Not only are patients being spared
the morbidity, mortality, and inconvenience due to such potentially preventable
medication errors but healthcare systems are beginning to note a positive
impact as well. While there is an upfront investment of time in the medication
reconciliation process, successful programs have noted a significant reduction
in rework and a net savings in time spent by nurses, surgeons and other
physicians, and pharmacists. Well-designed forms, whether paper-based or
electronic, seem to be particularly well-received by physicians because they
save time and improve accuracy.
There is often an economic impact
as well: hospitals, patients, and third party payors avoid the costs of
medications that are no longer necessary. For example, one of the more frequent
problems we see is that of patients being started on prophylactic proton pump
inhibitors during a hospital stay and then being inadvertently continued on
these long after the need has resolved. A good medication reconciliation
process identifies this issue and corrects it in a timely fashion.
Some excellent tools for medication
reconciliation programs are readily available. These include:
One of the most useful tools we
have come across is the Getting Started Kit from the
Canadian “Safer Healthcare Now! Campaign”. This toolkit was updated in 2007
after many participating Canadian hospitals had extensive experience with it.
Not only does the toolkit have a wealth of sample forms for use at each
transition of care, but it also has outstanding recommendations for
implementation, auditing, and measurement, plus tips for improving the accuracy
of information about medications the patient was taking prior to admission. It
also has a great reference section, including links to sites of many other
organizations having tools, forms, and educational presentations.
The key to the entire
reconciliation process is getting the most accurate possible list of
medications at admission. Getting a complete and accurate list of medications
that a patient is taking is very difficult in our fragmented health care
system. The primary care physician usually has the most comprehensive list, but
even then, the PCP may not be aware of all medications prescribed, altered or
discontinued by specialists.
Third party payors or pharmacy
benefit managers (PBM’s) often actually have the most up-to-date data on which
prescriptions are actually being filled by the patient. Because of formulary
issues and adjudication issues, most pharmacy claims come in to managed care
organizations very promptly. Thus, the managed care organizations have a
virtual real-time snapshot of the medication profile. Several collaborative
community projects are attempting to share such information through their
regional health information organizations (RHIO’s). Even if your community has
not developed such a RHIO, your organization should be insisting in its
contracts with managed care organizations that they provide electronic access
to those real-time databases to facilitate the medication reconciliation
process. After all, helping to ensure accurate reconciliation benefits the
managed care organizations in the long run. But even then, over-the-counter
medications and free samples usually are not listed in such databases and the
databases often do not contain (at least promptly) claims related to
medications administered in physician offices, such as biological drugs.
And patients themselves may not be
the most reliable source of information about medications. A study in this
month’s Journal of General Internal Medicine found that over 30% patients
thought to have good health literacy and almost 60% of those thought to have
poor health literacy could not name any of their antihypertensive medications1.
Involving the family or caregiver and actually bringing in the medications from
home may be very helpful in the medication reconciliation process.
The bottom line is that whatever
process you develop to create your Best Possible Medication History (BPMH)
should rely upon multiple data sources and require diligent cross-checking.
And a last comment is that many of
the available medication reconciliation forms that are currently in use lack a
field to clarify the indication
for which the medication was prescribed. Knowing the indication is extremely
important in avoiding look-alike/sound-alike medication errors. Many medications
(eg. beta-blockers) also may have several indications and you need to know
which one applies to your patient. And the dosage of the medication may vary
depending upon the indication for use. Similarly, most medication forms and
lists fail to include reason for
discontinuation. It is important to know if a medication was
discontinued because of lack of efficacy, side effect, allergy, or formulary or
economic reasons.
1Persell SD, Osborn CY,
Richard R, Skripkauskas S, Wolf MS. Limited Health
Literacy is a Barrier to Medication Reconciliation in Ambulatory Care. Journal
of General Internal Medicine 2007; 22: 1523-1526
Updates: See also May 13, 2008 Patient Safety Tip of the Week “Medication Reconciliation: Topical and Compounded Medications” and our December 30, 2008 Patient Safety Tip of the Week Print “Unintended Consequences: Is Medication Reconciliation Next?” and our September 8, 2009 Patient Safety Tip of the Week “Barriers to Medication Reconciliation”
http://www.patientsafetysolutions.com
Patient
Safety Tip of the Week Archive
What’s New in the Patient Safety World Archive