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Achieving successful medication reconciliation

Ambulatory Safety Monitor, December 9, 2005

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Medication reconciliation-one of the JCAHO's National Patient Safety Goals for 2005 -continues to present challenges to staff in all healthcare settings. Obtaining a complete and current list on ambulatory surgery center (ASC) patients can be a challenge because they tend to make one-time or infrequent visits to these facilities.

Karen Griffin, RN, MSN, CNAA, associate chief of nursing service for ambulatory care at South Texas Veterans Healthcare System in San Antonio, offers the following must-have knowledge for successful compliance:

A complete list of medications includes all prescription medications, sample medications, herbals, vitamins, nutriceuticals, over-the-counter drugs, vaccines, diagnostic and contrast agents used or administered during the episode of care, radioactive medications, respiratory therapy treatments, parental nutrition, blood derivatives, intravenous solutions, and any product designated by the Food and Drug Administration as a drug. This definition does not include enteral nutrition solutions (considered food products), oxygen, and other medical gases.

The patient/client should be involved in this process and asked about his or her current medications.

Each organization must decide what process it will use to communicate current medications to the next provider or setting. In emergent or urgent situations or when the resulting delay would harm a patient/client such as in a sudden change in clinical status, immediate care takes precedence over reconciliation.

The only documentation required is the medication list itself. It is up to each organization to determine what type of evidence is necessary to determine if the reconciliation/comparison process is taking place.

"Reconciliation prevents transcription errors, omission, duplication of therapy, drug-to-drug interactions, etc.," says Griffin, who is also an American Academy of Ambulatory Care Nursing board member. "Reconcile medications early to improve the organization's medication management process and patient safety."

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