Medication reconciliation process has collaboration
Key is use of electronic reports
The key to any intervention to improve medication safety is to achieve the best safety outcomes while using staff time and hospital resources efficiently.
Wesley Medical Center in Wichita, KS, sought to accomplish both of these goals by studying a medication reconciliation process that had nurses and pharmacists collaborate when patients most needed extra attention.
The idea was to have nurses continue to conduct medication histories when patients were admitted to the hospital, but in cases where the patients were taking multiple drugs for multiple conditions, a pharmacist would assist, says Joan S. Kramer, PharmD, BCPS, a clinical research and hospital medicine specialist at Wesley Medical Center.
Kramer and co-investigators designed an intervention, using an electronic process that resulted in the medication reconciliation capturing more patient allergies, more prescriptions, and more nonprescription medications.1
"We had multiple roundtable discussions with people who became co-authors of our study about what we could study that would benefit patient care the most at the hospital," Kramer says. "We had think-tank meetings to come up with the idea."
A data architect helped the investigators design a computerized report, and after several attempts, the electronic system was developed, Kramer says.
"Our director of pharmacy was instrumental in ensuring we had the resources we needed to accomplish the study and to provide input through crucial meetings when we had trouble with the electronic framework," Kramer says.
As a result of the intervention, the hospital has made some changes to its medication reconciliation process, says Leslie Eidem, BSPharm, RPh, a pharmacy manager.
"There are two primary changes that occurred to our medication reconciliation process since the study," Eidem says. "The first is the recognition that automation and the use of the electronic health record were key to improving the process."
This allowed any provider to retrieve data electronically, and it created automated and standardized reports, Eidem adds.
This electronic record process also expedited the medication history for re-admissions, Eidem says.
Also, the process included development of a side-by-side comparison of reconciliation medications by drug class, she says.
"This allows for recognition of duplication and therapeutic interchanges and the automation of patient education materials at discharge," Eidem says.
"The second change was the incorporation of the review of the home medications at each stage of reconciliation, including admission, transfer, and discharge," she adds.
The intervention worked in this way:
1. Nurses had 10 questions embedded in their admission report for new patients. For purposes of the study, the 10 questions were asked both pre-implementation and post-implementation of the medication reconciliation process being studied.
- Do you take seven or more medications, including prescription, nonprescription, and herbal products?
- Do you have asthma?
- Do you have chronic obstructive pulmonary disease?
- Do you have diabetes?
- Do you have any cardiac condition (i.e., myocardial infarction, congestive heart failure, arrhythmia, hypertension)?
- Were you admitted with an adverse drug reaction?
- Do you need to be vaccinated against pneumococcal disease (never received Pneumovax immunization or received it over five years ago)?
- Do you need to be vaccinated against influenza (not yet vaccinated this year)?
- Do you have more than three medication allergies?
- Do you have medications that need to be identified?1
The last question was included partly because patients sometimes think they know which drugs they're taking, but when they are admitted they'll seem unsure, Kramer notes.
"So we need to figure out what they're taking," she says. "Based on those trigger questions developed in the previous pilot study, one 'yes' answer could trigger the pharmacist intervention."
2. The answers nurses key into an electronic form generate a report to the pharmacy printer.
The electronic format makes the reports automatic, and a "yes" answer to any of the questions will result in a report that alerts the pharmacy department that a medication history is needed, Kramer explains.
"The pharmacy looks at the report and verifies that the patient meets eligibility for our study, and then the pharmacist talks to the patient and obtains informed consent," Kramer says.
3. Pharmacists meet with patients.
Patients who agreed to participate met with a pharmacist who obtained their medication history and compiled that information into the computer system, she says.
"We developed a set of interview questions that should be done when you obtain a medication history, and the pharmacists all felt very comfortable with it," Kramer says.
For instance, when a pharmacist meets with a patient, they ask them about their reactions to taking a medication rather than asking specifically if they had a rash, she explains.
"You ask open-ended questions because you want the patient to tell you what's happened, and you don't want to give them any ideas," Kramer says. "We trained everyone on how to ask these questions."
The average amount of time it took pharmacists to complete the medication history was 12.9 minutes, and the average amount of time it took them to clarify the medications was 5.84 minutes.1
Once the interview was completed, the pharmacist would generate a report containing the medication list for prescribers to reconcile on admission, Kramer says.
"Then nurses and pharmacists worked with prescribers to complete the medication reconciliation document," she says.
Either the nurse or the pharmacist would call the physician to go through the list of the medications, Kramer says.
"Sometimes prescribers would say, 'I'm going to see this new admit anyway, so just leave that list for me in the chart for when I see the patient,'" Kramer says.
Besides showing that an electronic and collaborative medication reconciliation process could work, the study also demonstrated significant improvement in patient satisfaction, Kramer notes.
Patients were asked both pre- and post-implementation questions about their experience during the medication reconciliation process:
- "When I was discharged from the hospital, I was given clear instructions about which medications I was taking at home."
- "I was given clear directions about how much and how often I am supposed to take my medication."
- "I was given clear directions about how and when to take my medicine."
- "I was given clear information about possible side effects of my medicine."
- "Overall, I feel like I understand my medicine."1
On all questions the patients reported a significantly higher rate of satisfaction in the post-implementation phase, Kramer says.
The main drawback to fully implementing the intervention is a staffing issue, Kramer says.
"If we were to continue this process for our hospital we'd need two additional pharmacists solely dedicated to medication reconciliation, and we'd need one to be put in the emergency department and one in the rest of the hospital," Kramer says.
But it could be argued that the benefits would be worth the additional expense, she notes.
Besides the enhanced patient satisfaction, there would be greater efficiency, and presumably improved patient safety — although that wasn't specifically measured, with a more complete medication list being scanned to the pharmacy department, Kramer says.
"In the post-implementation phase, when the pharmacist obtained the medication history, the medication history was printed out, and it was a clean list," Kramer says. "We knew all those dosages existed, the drug names were spelled correctly, and allergies clarified and verified."
There was no need for clarification because the work required to clean up the data had already been done, she adds.
"This saved at least 10 to 15 minutes of phone calls back to nurses and multiple pharmacies to verify the medication history on admission for each patient," Kramer says.
Reference
- Kramer JS, Hopkins PJ, Rosendale JC, et al. Collaborative pharmacist and nurse before/after study to evaluate patient safety using electronically standardized admission and discharge medication reconciliation in a tertiary care hospital. Abstract presented at 2006 Midyear Clinical Meeting by the American Society of Health-System Pharmacists; Anaheim, CA; Dec. 3-7, 2006.
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