Patient Safety Tip of the Week


December 30, 2008

Unintended Consequences: Is Medication Reconciliation Next?






When it comes to patient safety ideas, we need to constantly assess whether the impact we predicted has been achieved in practice and whether any consequences that we did not anticipate have cropped up. In the past year, we have discussed multiple examples of good ideas that have not lived up to their potential. Use of perioperative beta blockers has lost its luster and rather than being something to be used almost universally in surgery, we are now looking for subpopulations in which they might work. GI prophylaxis was included as part of IHI’s bundle to prevent ventilator-associated pneumonia but now is suspected of increasing susceptibility to C. diff infections. Rapid response teams have not yet demonstrated improvement in key clinical outcomes such as mortality or ICU days and numerous questions persist regarding but the most appropriate targets, the triggers, the makeup of teams, the mode of response, the logistics, and the best outcome measures. Yet numerous hospitals have rushed to develop RRT’s. And 2 weeks ago we discussed the newest Joint Commission Sentinel Event Alert about unintended consequences of healthcare information technology, a topic we’ve often talked about in the column over the past 2 years.


So it’s a pretty safe New Year’s prediction for 2009 that we will see another patient safety intervention become associated with some unintended consequences. Our prediction: medication reconciliation.


Medication reconciliation is a good idea. We have all witnessed bad patient outcomes from failure to reconcile medications at all transitions of care. We’ve seen the patient who develops an addisonian crisis because steroids he was on at home were overlooked and not ordered on admission. We’ve seen the patient who gets a withdrawal syndrome because no one knew about opiates or benzodiazepines he was taking at home. Or the patient who develops seizures in the hospital because the dose of anticonvulsants prescribed was lower than the patient had been taking at home. And the patient who gets excessive operative bleeding because no one asked about the OTC drugs he was taking. At discharge we all too often see the patient “sentenced” to perhaps lifelong PPI therapy because no one discontinued the PPI’s that were only for prophylaxis while he was an acutely ill ICU patient. And on in-hospital transitions we’ve seen the patient who gets a C. diff infection because his intended short course antibiotics were mistakenly continued on transfer to another service. There is ample evidence that medication errors occurring at transitions of care often lead to adverse patient outcomes, many or most of which are preventable (Commonwealth Fund 2008). So it was no surprise when IHI included medication reconciliation as part of its 100,000 Lives Campaign and 5 Million Lives Campaign and when Joint Commission added it as a new national patient safety goal. A good business case has been made for medication reconciliation and there are numerous spreadsheets available where you can calculate the potential savings for your organization by avoiding preventable medication errors with medication reconciliation.


But unless you are one of those very rare integrated health systems that has an enterprise electronic medical record encompassing care at all levels and among all providers, you are probably struggling with medication reconciliation. Most hospitals are struggling with it. Even though physicians have the ultimate responsibility for reconciling medications, we’ve often seen considerable resistance and resentment at the time required to do it correctly. Many physicians have remained skeptical that the outcomes of medication reconciliation will justify the time invested. And the cost and challenges of implementation may be substantial (Schenkel 2008). We’ve also seen battles between nursing and physician staffs as to who should begin building the “best possible medication history”.


Those organizations that have implemented medication reconciliation and successfully reduced ADE’s have usually used a model in which a specific individual or group of individuals have been charged with building the “best possible medication history”. In some cases those individuals have been nurses, in others pharmacists. But not all CFO’s and CEO’s have been convinced to invest considerable resources up front to realize both clinical and financial benefits on the back end.


Our October 23, 2007 Patient Safety Tip of the Week “Medication Reconciliation Tools” provided a good discussion of medication reconciliation and links to good tools and resources for medication reconciliation. We have advocated use of electronically downloaded medication lists from sources such as third-party payors, PBM’s, RHIO’s and other sources. But we have emphasized the need to use data from multiple sources in developing best possible medication histories and for diligent cross-checking of items on those lists.


But that is exactly where the potential for unintended consequences is arising. Those electronically downloaded lists may include drugs that a patient is not or never has been taking. Such medications can get on those lists for several reasons. In some cases, fraudulent activity is involved (eg. the medication is for a friend or relative) or there is medical identity theft involved. In most cases, though, it is simply due to honest mistakes taking place in the billing process. Remember, those lists are largely generated for the purpose of fulfilling the payment transaction between the pharmacy and the third-party payor. How many of you have ever had an item that you never purchased show up on your credit card statement? Probably most of you. Usually a harmless error that you can easily rectify via a phone call. Though we don’t know the frequency of such ID errors in healthcare, your ID number at the pharmacy often differs from that of one of your family members by only one digit so we would not be surprised at all if such errors are more frequent than in the credit card industry. And if such an error leads to appearance on your best possible medication history of a drug you have never taken, that can lead to problems. Shouldn’t that discrepancy be resolved when your physician goes over that list with you on admission? Certainly. But what if you are obtunded or comatose or otherwise not able to communicate on admission? You may well be started on a medication you have never taken. And you could ultimately also be discharged on that medication and have it continued indefinitely.


Also, from our experience with healthcare IT in general, we have learned that some of the unintended consequences may arise from excessive reliance on the computer (caregivers trust the computer to always be correct) and short cuts/workarounds may be seen (i.e. the physician under time constraints may not diligently question you about the medications on that list).


Additionally, confidentiality laws in many states often prohibit release of HIV-related medication or behavioral health medication information on such electronically downloaded lists. That may include medications whose cessation could lead to withdrawal syndromes. And other drugs, such as samples dispensed in a physician’s office, OTC drugs, or drugs administered in a physician office (such as biological agents) do not appear on the electronically downloaded lists in most cases.


The bottom line is that your organization must be diligent in truly reconciling the medications that appear on electronically downloaded medication lists. Especially in those patients who are unable to participate themselves in medication reconciliation on admission, you must have systems in place to prompt someone to repeat reconciliation once the patient has improved enough to communicate. And, of course, reconciliation via the patient’s outside physicians and family become even more important in the poorly communicative patient.


Medication reconciliation is an extremely important patient safety improvement process. There has not been much written about the downside of medication reconciliation. But you can bet that as we better utilize technological solutions to improve the medication reconciliation process, we are also likely to encounter unintended consequences. Do it diligently…but keep your eyes and ears open!




Update: Joint Commission must have been watching! See our March 2009 What’s New in the Patient Safety World column “Joint Commission Puts a Hold on Medication Reconciliation Scoring”.

See also our May 13, 2008 Patient Safety Tip of the Week “Medication Reconciliation: Topical and Compounded Medications” and our September 8, 2009 Patient Safety Tip of the Week “Barriers to Medication Reconciliation”.







Institute for Healthcare Improvement. 5 Million Lives Campaign.



Joint Commission. 2009 National Patient Safety Goals.



Commonwealth Fund. Case Study: Preventing Adverse Drug Events at OSF HealthCare. September 30, 2008



Northwestern Memorial Hospital. Making the Case for Medication Reconciliation.



American Society of Health-System Pharmacists. ROI Worksheet for medication reconciliation..



Schenkel S. The unexpected challenges of accurate medication reconciliation.[comment]. Annals of Emergency Medicine. 2008: 52(5):493-5










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