Special Report: Improving Medication Reconciliation
Medication discrepancies in hospital are reduced
Information transfer tool makes it easier
Hospitals that have poor or no medication reconciliation processes have dismal medication safety statistics, one expert says.
One study showed that nearly one-quarter of patients discharged from a hospital with no medication reconciliation process had an adverse event within 30 days of discharge and 72% of these were adverse drug events.1
"Roughly 40% of all patients in the hospital will have an unintentional discrepancy in what they were taking at home and what they were ordered to take in the hospital," says Olavo A. Fernandes, RPh, BScPhm, ACPR, PharmD, FCSHP, clinical director of pharmacy at Toronto General Hospital. Fernandes also is an assistant professor, Leslie Dan Faculty of Pharmacy at the University of Toronto.
"This has to do with the fact that people weren't getting good medication histories," Fernandes says. "The most common mistake we make is an omission."
Omissions can occur when patients are admitted for an acute illness, such as an infection, and physicians are so focused on treating that problem that they fail to capture the information about the patient's chronic disease medications, he explains.
Toronto General Hospital's solution involves the use of electronic medication information transfer tools that capture the best available medication history and changes and communicates the information to patients, providers, and pharmacists in the formats they prefer.
"This is a huge opportunity for health care professionals to work together and prevent something from happening," Fernandes says.
One key is to work toward obtaining what is called the best possible medication history (BPMH).
Sources for the BPMH include the patient and family interview, the patient's medication list or vials, a medication database, and previous patient health records.1
"You put the pieces of the puzzle together to get the most authentic representation of what the patient is taking," Fernandes says.
Then once this medication list is complete, it is altered in the hospital with new medication orders and changes. At that point when the patient is discharged, the goal is to obtain the best possible medication discharge plan (BPMDP).1
"Then we translate the same information back to the community and community practitioners, so they are aware of all the changes made in the hospital," Fernandes says. "This can be confusing for families and community pharmacists and physicians if it's not communicated to them in a clear way."
The communication piece can be handled with streamlined medication list forms that are designed with a particular audience in mind.
For example, a standard medication reconciliation form might list the hospital discharge prescriptions, dose, route, frequency, and quantity on one side of the chart, while also displaying a table with additional information of interest to pharmacists. This information might include a summary of medication allergies, a summary of medication changes since admission, new medications, discontinued medications, adjusted medications, unchanged medications to be continued, and additional comments.1
This form gives physicians a clear and logical way to communicate the medication changes and history at discharge. Then this information can migrate electronically into a second type of form, one that is designed specifically for community pharmacists who have some different data needs.
"The community pharmacist then can see very clearly the changes we made and the unchanged medications," Fernandes says. "When we spoke with community pharmacists, they said, 'Don't tell us only what changed; tell us why it changed give a rationale.'"
So, the hospital developed a letter to community pharmacists. It illustrates the BPMDP and has a different style and format than the basic discharge medication reconciliation form. For instance, the community pharmacist's list includes a table with new medications on the left and "rationale" on the right. For example, if the patient was newly prescribed iron, the rationale might say that the patient was found to be anemic in the hospital and list those lab values.1
The same would be done for stopped medications and dose changes. The community pharmacist's letter also addresses unresolved and ongoing medication-related issues and offers advice on education, counseling, and monitoring.1
The medication data then migrate to another format, which is used to educate patients. Patients prefer a format in which the medications are listed according to the time of day at which they are taken, Fernandes says. So, their medication chart has tables for morning meds, drugs taken at noon, medications taken at supper, as well as bedtime and as needed.1 One column lists the medication's name and dosage. The next column lists comments, such as "Take with food," and the third column provides directions, including, "Take 1 tablet."1
Before changing the medication reconciliation system, the hospital's experience was that patients were confused, Fernandes says.
"We found that everybody was trying their best, but they often were giving different information to patients, and we were creating their confusion," he says. "Doing it this way requires that everyone work together."
All disciplines involved in the hospital discharge process begin with the same data, but the information is presented in different ways and for different purposes.
"Ideally, the electronic system ensures that everything is linked together," Fernandes says.
Reference
1. Fernandes OA. Medication reconciliation; practical tips, strategies and tools for pharmacists. Pharm Pract. 2009;October:24-55.
Source
Olavo A. Fernandes, RPh, BScPhm, ACPR, PharmD, FCSHP, Clinical Director of Pharmacy, Toronto General Hospital, University Health Network, Clinical Services Wing, Basement 075, 585 University Ave., Toronto, Ontario M5G 2N2. Telephone: (416) 340-4800. E-mail: [email protected].
Hospitals that have poor or no medication reconciliation processes have dismal medication safety statistics, one expert says.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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