Accreditation

Medication Reconciliation

Accreditation Monthly, March 6, 2006

Well, it is the beginning of March 2006, how well is your organization performing medication reconciliation? Are you still at the drawing board stage? Are you still pilot testing? Or are you comfortable in knowing you have in place a robust and accurate process to reconcile medications across the continuum of care?

If you have failed thus far to meet the JCAHO's January 2006 deadline it is not for lack of suitable resources to draw upon to assist with your process design. The Institute for Healthcare Improvement's (IHI) and The Massachusetts Coalition for the Prevention of Medical Errors each have an excellent set of instructions and sample materials found at www.ihi.org and www.macoalition.org respectively. And the JCAHO has published Frequently Asked Questions and Implementation Expectations found at www.jcaho.org along with a companion article in the current (March 2006) issue of JCAHO Perspectives.

For those of you still in the early phases of medication reconciliation process development you may still be struggling with a few of the fine points of process design. For instance, several clients have expressed concern over how far they have to go to meet JCAHO's intended scope of the safety goal ".across the continuum of care...including ambulatory care, emergency and urgent care, long term care, home care and inpatient services." Clients ask, "Does this require that we reconcile medications for every patient encounter for, say for instance, an outpatient lab test or imaging examination? What about outpatient physical therapy visits?"

My advice is that common sense must prevail. If no medications are given during the encounter then no medication history or reconciliation need occur. That exempts routine outpatient testing and therapy visits. What about contrast media used in some imaging examinations? By definition, contrast media is inert and not absorbed by the body - thus no reconciliation need occur. The JCAHO is clear; organizations are free to specify in policy a reconciliation opt-out clause for those transitions/encounters involving no new medication orders or rewritten orders.

In the emergency department or urgent care setting a listing of current medications including dosage and schedule (including when last taken) along with any drug allergies or intolerances should already be routinely recorded during the history portion of the patient's intake process. If medications are given during an emergency department/urgent care visit, the physician is most certainly going to take into account the medication history before ordering the new medication. This step, if performed consciously, accomplishes the reconciliation requirement at the time of the order. So no change in process is likely required to this point.

But upon discharge from the ED/urgent care setting the new expectation is that we provide the patient and the next provider of care (if there is one) a list that includes the current medications plus any new medication(s) the patient is to take following discharge. Patient education at discharge should address instructions on how and for how long to take the new medication in addition to making clear how the patient should (or should not) continue to take the medications they were already on. While not specifically required, it thus may make sense to create a new form for the recording of medication history and orders for new medication(s) (or modify an existing history form with a tear off section) to facilitate the step of providing the patient a copy of the list of continuing and new medications. Encourage them to bring it with them the next time they receive care.

Are we obligated to teach the patient about only the new medication or should we also include each continuing medication specifically? Again, common sense should apply. If such teaching would provide important information relative to the newly prescribed medication(s) including how they might interact with current medications, then yes, that education should be part of your process. On the other hand, if there is no clinical relevance to the old versus the new medications, a simply instruction to "continue or resume taking these (pointing to the list) current medications" would suffice.

Ah, you say, but continue or resume orders are unsafe and no longer permitted! And you are correct. But think about it, what we are doing at discharge is not ordering these current medications, we are merely instructing the patient to continue taking the medications as they have been previously instructed.

That is all for this month.

Sincerely,

John Rosing
Practice Director of Accreditation
and Regulatory Compliance
The Greeley Company

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