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Five tested ways to reconcile medications, meet new JCAHO National Patient Safety Goal

Hospital Pharmacy Regulation Report, November 1, 2004

Pharmacy can play a major role in getting a complete and accurate medication list upon admission-something a new JCAHO National Patient Safety Goal requires-and a recent study conducted at Northwestern Memorial Hospital in Chicago provides some proof.

In 204 medication-history interviews conducted out of 2,046 direct admissions to medical-surgical units, pharmacists made 97 interventions involving 55 patients, according to the study published in the August 15 American Journal of Health-System Pharmacy. The most common discrepancy-42%-that pharmacists found when reconciling medications was an omission of a medication that the patient reported taking before being hospitalized.

"The biggest take-away point is that we have to get a complete, accurate medication history at admission to help ensure safe medication usage, as this forms the basis for the patient's initial treatment plan and serves as a reference throughout the hospital stay," says Kristine Gleason, RPh, research pharmacist coordinator at Northwestern Memorial Hospital.

Start your list upon admission

JCAHO National Patient Safety Goal #8 requires organizations to develop a process to obtain and document a list of the patient's current medications upon admission, and the organization must involve the patient in the process. Staff must make the list available to the next healthcare provider when the patient is transferred or referred for more treatment.

The JCAHO will require full implementation of this process by January 1, 2006. Surveyors will check whether hospitals have a compliance plan in place during 2005, according to a source close to the JCAHO.

"[Medication reconciliation] needs to become part of the checklist of admitting a patient," says Grena Porto, RN, MS, a principal with QRS Healthcare Consulting, LLC, in Hockessin, DE. "It just needs to come to the front of the mind when a patient is admitted."

Get a full list, reduce errors

Northwestern Memorial Hospital conducted the study on medication reconciliation from August 2002 to July 2003. Patients admitted directly to any of 12 medical-surgical units were eligible for the study, and they spoke with a pharmacist about their medications within 24-48 hours of admission.

The pharmacist reviewed the patient's medication and allergy information documented in the physician's history, the patient's admission profile, a form completed collaboratively by the nurse and patient/surrogate, and the admission medication orders. The pharmacist then interviewed the patient to gather information about his or her medication use before admission-including over-the-counter medications, herbals, and other supplements-and allergy history.

The true "reconciliation" in the JCAHO goal occurs when staff alert the physician to any discrepancies, the physician makes any necessary changes in orders, and the physician or nursing staff documents the changes in the patient's medical record, says Paula Griswold, MS, executive director of the Massachusetts Coalition for the Prevention of Medical Errors.

Of the discrepancies found in Northwestern's study, 22% could have resulted in patient harm during the hospital stay, and 59% could have resulted in harm after discharge if reconciliation did not occur. The most frequent medication class involved was vitamins and electrolytes, highlighting the importance of gathering information about a patient's supplements and over-the-counter medications, Gleason says.

The hospital spent almost $5,000 on pharmacist salaries during the study, but the authors estimated savings of almost $39,000 by preventing errors and potential harm when pharmacists interviewed patients.

Tap into your resources

Pharmacists may also suggest an alternative therapy if the medication a patient took before admission is not on the hospital's formulary, Porto says. The pharmacist can explain the substitute medication to both the physician and the patient and highlight any dosing differences between the normal drug and the substitute, she says.

Hospitals should utilize the pharmacist's medication knowledge to their advantage in meeting the JCAHO goal, Gleason says.

"Pharmacists are more likely to recognize inaccurate or inappropriate dosages, contraindications, and omissions in drug therapy," Gleason says.

How do you document it?

Once you collect this information, where do you keep it? You could create one form for reconciling medications.

The form should include

  • the dosage and frequency of each medication

  • the date and time of the last dose

  • information about the patient's compliance with prescribed dosages and frequency

  • information about allergies

  • a space for the verifier's initials

  • a signature line for the physician

  • "People [in the group] agonized over how to get that gold-standard, perfect list," says Griswold. "But don't let the quest for the 'perfect' list be the enemy of the 'good' list. Just get the best information you can about the home medications that patients are taking."

    Tip: Place the form in a visible location in the patient's chart. The history and physical or nursing assessment are also good forms to document a patient's medications, Porto says, as reconciling medications using these forms can help reduce the workload on a resource-strapped hospital.

    Enter the reconciled medication list into the electronic medication administration record (eMAR) if your hospital uses electronic medical records. Northwestern Memorial Hospital is currently transitioning to an eMAR and computerized physician order entry (CPOE), Gleason says.

    Tip: Design your eMAR and CPOE system to alert caregivers to reconcile patients' medications upon admission or each time they transfer to a new unit.

    Create a team approach

    Some hospitals may not have enough resources to have pharmacists interview patients upon admission. Remember physicians, nurses, and pharmacists all play an integral role in the medication reconciliation process. Gleason knows of one hospital that has a nurses reconcile medications upon admission, physicians reconcile them upon transfers, and pharmacists reconcile them upon discharge.

    "It needs to be a multidisciplinary effort, and hospitals should develop a process for collaboration between clinicians to maximize resources and minimize rework," Gleason says.

    Patients should also be educated about the importance of maintaining an updated medication list and reconciling their medications at every healthcare encounter.

    Tip: Have pharmacists work with patients upon discharge to develop an updated medication list and explain any new medications they may be taking, any differences in doses, and how drugs may interact with each other.