Joint Commission, pharmacists discuss successful reconciliation practices
Joint Commission makes new recommendations
Every pharmacy has a medication reconciliation plan and process, but how many of these are successful? The Joint Commission on Accreditation of Health Care Organizations (JCAHO) of Oakbrook Terrace, IL has made medication reconciliation one of its priorities in 2008, partly because this is such a difficult process for hospitals.
"A national patient safety goal and topic is medication reconciliation," says Peter Angood, MD, vice president and chief patient safety officer of JCAHO. "It has been one topic of importance for the field for a couple of years now."
While no one challenges the notion that medication reconciliation should be a priority for hospitals, the actual process of medication reconciliation is very complicated and difficult to do effectively, Angood notes.
"So we held a summit in September, 2007, with 60 organizations who provided feedback and input on the complexity of medication reconciliation," Angood says. "We've since revised our medication reconciliation patient safety goals and are in the final phases of the approval process."
The revised goals were expected to be released in June, 2008, shortly after the deadline for this issue of Drug Formulary Review.
Research has shown that most medication errors occur during transitions in care, but errors can be reduced when pharmacists obtain medical histories, says Joan S. Kramer, PharmD, BCPS, clinical research and hospital medicine specialist at the Wesley Medical Center in Wichita, KS.
"Patients sometimes don't know what drugs they're taking, and it's difficult to find the information," Kramer says. "You have to make multiple phone calls."
Also, patients receive medication from multiple pharmacies, and their doctors often are not aware of all of the prescriptions they have, and this can lead to errors.
When pharmacists conduct medication histories, they know precisely which questions to ask to help the patient recall the drug he or she is taking, Kramer says.
If the pharmacist is carrying a portable laptop then he or she can pull up a picture of a drug on the computer and show the patient to verify that this was the medication the patient was taking, she adds.
While medication reconciliation seems like it should be an easy process to accomplish, the reality is the opposite, says Leslie Eidem, BSPharm, RPh, pharmacy manager at Wesley Medical Center.
A major obstacle is that there are many health care providers involved with a patient's care both prior to admission and during hospitalization, Eidem says.
"Patients have multiple physicians and use multiple sources for their medications," Eidem says. "The medication history can be asked of the patient several times by different providers and documented in different parts of the medication chart."
So if a reconciliation process isn't defined and formalized within the health record through manual or electronic means, then there is a significant disconnect in the reconciliation and communication at admission, transfer, post-op, and discharge, Eidem adds.
Since it's not practical for many hospitals to involve pharmacists in every medication history, pharmacist researchers and institutions have created and studied some alternative models.
For example, the Wesley Medical Center designed a study intervention that involved a collaboration between pharmacists and nurses, Kramer says.
"We wanted a mechanism to identify the patients that had a high medication utilization and would benefit from a pharmacist intervention versus a patient hospitalized with one medication and where a nurse could take that history," Kramer explains.
In other models, pharmacy students are used.
For example, one study shows that pharmacy students trained by a clinical pharmacist could conduct admission medication histories, improving the process.
"We were looking at what's in the literature to see how medication reconciliation was being done, and I wanted to see if the pharmacy department could enhance the process or provide more accurate histories," says Rosalyn S. Padiyara, PharmD, CDE, an assistant professor in the department of pharmacy practice at Midwestern University Chicago College of Pharmacy in Downers Grove, IL.
Where electronic medication data are available, these can contribute greatly to medication reconciliation accuracy, one expert notes.
St. Rita's Medical Center in Lima, OH, receives electronic medication data on about 60% of patients, says Brian D. Latham, PharmD, a pharmacy operations manager.
The electronic data are collected from prescription purchases made at retail pharmacies, using third-party payers, but excludes pharmacy purchases made with cash, Latham notes.
"If someone goes to a CVS, Wal-Mart, or somewhere else to get drugs, all of those data are picked up on the electronic report," Latham says. "That gives us baseline data for patients who are unconscious or who don't have all the information they need about drugs."
However institutions handle medication reconciliation, Angood says, there are four areas of focus to consider:
1. Obtain an accurate list of the patient's current medications.
"This information is obtained whenever a patient is admitted to the organization," Angood says. "It includes any type of prescribed medications, nutritional support, and includes supplements and alternative medicine."
This list should be generated upon admission and as changes are made to it, he adds.
"These are reconciled as the patient goes through the course of stay in the organization, and those changes are documented," Angood says.
This often is the most challenging part of medication reconciliation for health care organizations, he notes.
"You'll have a Mrs. Jones who shows up with a brown bag of bottles, and she doesn't know what they are, or she left her medications at home," Angood says.
Electronic information typically is limited.
"Electronic health records have only penetrated 12-14% of organizations so far," Angood says. "Also, the electronic interaction between external providers or facilities is in a very early stage."
So a weak link in medication reconciliation is the link to pharmacy providers outside the health care organization, and even the largest chain providers may not have the most sophisticated information systems, Angood explains.
2. Whenever patients are discharged or transferred, the updated medication reconciliation list is sent to all providers involved.
"The up-to-date reconciled list is sent to the receiving organization, as well as to the patient's primary care provider or original prescribing physician," Angood says. "So there's continuity to the prescribing list."
This second area has been part of the original medication reconciliation goal, but it turned out to be far more complicated for organizations than anticipated, he notes.
"The issue is they didn't know who the next provider was, and the patient didn't know who the next provider was," Angood says. "We've continued to push that this is part of medication management."
Too often, people go into a facility, get their medications adjusted and are discharged, but nobody remembers their medications, he says.
While the pharmacy can help with this, it's also important that the primary care physician or the original referring physicians or the patient's next known provider receive a copy of the reconciled list, Angood says.
"Patients are not reliable in terms of providing their medication list, so we need organizations to improve their communication," he says. "It's a burden on organizations to make an effort to find out who the providers are, but it's best to send the information to the patient's doctor."
Occasionally, this will not work out.
For example, a patient might be a resident of one state and is seen in the emergency room of another state. So in some settings it might be acceptable to give the medication reconciliation list to the patient, Angood says.
3. Give the patient an updated list.
"Make sure the patient or patient's family also receive an up-to-date list of all medications," Angood says. "And make sure they receive education on why the list has changed."
4. For some short-term medical settings, do a shortened medication reconciliation process.
"Those types of settings where new medications are not given or that are only temporarily given, you can do a shortened, modified medication reconciliation process," Angood says. "This is when new medications might be ordered for just a short term like one week of an antibiotic."
Such settings might include office-based surgery, outpatient radiology, dialysis, and emergency care.
"These are settings where the patient is in and out and may not receive changes to his meds, but they're being assessed," Angood says. "If you're taking three to five medications and you're going for a radiology procedure and receiving an intravenous contrast, then you want them to assess what medications you're already on.
"If there are significant changes to the patient then the complete medication reconciliation needs to be performed," Angood adds.
Every pharmacy has a medication reconciliation plan and process, but how many of these are successful? The Joint Commission on Accreditation of Health Care Organizations (JCAHO) of Oakbrook Terrace, IL has made medication reconciliation one of its priorities in 2008, partly because this is such a difficult process for hospitals.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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