ED Accreditation Update

The Joint Commission says the goal for medication reconciliation is unchanged

Keeping up with changes in standards from The Joint Commission and the attendant interpretations can be a challenge for the most conscientious of ED managers — especially when they come as quickly as they have in the area of medication management. The most recent action was the suspension of a Jan. 1, 2007, interim action that had changed the requirement for pharmacy review of ED medication orders [element of performance (EP) 1 for standard 4.10 of medication management]. Once again, prospective review is required, although The Joint Commission is allowing broader interpretation of the exceptions to the requirement for prospective review.

With this being the fourth stance taken by The Joint Commission on this issue, it is not surprising that some ED managers believe there has been a change in another medication management area: medication reconciliation. However, as one Joint Commission official emphasizes, that is not the case.

"We have not changed our National Patient Safety Goals [on medication reconciliation]," explains Peter Angood, MD, vice president and chief patient safety officer for The Joint Commission. While standard 4.10 is "mostly focused toward pharmacy review," he notes, it does mention medication reconciliation as well — thus the potential source of confusion. The specific expectations, however, are delineated in National Patient Safety Goals 8, 8a, and 8b. Both the goals and the standard, he notes, are surveyed and evaluated for accreditation.

"We are concerned enough with the confusion about medication reconciliation that we are planning for a summit conference in the fall to review the different issues that have come up," Angood adds. The summit will be for invited participants only.

ED managers should not underestimate the Joint Commission's commitment to medication safety, warns Andrew Jenis, MD, the ED director and chairman of emergency medicine at Cortland (NY) Memorial Hospital. "The impression I've always gotten from the Joint Commission is that there may be some wiggle room, but they are all about safety; just because some people argue [medication reconciliation] involves a few inconveniences, that doesn't mean they are changing their stance," he says. "That would be a complete reversal — saying that knowing patients' meds is not important — and the biggest risk patients face when they wander into a hospital is going to be an adverse drug reaction."

In reviewing the medication reconciliation requirements, Angood notes that a facility must have and do the following:

  • A complete list of home medications at time of entry, including prescribed drugs, supplements, and vitamins. "What is often forgotten are things like inhalers, so the generation of an initial list is an important part of the whole process," says Angood. The need to generate this initial medication list is required in the ED, he emphasizes. For ED patients who are unable to provide these details, an attempt should be made to obtain the information from family or designated care provider. "Many institutions with successful programs have set a self-imposed 24-hour time limit to complete this initial step in the reconciliation process," notes Angood.
  • As the patient moves through the facility, the list must be reviewed, and any changes, subtractions, or additions must be reconciled as part of a standard process.
  • At the time of discharge, including discharge from the ED, the patient must receive the updated list, along with the name of the next facility they are going to (if applicable), and ideally, that of the primary care provider.

"The places that seem to do well [with compliance] are those that have standardized processes from the ED to the inpatient setting to the time of discharge," notes Angood. This standard does not, he emphasizes, require an electronic medical record. "This can be easily done with handwritten medical notes," he says. "What's most important is that the standardized pattern is such that it comes to be expected by doctors, nurses, and pharmacists." The forms should be set up so the users can look through them quickly and add or subtract their own modifications to get it updated, he says.

The best forms, says Angood, include breakdowns between prescribed medications, supplements, and other nontraditional therapies. "The goal is to stimulate the care provider to ask questions in those categories," he explains. "Left to their own devices, patients will not remember to tell anybody [about supplements]."

Mary Fran Hughes, RN, MSN, nurse manager of the ED at Massachusetts General Hospital in Boston, says, "We don't have electronic medical records in the ED, so we designed a two-part form [made of pressure-sensitive paper] where nurses and physicians can both collect patient medication information and give a completed copy to the patient on discharge in end." This form, Hughes explains, eliminates the need for "double documentation."

Before the form was finalized, the staff nurses and physicians reviewed it to make sure it was easy to use, that there was enough space between items, etc. Ann Morrill, RN, a staff nurse in the ED at Massachusetts General, says, "It's so well laid out that we really don't even have to think about it; it just flows right across the paper." [Editor's note: Click here for a copy of the form.]

Jenis says they're lucky. "We have an electronic health record, so if the patient has been to our ED before, we just look at their record and ask if they are still on the same meds or taking new ones," he says. "If they haven't been here before, of course, we get the list up front."

When he enters a medication, the system automatically conducts an adverse reaction and allergy search. Before he had the electronic record, Jenis used a software program from Pepid in Evanston, IL, which he ran on his personal digital assistant (PDA) to warn him of potential interactions. You need to use a program like that, he maintains. "You must realize how incredibly safe it can make your care, as you can't possibly memorize every drug interaction," Jenis says. "On discharge, you can also make sure the new meds you are giving will not cause any interactions."

Jenis has some additional tips for EDs that are not on an electronic system. "If people come by ambulance, the EMTs are going to have to bring in their meds," he says. "They should be trained to scoop the home meds up and bring them in — the families, too." When the patients and families are really not sure of the meds they are taking, Jenis recommends calling the patient's pharmacy to obtain an instantaneous list. "Most places will fax it to you, while others will read it off," he says. "If a family member wants to be helpful, you could ask them to go home and get all of their relative's meds."

Jenis says he and his staff also work with outpatient clinic physicians to try to create a better list, by asking for their assistance in keeping the medication lists up to date. "We don't hold formal seminars, but sometimes we'll have patients who complain the list of meds they had for admission were bad," he notes. In such cases, he says, "It's worth it to have your nurses put in a little labor and call their physicians."


For more information on Pepid medication reconciliation software for personal digital assistants (PDAs), contact:

  • Pepid, 1840 Oak Ave., Suite 100, Evanston, IL 60201. Phone: (888)321.7828. Fax: (866) 681-8207. Web: www.pepid.com.