Medication reconciliation
Medication lists – too many shades of gray for black and white
The goal seems simple and straightforward enough – the medication list should reflect accurately what the patient is currently taking. But getting to that goal when there are frequently significant discrepancies between what a provider has recommended and what a patient is taking creates significant challenges.
Patients frequently do not take medications they’ve been prescribed, for a myriad of reasons. They frequently don’t take them as they’ve been directed to do so. In many health systems, our support staff start this complex process of validating medication history and make notations to alert the provider to discrepancies so the provider can make decisions about discontinuing, changing sigs, or counseling the patient why it is critically important that they continue this therapy.
Too often providers blow past these comments, and meds that are outdated and long discontinued even legitmately remain on the medication list. But if we enable staff to discontinue medications that the patients report that they are not taking, we risk unrecognized discontinuation of therapies – suddenly the patient has a stroke and it turns out they were off their anti platelet therapy but the provider never knew.
Interested in how others have tried to balance this ongoing challenge of updating and maintaining the medication list.
Medication reconciliation has been a big challenge in Bulgaria. It also was one of the major aspects during the Joint Commission accreditation. The way we addressed it was from several aspects. First, we maintained at all times an up-to-date formulary with all the medications that were used in the hospital and have been used in the past. The medications were included with both their generic names and the brand names. At any visit in the clinics, the patient was given a med reconciliation sheet that he was asked to fill in and then this was transferred to the electronic record with drop down menu of the actual formulary.
We also learned from experience that medical assistants should not be allowed to “discontinue” a medication from the list; that could perhaps be viewed as a scope of practice issue. However, they can review medication adherence with patients, and to flag them appropriately. Attestation of “review of medications,” while imperfect, is a metric that can be monitored and feedback given to physicians with reference to peer averages and an institutional goal. Also, consider presenting physicians with an anecdotal case to illustrate the problem they want to prevent (e.g. someone stops their beta blocker, it’s inappropriately removed from their list, and then they have an MI and end up in the ICU). Finally, I would attempt to standardize rooming/medication reconciliation process across departments, so that for example, primary care is empowered to discontinue clearly expired acute medications (even if prescribed by a specialist), and so that your top performing specialty groups will at least notify a PCP, if it is noted that a patient has stopped taking one of their chronic medications such as aspirin or statins. Calling out certain departments or providers for helping other departments in this way could be powerful positive reinforcement.
Our experience is that in the care proces of a hospital admission medication history was taken several times by several professionals ( nurse, doctor on the ward, anaesthesist) because they checked again whether the list in the record was accurate. Still mistakes occurred.
By verifying medication on entry by a skilled farmacy-nurse we try to check medication upfront only once and thereby saving time and reducing errors.
Our organization is working on a project around this now. Our issues have been the same as others have articulated- inconsistent process completed by a myriad of staff types. We are in the process of dedicating a team that has the sole function of completing medication reconciliations for all inpatients. As an admit to inpatient order is entered into the EMR, the med reconciliation team will receive an alert, which triggers their review. To justify the project (beyond improved patient care), we reviewed published literature and internal cases where medication errors occurred, and looked at the added cost to the system due to medication errors. We found that correcting the errors, and eliminating excess costs due to errors, far outweighs the expense of the medication reconciliation team.