Special Report: Improving Medication Reconciliation
Health systems show best practices in improving medication reconciliation
More accurate med histories help at discharge
Editor's note: Medication reconciliation is a challenging process for hospitals, particularly since the optimal process often involves more staffing and financial resources than many hospitals can budget comfortably. So as part of a special report on how to improve your discharge medication reconciliation, Discharge Planning Advisor has asked several health systems that have established best practices in this process for tips and guidelines.
Health care reform and recent regulatory initiatives are pushing hospitals closer to the day when it will cost more to do unambitious medication reconciliation than it will to put expensive resources in this process at discharge.
The tipping point could be when hospitals begin to lose Medicare funding due to avoidable readmissions or medication errors. This is what has caused some hospitals to run pilot projects in medication reconciliation to find out which method will produce the best outcomes and yet be feasible from a resource standpoint.
"I think medication reconciliation is extremely challenging as a process," says Cynthia Rawlinson, CPHQ, corporate director of quality at Winchester (VA) Medical Center, which is part of Valley Health System.
"You want patients to go home with a clear understanding of what medicines they should take or discontinue, and if you don't do that well, then you have a high risk of readmissions due to medication interactions," she explains.
"We have attempted several different types of medication reconciliation," Rawlinson says. "One in particular was related to pharmacists and pharmacy technicians, where they performed a medication reconciliation that was highly successful."
The health system considered employing that model, but it was resource-prohibitive, especially since the hospital's region had a pharmacist shortage for hospital work, she notes.
"Part of the problem was the cost, and part of it was the decreasing availability of clinical pharmacists," Rawlinson says. "So, even if we wanted to use pharmacists, they were a hard group to recruit."
Instead, the health system has developed a medication reconciliation process that makes good use of available resources and includes checks and balances to provide even better medication safety.
"We went back to the drawing board to try to create the best model for medication reconciliation," Rawlinson says.
Toronto General Hospital of the University Health Network also has created a model medication reconciliation process within the past six years. The Toronto hospital's process focuses on providing better systematic and integrated information at discharge to patients, their families, and to community pharmacists, 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.
"Our system was to develop an electronic medication information transfer tool," Fernandes says.
The tool provides a systematic way to share information from primary care physicians, nurses, hospital physicians, medical residents, and everyone involved in patient care from community to hospital and transitions and returns to the community.
"A lot of medication discrepancies happen at that interface of care as the patient goes home," Fernandes says. "We put the system in place to address those specific deficiencies."
A large proportion of patients who leave the medical unit have some sort of medication discrepancy in their prescription when they return home, he says.
Canadian studies demonstrate that nearly half of patients have unintentional medication discrepancies at hospital admission, and at least 40% have discrepancies at hospital discharge.1
"That's a huge number, and those statistics apply to hospitals around the world," Fernandes says.
For instance, the World Health Organization (WHO) has recognized this global problem and made medication reconciliation one of its top five inpatient safety intervention issues, he adds.
"Medication reconciliation is a big patient safety issue," says Jan Ward, MSN, RN, patient safety officer and director of infection control nursing and professional practice at Saint Vincent Health Center in Erie, PA.
"We know that when patients receive the wrong drug or wrong dosage, there is a potentially life-threatening situation, especially when the mistake involves blood thinners and cardiac drugs," Ward says.
The issue of reconciling medications at discharge further is complicated by the astonishingly high number of drugs that elderly patients have when they are hospitalized, she notes.
"People come into our hospital with an average of 10 medications," Ward says. "It's a big amount to keep track of, and you wonder how they are handling all of these drugs at home."
Saint Vincent Health Center officials decided to improve the medication reconciliation process after undergoing accreditation and receiving a recommendation to improve the process, Ward says.
The hospital had received full accreditation, but wanted to tackle this process for improvement.
"Our medication reconciliation process was not consistent, so we formed a team of pharmacy, physicians, and nurses to take a look at it," she says.
The committee met for an hour each day for a month until the revised medication reconciliation form was satisfactory.
"We felt like we had a deadline to get this done, and then we spent a lot of time educating staff," Ward recalls.
They wrote a discharge medication reconciliation form that was several pages long, and then revised it and tweaked it to make it a simplified one-page form.
"We took time to pilot the form's use in our emergency room first," Ward says. "Then, we did a lot of education with physicians and nurses about what they needed to do."
When they launched the educational efforts, they created pocket cards that were handed out to physicians in their hospital lounges. These pocket cards listed frequently asked questions about how to fill out the form and use it, she says.
"The cards say to consult the hospitalist for medication management," she adds. "I still have some pocket cards, and we give these out to our graduate nurses, so they'll know how the medication reconciliation process works."
The one-page medication reconciliation form is used at intake and discharge. It has a section where the nurse writes down the medication, dosage, and last dose given to the patient. The doctor has a check box to note whether the medication will be continued or discontinued while the patient is in the hospital, Ward says.
"This form then becomes an order for the medication while the patient is in the hospital," she says. "The form is not electronic, but we're in the process of switching over to an electronic system."
The medication reconciliation form stays on the chart and becomes a permanent part of the chart that is signed by the nurse and faxed to the pharmacy where the medication order is entered, she adds.
The form also lists the patient's medication history, allergies to medications, and over-the-counter (OTC) and herbal/vitamin drugs.
"A lot of times, patients bring in medication lists, and we ask about over-the-counter drugs and vitamins, Ward says. "We do some education from a nursing perspective about that process, so patients will understand that there are some drugs they should not be taking in conjunction with other ones," she adds.
When necessary, the hospital nurse or pharmacist will call the patient's pharmacy to clarify a medication that's on the list.
"When the patient comes to the point of being discharged, there's another separate column that says, 'Continue medication on discharge or discontinue medication on discharge,'" Ward explains. "And physicians check the box if they want patients to go home on the medication."
Also, there is a place at the bottom of the form to write new discharge medication prescriptions, she adds. Nurses go over the medication list with patients and answer their questions when giving them a copy of the list.
"All medication reconciliation forms are faxed to the next provider of care when the patient is discharged," Ward says.
The hospital has conducted a pilot project on double-checking the discharge medications with two nurses going over the medication list from the form, she says.
"They eyeball it before the patient is discharged to make sure we don't have any mistakes, errors of omission, or other medication errors," Ward explains.
"We had a meeting last week, and we discussed feedback," she adds. "The double-check process is more work, but we have caught a couple of errors, so that's a good thing."
Eventually, the hospital probably will take the pilot project hospitalwide and have all nurses on all units perform the double-check, she says. Another goal is to improve compliance in using the medication reconciliation form as the hospital transitions to an electronic system, Ward says.
"We don't know when the medication reconciliation piece will be ready for the electronic system, but people are in the mode of doing it this way now," she adds.
Reference
1. Fernandes OA. Medication reconciliation; practical tips, strategies and tools for pharmacists. Pharm Pract. 2009;October:24-55.
Sources
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].
Cynthia Rawlinson, CPHQ, Corporate Director of Quality, Winchester Medical Center, Valley Health System, 1840 Amherst St., Winchester, VA 22601. Telephone: (540) 536-8000. E-mail: [email protected].
Jan Ward, MSN, RN, Patient Safety Officer, Director, Infection Control Nursing and Professional Practice, Saint Vincent Health Center, 232 West 25th St., Erie, PA 16544. Telephone: (813) 452-5874. E-mail: [email protected].
Medication reconciliation is a challenging process for hospitals, particularly since the optimal process often involves more staffing and financial resources than many hospitals can budget comfortably. So as part of a special report on how to improve your discharge medication reconciliation, Discharge Planning Advisor has asked several health systems that have established best practices in this process for tips and guidelines.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content