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Improve medication reconciliation process to eliminate discrepancies
Match medications with disease condition
It's a given in 21st century United States that many patients are caught up in polypharmacy; they're taking a variety of medications, prescribed by various providers, and fulfilled at any number of pharmacies.
This is why it's so challenging for nurses, physicians, and pharmacists to find out precisely which drugs each patient has been taking at home.
The medication reconciliation process is laden with problems, notes Douglas Slain, PharmD, BCPS, FCCP, an associate professor in the department of clinical pharmacy at West Virginia University School of Pharmacy in Morgantown, WV.
"Patients go to a lot of practitioners and start on a lot of drugs," Slain says. "They might be started on a drug for a short-term reason, and then they'll stay on the drug without a critical need for it."
Slain co-authored a study about medication discrepancies that showed that nearly 70% of patients admitted to a hospital had at least one unspecified medication listed in the admission note. Unspecified medications were those where an indicated disease state or condition for the medication was not reported.1
So as part of the medication reconciliation process, it's important to have a pharmacist match the patient's medications to the patient's disease condition and symptoms.
"Oftentimes patients are on drugs for which we never hear that they have a disease that requires those drugs," Slain says.
This could result from the patient using a drug for a short-term problem and then staying on it, or it could be that the patient does have a condition that might require the medication, but no one has documented this diagnosis.
For example, Slain's research has demonstrated that patients sometimes are taking selective serotonin reuptake inhibitors (SSRIs), although the patient doesn't mention having depression or anxiety when the medical history is taken, Slain says.
"What I advocate is probing when something is not clear-cut, or when there's not a definite match," he adds. "If there isn't a disease that is directly stated, then you should ask direct questions like, 'Why are you taking this medication?'"
Slain and co-investigators have developed a simple algorithm that a pharmacist could use to help clarify why a patient is taking a particular drug.
"When there is a drug that has no specified indication in the medical history, then there's this algorithm a person could go through to clarify why the person is on the drug," Slain explains. "If it couldn't be clarified, then the pharmacist would notify the hospital physician and recommend discontinuing the medication."
Besides clearing up discrepancies and alerting physicians to unnecessary prescriptions, this process will improve safety, Slain notes.
For instance, the Beer's Criteria contains a list of drugs that are potentially inappropriate in elderly patients. Some of the medications on that list appeared in the medication reports of elderly patients included in Slain's studies, he says.2
When patients are admitted to the hospital, it's a good time to evaluate the patient as a whole and figure out if the patient's home medication regimen is good for them, Slain says.
"We have so much knowledge at the hospital, and we could evaluate what the patient truly needs," he says. "We might be able to decrease some of these medications."
This approach makes sense, and it's time that hospital physicians move beyond their reluctance to discontinue medications that were started by primary care physicians in the community, Slain adds.
Also, pharmacists must rely on direct questioning to fill in the medication and diagnosis blanks.
In Slain's medication discrepancy research, direct questioning of either the patient or a family member has been the best way to fill in gaps.
"Sometimes we had to go through previous on-line clinic notes to find out more about medication we didn't have a disease to match," Slain says. "But most of the time we did this through direct questioning."
In a second study, they were able to clarify the medications and diagnoses 92% of the time, Slain adds.
"We concluded that if you had a pharmacist working in the emergency room or involved in medication reconciliation, you could have enhanced the rate," Slain says.
Although putting pharmacists in this role is expensive for a hospital, there are ways to make it more affordable, including assigning pharmacy residents or students to the job of medication reconciliation, Slain suggests.
With training, they can conduct these reconciliations fairly quickly, he says.
"It took us 9 minutes per patient to evaluate the medications and get clarity when performed within several hours of admission," Slain says. "The range was from 2 minutes to 25 minutes, and it could have been less time if the medication reconciliation was done at the front end at admission."
Also, most of these were cleared up through conversations with the patient.
"The percent clarified at the patient level was 80%," Slain says "So 80% of unspecified medications were clarified by the patient or caregiver."