile. For instance, a patient might be on one medication when hospitalized but on another one for outpatient, under MediCal's formulary.
The hospital's computerized documentation system created a challenge for the hospital's medication reconciliation efforts because it did not have the tracking built in, Fitzgerald says.
"Electronic systems don't necessarily have as much flexibility as a paper system. It was a difficult hurdle initially, but the electronic system has great potential to make the process easier," he says.
At El Camino Hospital in Mountain View, CA, medication reconciliation is an essential part of the admissions process that needs to continue at discharge or transfer of care, reports Michael Fitzgerald, MS, RN, CS, clinical nurse specialist, who chairs the hospital's medication reconciliation committee.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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