Reconciled to Safety: The Role of Pharmacy in Effective Medication Reconciliation

The Joint Commission for Accreditation of Healthcare Organizations (The Joint Commission) incorporated medication reconciliation into the National Patient Safety Goals (NPSG) in 2005, to be implemented in institutions by January 2006. This was done in order to ensure that a complete list of the medications taken by a patient is communicated to the next healthcare service provider when the patient is referred or transferred to another care setting, service, practitioner, or level of care. Medication reconciliation promotes a decreased risk of transition-related adverse drug events due to poor communication among healthcare professionals.

In the years following initial NPSG implementation, several issues have arisen surrounding the delegation and process of reconciling medications across the continuum of care.

Medication reconciliation is defined by the Institute for Healthcare Improvement (IHI) as the process of creating the most accurate list possible of all medications a patient is taking—including drug name, dosage, frequency, and

route—and comparing that list against the physician’s admission, transfer, and/or discharge orders, with the

goal of providing correct medications to the patient at all transition points within the hospital. Medication reconciliation involves verification of the patient’s medications, clarification of the appropriateness and dosage, and reconciliation of discrepancies in the medication profile (this includes incorrect dosage form, strength, dosing regimen, or route of administration).

Although medication reconciliation is conducted by physicians, nurses, caseworkers, and pharmacy technicians

at institutions around the country, pharmacists are the healthcare professionals who are best equipped to complete this task. Each medical admission can require approximately 15—20 minutes of a pharmacist’s time, with approximately the same amount of time needed for discharge medication reconciliation. The medication reconciliation process provides pharmacists with the opportunity to establish their role in the admission, transfer, and discharge of patients. It also provides the opportunity to eliminate duplicate therapy, correct/incorrect dosage or frequency information, document allergy information, and update vaccine recommendations. Unfortunately, time constraints and lack of resources lead many institutions to delegate this responsibility to other healthcare professionals, instead of assigning a dedicated pharmacist to this role.

An Opportunity for Communication

Medication miscommunication, manifested by discordance between patients (and their caregivers) and healthcare providers, creates the necessity of establishing effective medication reconciliation processes. Patients, caregivers, physicians, pharmacists, and insurance companies may all need to be involved in the reconciliation process.

One potential problem surrounding medication reconciliation is a lack of knowledge about the necessary information to collect. Key questions to be addressed by patients and their caregivers include the patient’s height and weight; community pharmacy name and phone number; current prescription medications, nonprescription products, and herbal supplements; and the dosage, route, frequency, indication, and date and time last taken for all current medications. Medication reconciliation should include prescription medications, over-the-counter medications, complementary-alternative medications, and vitamins and other supplements. Substances other than those traditionally associated with allopathic medicine are increasingly popular with patients and can often be overlooked when taking a medication history. Because physicians may not ask about these substances, patients may be reticent to disclose that they are currently taking them, and key information may be lost, including issues regarding toxicity and the time of last dose of each medication.

Establishing and adhering to clear and effective medication reconciliation procedures can help ensure that this and

other pertinent information is known and documented. For example, a patient’s social history (including tobacco,

alcohol, and illegal drug use) can play a role in diagnosis and treatment. Undocumented allergic reactions could falsely lead a prescriber to avoid selecting a particular medication or medication class that may actually be beneficial for the patient.

Ideally, all medications should be reconciled within 24 hours of admission, with high-risk medications reconciled earlier. This may not always be possible, for a variety of reasons. For example, language barriers may make the reconciliation process difficult (this includes non-English speaking patients and patients who are unable to communicate due to traumatic injury). Reconciliation should also be completed upon transfer of patients to another level of care in the institution and at time of discharge. The most common error at discharge is failure to resume medications that patients were taking prior to admission and should still be taking. Medications that are reconciled throughout the hospital stay should be recorded for comparison to their restart at discharge.

Medication Reconciliation by the Numbers

Approximately 72% of hospitals met the The Joint Commission National Patient Safety Goal on Medication Reconciliation in 2006, with larger hospitals more likely than smaller hospitals and institutions to have met this goal. Many institutions still not compliant with The Joint Commission medication reconciliation goals continue to struggle with the actual logistics of the process. Responsibility for medication reconciliation is interdisciplinary, which means that delegating the task can become difficult. Doylestown Hospital, in Pennsylvania, reported 100% reconciliation when it implemented a process that assigned medication reconciliation to be completed by case managers. This hospital also incorporated a new section into patients’ charts for medication reconciliation.

Physician and nursing shortages often promote pharmacists to the front line of reconciliation. However, due to the

time commitment involved with the process, financial support or realignment of resources may be necessary to account for a dedicated professional such as a clinical or staff pharmacist assigned to the emergency department. This potential solution, however, only protects the patient upon admission. The need for medication reconciliation has been established over the past two years. Despite this, many institutions have not reached 100% compliance as represented by the ASHP pharmacy practice survey in 2006.

Planning Is the Key

Proper planning can increase the success of a medication reconciliation system. The Joint Commission has stressed the importance of designing and implementing an effective process in order to enhance patient safety. A medication reconciliation system should be designed using information derived from literature searches, peer recommendations, and internal brainstorming. Many hospitals and health systems have utilized a formalized process implementation in clinical areas, using evidence-based medicine for clinical pathways and/or guidelines. Using a similar approach may help to increase successful outcomes for patient care.

To begin the process, a designee of the hospital (eg, a pharmacist, nurse, or physician) or member of the facility’s patient safety committee should be given oversight of the process. Once an individual has been charged with shepherding the process, a thorough review of the literature should be completed. This review will illuminate the successes (and failures) of other institutions who have tackled this process. Institution size and acuity level should be taken into consideration when utilizing references. This will allow for the designee to weigh the appropriateness of the recommendations and conclusions from the literature. After collecting examples of systems and processes that are compatible with the unique needs of the hospital, an interdisciplinary team should be created in order to evaluate the possible solutions. Additional research may need to be done by the designee or members of the newly formed team.

If a plan is chosen without properly considering the workflow of all staff involved, compliance with the solution will

most likely be poor. Examples in the literature can help determine the amount of time needed to conduct an evaluation of a patient’s medication history (eg, 15—20 minutes for a pharmacist per patient). The department overseeing the process can integrate the system into medication error trending for the institution. Compliance among pharmacists, nurses, and physicians should be monitored to improve adherence to the system. Throughout the implementation process, careful oversight and support will be required from the designated project leader and interdisciplinary team of healthcare professionals.

Institutions without appropriate monitoring may suffer from poor compliance or an increase in incidents of “turfing” the reconciliation process to other departments or staff. The pharmacy practice survey from ASHP highlights the potential problems that may arise due to lack of prioritizing or assigning ownership of this critical process.

Reconciled to Safety

In the past, the burden of medication reconciliation has been ultimately in the hands of the patients and caregivers.

Medication reconciliation could potentially lower the morbidity/mortality and costs associated with medication

errors. Medication errors can occur at all levels of the processes involved in dispensing medications: prescribing,

transcribing, dispensing, administering, and monitoring. Incorporating other healthcare information technology systems can also help to reduce errors, such as computerized physician order entry (CPOE). These systems may have functionality to promote and ensure proper medication reconciliation built into the order entry process. Facilities that have implemented CPOE have less frequently reported medication errors that reached patients or harmed patients.7

Although advanced technology is in place to minimize medication errors, adverse drug events still occur, costing

an estimated $4,700 in extra hospital days and ancillary services. Because medication errors are generally the result of process and system flaws rather than individual flaws, so too should the solution to these problems be implemented on a system-wide basis. Medication reconciliation is a key component of a solution to reduce and/or eliminate the errors that occur due to lack of communication in the healthcare system. Now that effective medication reconciliation has been clearly defined as a patient safety issue, it is up to all healthcare professionals to prioritize adoption and ensure successful adherence and implementation.

Amber Fullmer, PharmD, is a pharmacy practice resident at Allegheny General Hospital in Pittsburgh, PA.Rickey C. Miller, PharmD, BCPS, BCOP, is a clinical pharmacy specialist at the Allegheny General Hospital Cancer Center. He is also an adjunct faculty member at the University of Pittsburgh and Duquesne. University.