When accreditation surveyors visit ambulatory settings, including ambulatory surgery centers (ASCs), they frequently find problems related to medication reconciliation.
“It’s a relatively high deficiency standard for organizations surveyed for accreditation,” says Naomi Kuznets, PhD, vice president and senior director at the Accreditation Association for Ambulatory Health Care (AAAHC). “Over 10% of certain healthcare settings, including surgery centers, have this deficiency. As studies have shown, when patients go into hospitals, their [listed] medications often are not accurate, and when they leave the hospital, they are not necessarily accurate, either.”
There are an estimated 1 million ED visits each year in the United States attributed to medication errors. Medication reconciliation can reduce problems for patients and prevent some ED visits and hospital admissions.
For example, one medication reconciliation program in which an ambulatory setting pharmacist collaborates with nurses and physicians has positively affected patient care in an Arizona community. After the medication reconciliation program began, readmission rates dropped. They declined from 33% in 2014 to 10% in 2016, according to Lindsay Sampson, PharmD, BCPS, BCGP, clinical pharmacy coordinator at Winslow Indian Health Care Center in Winslow, AZ. This center received AAAHC’s 2017-2018 Bernard A. Kershner Innovations in Quality Improvement Award for its medication reconciliation work.
“We looked at discharge summaries, did medication reconciliation, and gave them a phone call to work their medication issues and errors,” Sampson says. “Sometimes, when people get to the hospital, they don’t list their home medications or are confused and don’t get the dosage correct.”
Within the Winslow program, nurses (called clinical coordinators) are assigned to specific physicians and are the first people to make contact with ambulatory clinics’ patients after a hospital discharge. “They call the patient, put a note in the electronic health record, and if they have any questions about medications, they call providers,” Sampson explains. “If [patients] have a long list or a confusing list of discharge medications, we give them a call as well.”
AAAHC created a new toolkit to educate ambulatory providers about how to avoid preventable adverse drug events. It features the essential elements of medication reconciliation. (Editor’s Note: Learn more about the toolkit by visiting: http://bit.ly/2CKsoBX.) The toolkit advises ASC providers to familiarize themselves with the medications their patients are taking before procedures and to ensure accurate medication information and instructions after surgery. The toolkit also outlines how the medications taken presurgery can affect patients if they are taking that medication in the days leading up to surgery.
For example, surgeons should know whether their patients are taking medications such as beta-blockers, calcium channel blockers, anticoagulants, or antiseizure medications so they can instruct patients about whether they need to stop taking these drugs in preparation for the procedure and when patients can restart the medication after surgery.
“There is a class of drugs — benzodiazepines — that interact poorly with opioids,” Kuznets says. “If a patient is already on one of these drugs and you plan to use an opioid after the surgery, you can have a bad interaction.”
Also, it is problematic when surgery patients have been on opioids prior to a surgery that will result in an additional opioid prescription.
“As a surgery center, you’d need to know what is going on with the patient if you are going to use opioids,” Kuznets advises. “When people have pain and already take opioids, they may take more after surgery if they’re not getting adequate pain control. This could lead to an overdose.”
There also are patients on medication that can cause bleeding. “For instance, with a colonoscopy, where you have a number of biopsies, you don’t want bleeding issues,” Kuznets warns. “If you know the patient is taking an anticoagulant and stops it for the procedure, then, afterward, make sure the patient goes back on that medication after a period.” In its toolkit, AAAHC lists essential elements of medication reconciliation, including:
- making medication reconciliation part of the organization’s safety culture;
- tracking patients’ current and past medications, using a single source document policy;
- verifying and documenting medications before and after each exam;
- comparing any medication collection form against the single source document;
- communicating with the patient, provider, and/or pharmacy to resolve any discrepancies;
- directing patients to verify they agree with the current medication list.
The toolkit does not specify how ASCs and other ambulatory sites can comply with accreditation standards, but it suggests the endpoint that surveyors want to see, Kuznets says. “We [explain] the issues here, and then we give [patients] evidence-based recommendations, including recommendations by the U.S. government.”
ASC administrators can show the toolkit’s poster and charts to physicians when they ask why the surgery center is making medication reconciliation changes.
“The surgery center manager can say, ‘Here’s why we might want to do this. All evidence points to this. We have a nice tool we can use to make sure we do this routinely and don’t leave anything out,'" Kuznets says.
In general, many patients do not take medications as prescribed, Kuznets notes.
“When you do medication reconciliation, you see if they’re taking their medications as prescribed.”
Medication reconciliation also concerns whether patients’ current medications, vitamins, supplements, and over-the-counter drugs will interact with newly prescribed medications. When asked to list their drugs, patients often omit their herbals and vitamins, although these also can produce drug-drug interactions.
Kuznets and Sampson offer a few additional tips on how to improve medication reconciliation:
- Coordinate with surgeon.
“Coordinate with the surgeon or proceduralist to make sure they know what medications the patient is taking and what medication instructions are needed prior to the patient arriving onsite,” Kuznets offers.
The physician should provide this information to the surgery center. ASCs should insist on knowing exactly what the patient is supposed to do prior to the procedure. Staff need to know what they will have to ask the patient at check-in.
“For instance, if the surgeon has instructed a patient to discontinue a certain medication for a certain period of time prior to the procedure, ASC staff need to ask whether the patient followed those instructions,” Kuznets explains.
There are a few questions ASC staff can ask patients at check-in, including:
- “Have you eaten since midnight?”
- “Did you take your medication?” Staff also can ask which medications (even aspirin and herbal supplements) patients have ingested recently and if patients stopped taking those medications 10 days earlier.
- Ensure the patient’s discharge instructions are in writing.
“Instructions absolutely should be in writing because patients and families might not necessarily follow [the oral] post-procedure instructions,” Kuznets notes.
Also, ASCs should make sure written instructions include a date for when the patient could resume presurgery medications.
- Call patients to ask about medications before and after surgery.
Surgery centers often call patients prior to the scheduled procedure to confirm the procedure itself and to answer any last-minute questions. But they also should find out if there are any new issues and whether the patient has discontinued medication as directed, Kuznets says.
After surgery, the ASC could follow up with a call to find out whether the patient is experiencing any complications and also to remind the patient to resume medication. The ASC caller might say, “We see you are supposed to start your aspirin regimen again, but remember to wait a couple more days before starting it. Set up a reminder so you’ll know when to start it.”
When healthcare providers call patients about their medications, they should know about drug-drug interactions and adverse events and explain these to patients, Sampson says.
“A lot of times, patients are told to stop taking a medication, but they’re unclear or, occasionally, convinced they still should be taking it, so I document that in my notes,” Sampson says. “I say that these medications can interfere with each other. Usually, I say to stop taking it until you see your doctor and the doctor can clear this up for you.”
Expect these phone calls to last five to 15 minutes, depending on patients’ medication list and chronic condition, Sampson adds.
- Follow through on medication lists, if needed.
Sometimes, there are no reliable lists of patients’ medications. When this happens, nurses might call the patient’s pharmacy to verify the drugs prescribed, dosages, medication allergies, and how regularly the patient picks up the medication, Sampson says.
“Sometimes, the patients — especially if they’re on a lot of meds — will find it hard to remember everything and their exact doses,” she says. “Or, they might confuse their medications with prior doses, and they might not be lucid.”
- Learn of hospitalized patients and potential medication errors.
Medication problems can lead patients to the ED or result in hospital admission. When this happens after surgery, ASCs should know. Staff will need to communicate well with local hospitals to find out when their patients are hospitalized and to get to the bottom of the problem that led to this outcome.
For ASCs that are on the same electronic medical record system as local hospitals, this might make the task easier.
For example, Sampson logs into electronic medical records to compare patients’ medications at discharge from the hospital with what the health organization put on its list for them.
“If something doesn’t make sense — maybe they’ve changed their blood pressure medication — I go back and look at what it was when they were admitted to the hospital,” Sampson says.
Medication Reconciliation Toolkit
The AAAHC's new medication reconciliation toolkit includes this list of essential elements determined by the National Institute of Standards and Technology:
- Prescribed vs. dispensed medication;
- Prescriber name;
- Dispensing pharmacy;
- Prescription date;
- Dispensed date;
- Administration start and end dates;
- Drug status (active, on hold, history, no longer active);
- Indication/diagnosis;
- Textual drug description (name, strength, unit of measure, dosage form) or coded medication (name, strength, dosage form);
- Quantity prescribed;
- Quantity dispensed;
- Number of days’ supply;
- Whether refills are allowed;
- Administration directions;
- Alerts (allergies or intolerances; drug interactions);
- Fulfillment instructions (substitutions or dispense as written).
Medication reconciliation can reduce problems for patients and prevent some ED visits and hospital admissions. A new toolkit educates ambulatory providers about how to avoid preventable adverse drug events. Providers should familiarize themselves with the medications their patients are taking before procedures, ensure accurate medication information and instructions after surgery, and learn how medications taken presurgery can affect patients if they are taking that medication in the days leading up to surgery.
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