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How will you obtain your patient’s complete list of current medications?

Accreditation Connection, October 14, 2004

According to the 2005 National Patient Safety Goals, your hospital must develop a process for involving patients upon admission in obtaining and documenting a complete list of their current medications beginning January 1, 2006. This process includes comparing the medications that the organization provides with those on the list.

"Have a process for obtaining and documenting a complete list of the patient's current medications upon the patient's admission to the hospital. Many hospitals may struggle with the words 'admission to the organization,' " says Brenda Gail Summers, MBA/MHA, MSN, RN, CNAA, senior consultant with the Marblehead, MA-based consulting firm, The Greeley Company, a division of HCPro.

Basically, this means you need medication information every time you have contact with the patient. Your process must allow a medication history to move with the patient through the continuum of care and be continuously updated as changes are made to his or her medication regimen. Educate your staff about the process.

Ask patients about their prescription drugs, over-the-counter medications, and any herbs they take, says Sue Dill, RN, MSN, JD, vice president of legal services at Memorial Hospital of Union County in Marysville, OH. If your pharmacy doesn't carry a particular medication, find a way to maintain a patient on that medicine. Be aware that the Centers for Medicare & Medicaid Services also has a standard about this.

Expect this new goal to add time to the admission process. During a recent nursing assessment improvement program, says Paula Swain, MSN, CPHQ, FNAHQ, director of clinical and regulatory review at Presbyterian Healthcare in Charlotte, NC. Swain's hospital discovered that it added about 0 minutes to its admission process for an average elderly patient with a few chronic diseases. It takes that long to list the drug, dose, frequency, and indications.

The hospital decided its next best step would be to have all of the drugs listed on a separate sheet, which would become the initial physician's order sheet. Physicians can check off medications they want continued during the patient's hospitalization.

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