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Involve pharmacists in medication reconciliation activities

Patient Safety Monitor Alert, August 31, 2004

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Your medication error-rate will drop noticeably if your organization assigns pharmacists to your medication reconciliation program, according to a study published this week in the American Journal of Health-System Pharmacy.

The study findings are particularly significant in light of the recent announcement by the JCAHO that medication reconciliation for all hospital patients is one of its 2005 National Patient Safety Goals. The JCAHO gives organizations until January 2006 to develop a process to obtain and document each patient's current medications upon admission, and to reconcile that list with medications that your organization provides for the patient.

Data collected by researchers at Chicago's Northwestern Memorial Hospital showed that in the absence of a pharmacist intervention, 22% of medication discrepancies may have resulted in patient harm during hospitalization and 60% may have resulted in patient harm if continued beyond discharge.

The most common discrepancies included:

• Complete omission of a medication that the patient reported taking prior to hospitalization
• A different dose, route, or frequency of medication ordered compared to what the patient was taking prior to admission

The discrepancies occur most often during patient transfers, when a patient is discharged or moved to another hospital, nursing home, or even another floor within the same facility. The researchers defined a discrepancy as any inconsistency or difference in the medication regimen noted during this manual comparison process.

The reconciliation process consisted of comparing the patient's medications listed in the admission orders to the medication information documented in

• the physician's history and physical
• the patient's admission profile, a form completed collaboratively by the nurse and patient (or patient's advocate)
• information obtained during the pharmacist-conducted interview

The researchers recommend that healthcare professionals educate patients on the importance of maintaining an updated medication list, keeping it on a card that they carry all the time, and reconciling this information during every healthcare encounter.

"A medication error, once in a patient's medical record, can carry over from admission through discharge unless medication reconciliation is performed," says Kristine Gleason, lead author of the study. "Doctors, nurses, pharmacists, and patients often just assume medical histories are accurate, and that's not always the case."

"We believe that pharmacists are especially suited to obtain medication histories and perform reconciliation based on their education, experience, medication knowledge, and patient counseling skills," she adds. "Pharmacists can recognize sound-alike and look-alike medications or omissions that others may miss, or dosages that don't seem right."

A previous study at Northwestern Memorial found that a combination of pharmacist involvement and a computerized physician order entry system with significant clinical decision support will likely provide the best approach to improve medication safety among patients.

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