Accreditation

Who Should Perform Medication Reconciliation Upon Admission? Why "Shared Accountability" in Reconciling Home Medications is Necessary

Accreditation Monthly, May 8, 2006

Dear Colleague,

Over the last few months I have seen a number of hospitals implement a medication reconciliation process as required by JCAHO National Patient Safety Goal 8 and many seem to struggle with one particular question - namely, upon admission should the physician or should the nurse be responsible for reconciling the home medication list against the initial set of medication orders?

In their Frequently Asked Questions concerning this Safety Goal JCAHO has said either discipline may perform the reconciliation. My answer, supported by the Massachusetts Coalition for Patient Safety and JCAHO, is that the initial reconciliation needs to be a clearly defined Shared Accountability between the physician, nurse, and pharmacy staff.

Many hospitals have designed a home medication list/medication order "combo" form on which the admitting nurse is responsible for first creating the home medication list (drug name including over the counter and herbals, dose or concentration, route when applicable, frequency, and date/time last taken) followed by the physician coming along and considering (i.e., reconciling) this list while ordering the initial set of medications appropriate to the patient's condition now as an inpatient.  Ideally the form is created to allow the convenient use of check boxes for the physician to "continue, hold, or discontinue" each medication on the home medication list as well as space for the physician to enter an order for any new medication.  The form is then transmitted to pharmacy per the usual process (e.g., faxed, scanned, picked up, etc.) with a copy added to the "orders" section of the chart.

This process seems to work fine in circumstances in which the nurse has completed the admission history including the accurate creation of a list of home medications prior to the physician making timely rounds on his or her new admissions, usually within a few hours of the patient arriving to the unit.  But what about those admissions in which the physician rounds on the patient prior to the home medication list being created?  Or how about admissions in which the physician telephones in or sends over written orders prior to the creation of the home medication list.  In these circumstances the cart (admission orders) is before the horse (creation of the home medication list) and many hours might pass before the physician again rounds on the patient and is physically available to visually inspect the current orders and reconcile them against the home list.  Indeed, I have seen instances where the physician on day two or three of the hospitalization did not use the "combo" form to perform the reconciliation or order medication - rather, they entered orders on the "traditional" order form with no evidence that the home medication list was ever considered. 

Perhaps this breakdown occurs because everyone is still trying to grapple with a new process, or maybe the physician could not locate the list of home medications in the chart, or perhaps the physician assumes they would have heard from someone (e.g., nurse or pharmacy) that a critical home medication had been inadvertently omitted or that current therapy was duplication of a home medication, etc.

Regardless, it is obvious that a potentially dangerous gap exists in the process in these hospitals and revisiting procedures governing the reconciliation process to establish clear responsibilities and time frames for Shared Accountability and action is essential to filling the gap.  Shared accountability means a nurse (or perhaps pharmacy staff if so assigned) would take notice when the cart is before the horse and compare the recently created home medication list to the previously written orders and identify any variances or discrepancies.  Procedures should be clear in directing the nurse to contact the physician within a specified time frame (sooner is better than later; in other words, don't wait 23 hours) including defining when it would be appropriate to stat page the physician or work up the chain of command.  Upon reaching the physician any new orders or changes to existing orders should be recorded as telephone orders either on the "combo" form or "traditional" form (you decide one or the other,) but in either case the fact that the nurse together with the physician actually performed the reconciliation should be recorded in the record (entry signed and dated by the nurse, for example.)

By adopting clearly defined procedures assuring Shared Accountability for medication reconciliation upon admission you can prevent a potentially life threatening medication error from occurring in your hospital.

Sincerely,

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

For more information on our accreditation and regulatory compliance consulting services, click here or contact Sandi Reen, Practice Manager, at sreen@greeley.com or call 888/749-3054, ext. 3263.

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