First, Do No Harm: Role of Medication Reconciliation in Reducing Preventable Errors

The Joint Commission, the Institute for Healthcare Improvement, and other organizations have identified medication errors and the points of transition during patients’ care that increase their likelihood as promising targets in the push to improve quality outcomes. Communication, coordination of care, and the effective application of health IT hold the key to reducing errors and improving patient safety.

The Joint Commission states that medication errors continue to be one of the most frequent causes of preventable harm in healthcare. Poor communication at transition points in patient care is responsible for as many as 50% of all medication errors and up to 20% of adverse drug events in the hospital setting. The Joint Commission also notes that its National Patient Safety Goal 8 (accurately and completely reconciling medications across the continuum of care) has been exceptionally difficult to score since its introduction in 2005. Because of this difficulty in scoring, as of January 1, 2009, findings will be evaluated during the on-site survey; but, “given the difficulties many organizations are having in meeting the complex requirements of this goal, they will not be factored into the organization’s accreditation report.” This difficulty in scoring makes it all the more necessary to have electronic systems and other technologies in place to meet and exceed expectations not only for when the Joint Commission comes to visit, but also for the betterment of our patients.

Technology solutions to medication errors continue to evolve on a number of fronts, including simplified dispensing, direct order entry, PCA pumps that are programmed to be both patient- and drug-specific, and even experimentation with “polypills,” capsules that may contain up to seven drugs (all in low doses) for a variety of adult maladies. The Institute for Healthcare Improvement has been a leader in promoting advanced medication reconciliation at all transfer points, having identified early on that medication errors are one of the leading causes of injury to hospital patients. Chart reviews reveal that more than half of all hospital medication errors occur at the interface of care. As I see it, IT solutions hold the greatest promise to eliminate these errors, with programming that will focus on care transitions and any discrepancies or disruptions in medication management.

One patient, one record

It is across the continuum of care that the reconciliation process has its greatest impact. According to the American Geriatrics Society, “transitional care is defined as a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same location.” These locations and their transfers include hospitals, subacute and postacute nursing facilities, the patient’s home, the office practice (both primary and specialty), and longterm care or assisted living facilities. As we begin to evaluate the quality and safety of each movement and point of handoff, we see that proper management of medications and medication lists will fall under the rubric of medication reconciliation.

The integrated medical record has great potential to put all of this information “on one page”--or at least to have it reside in only one location. Even when care is provided across multiple sites and services (as is often the case), only one medication record need exist. It can be used to prescribe, populate clinical notes, handle admission orders and refills, and be included in discharge summaries. At a minimum, required fields include drug name, dosage, frequency, and route. The record system we use at the Mayo Clinic also requires amount and date of last refill, and it does an exquisite job of identifying drug—drug interactions. With our system, all providers who are addressing medication needs can access the electronic record at each site of service and update the medication list in real time. The medication history can also be brought up to discover when a drug was discontinued, and perhaps why (there is a voluntary field of entry for this information at my institution).

As we pursue a patient-centered approach to care, the medical record and the individual it reflects should be able to travel together. Moreover, medication lists are becoming available to patients, home care providers, and families as medical practices make patient-specific information available on the Internet.

Technology may be the key

In 2008, the AMA’s Physician Quality Reporting Initiative (PQRI) allowed 119 measures that were published in the Physicians’ Fee Schedule to be used for reporting and additional reimbursement. Of those, 117 were clinical performance measures and two were structural measures that focused on either the use of an EHR or e-prescribing technology. The savvy practice will utilize its EHR to not only report clinical performance, but also to advance the care and safety of each patient and be rewarded along the way.

With the transition of care measures at various stages of development both at PQRI and at the National Quality Forum, medication reconciliation is the keystone for measure development. The current focus is on hospital discharges and how well the handoff goes. One way to judge is how well the medications were reconciled—what was omitted, what failed to restart following transfer or discharge, what has been duplicated, and what dose or dosages are incorrect. The next frontier, subject to the same analysis, will be how well nursing homes and home health agencies pass or receive the baton of responsibility. It behooves all of us to work as quickly as possible to integrate hospital and outpatient records along with pharmacy records in order to eliminate errors of duplication, omission, and transcription.

I believe that we can only take quality measures so far. Although the science of qualitative measurement continues to advance, much still remains in the eye of the beholder. Medication errors, on the other hand, are quantitative and can be approached with methodical measurements toward Six Sigma. In the elimination of duplicate steps, we have less opportunity for error and also save time and money. Again, a unified record can give us the opportunity to keep track of who prescribed what, as well as when and even for what reason.

I know of no fully integrated programs that can follow patients across more than two or three sites of service. Nonetheless, progress is being made across the country as we explore the opportunities provided by the EHR. At Mayo, we have adopted a master medication list that is used by all outpatient primary and subspecialty practices. It is available to our two teaching hospitals and is also available to staff who are attending to patients in our local nursing homes. It is not yet integrated with pharmacies at any location other than Mayo for e-prescribing, nor does it populate the hospital or the nursing home record. However, it is a step in the right direction and has put far more physicians on the same page.

This integration also allows for instant review by the patient at every encounter. If adjustments are made, they are only made once and are stored in only one location. The medication list is maintained in its own repository and then loaded to the next clinical encounter. Institutions moving along these lines will be better able to follow patients across all transitions of care with a singular health record that recognizes only one medication list.

Dr. Tangalos is an MDNG editorial board member, and a professor of medicine and co-director of the Robert & Arlene Kogod Program on Aging at the Mayo Clinic in Rochester, MN.