Help your hospital meet the new medication reconciliation requirements
Help your hospital meet the new medication reconciliation requirements
JCAHO requires complete medication lists at admission, transfer, discharge
Case managers should be part of the team that ensures hospitals meet the Joint Commission on Accreditation of Healthcare Organizations' medication reconciliation requirements, says Patrice Spath, RHIT, health care quality consultant with Brown-Spath & Associates in Forest Grove, OR.
The 2007 National Patient Safety Goals call for hospitals to accurately and completely reconcile medications across the continuum of care to make sure there are no errors of transcription, omission, duplication of therapy, or drug-drug interactions, says Carol Ptasinski, RN, MSN, MBA, senior associate director of standards interpretation for the Joint Commission.
"Completely reconciling means comparing medications that the patient has been taking prior to admission with medications the organization is about to provide," she says.
In addition, the Institute of Medicine of the National Academies released a report in July, Preventing Medication Errors, in which it called for a series of actions for health care organizations, including medication reconciliation, electronic prescription writing, and better communication between health care providers and patients.
Medication reconciliation needs to occur any time the organization requires that orders be rewritten and any time the patient changes services, setting, provider, or level of care and new medication orders are written, Ptasinski says.
Beginning in 2007, the Joint Commission will require an organization to provide the list of medications to the patient and his or her primary physician or send it to the post-acute facility that will care for the patient.
"The list should be provided to the primary care physician before the patient's next appointment to ensure continuity of care," Ptasinski says.
Some organizations were not sure that the medication list had to be given to the patient, under the 2006 goals. The 2007 goals clarify that and say if a patient is discharged to home, the list should be given to the patient in a form he or she understands, Ptasinski adds.
Case management's role in a hospital's medication reconciliation efforts depends on the case management model, Spath points out.
At the very least, case managers should be aware of the medication reconciliation requirements and should be involved in the discussions of how the hospitals will meet the requirements, Spath says.
"Unless case managers are managing the care of 100% of patients, they can't be totally responsible for medication reconciliation. If the case managers do not see every patient in the hospital, they are likely to have a secondary role in medication reconciliation efforts," Spath says.
Even if case managers don't have the primary responsibility for medication reconciliation, they can act as a backup or safeguard to make sure that the medication reconciliation process occurs as patients move through the system, she says.
At Calvert Memorial Hospital in Prince Frederick, MD, case managers are a safety net for the hospital's medication reconciliation efforts, says Jennifer Stinson, RN, BSN, CCM, director of case management.
The case managers round daily with the clinical pharmacists, who are located on every clinical unit in the hospital.
"The clinical pharmacist is on the unit and easily accessible by the staff. They are the medication gurus, and we can pull them in at any time to answer any questions the patient may have," Stinson says.
They go over the medications that are ordered while the patients are in the hospital, those they were taking before admission, and those they are supposed to take after discharge.
"The case managers are in a unique position at this institution. They see the patients from admission to discharge and are in a great position to monitor the medication reconciliation process to make sure it is taking place," Stinson says.
Under the JCAHO requirements, the hospital should make sure the patients are on the right medication regimen when they are transferred from the intensive care unit to a step-down unit and from the hospital to home or a post-acute facility.
At the time of admission, someone, usually a nurse, should collect information about what medications the patient is taking, according to Ptasinski.
The Joint Commission encourages hospitals to identify medications, such as insulin, that are higher risk and that should get priority in your medication reconciliation efforts.
"You don't want to wait 24 hours to find out a patient is taking some kinds of medications," Spath says.
One role for case managers is to serve as a backup person who alerts the rest of the staff when the medication reconciliation requirements have not been completed.
Case managers can be particularly helpful as the hospital compiles lists of medications the patient was taking before admission, Spath points out.
"A lot of patients don't carry a list of their medications in their pockets, and they may not have the information when they are admitted," she says.
Case managers should encourage patients and family members, particularly those with chronic conditions, to create a list of medications and keep it with them at all times.
"Maybe hearing the case manager explain the importance of keeping the list will encourage them to write their medications down," Spath says.
Many hospitals develop medication wallet cards that they give patients with the admonition to keep them updated.
"Case managers can help reinforce the importance of keeping the medication list," she says.
El Camino Hospital in Mountain View, CA, has been involved in educating the public about the importance of letting their medical providers know exactly what medications they are taking.
"The community is getting more attuned to the medication reconciliation issue. Some patients are coming into the hospital with a bag of pills saying they know they're supposed to bring them," says Michael Fitzgerald, MS, RN, CS, who chairs the hospital's medication reconciliation committee.
The hospital plans to participate in community health events, handing out cards with places for people to list the medications they are taking.
"The goal is that they will bring the card with them when they see their physician or come into the hospital," he says.
The hospital is working with physicians to encourage them to update their patients' list of medications during every office visit.
At Calvert Memorial Hospital, the case managers support the efforts of the bedside nurses to educate patients on their medication use and other discharge issues from the beginning of the stay.
"Medication reconciliation and patient education is very much a team effort," Stinson says.
The case managers document that the patient has received discharge education about his or her medicines. For instance, if a patient is taking a lot of medication or his or her medication has been adjusted during the hospital stay, the case manager and pharmacist work together to make sure the patient understands the medication changes and that he or she should throw out the old medication after discharge.
Case managers often are the first to pick up if a patient is having a problem with his or her medication, Stinson says.
"Case managers are in such a unique position with patients. We see them from start to finish and are in a position to identify any system failures or risk management issues that occur," Stinson says.
Medication lists
The Joint Commission's 2007 goals call for an organization, with the patient's involvement, to create a complete list of the patient's medications at admission and to ensure that the medications administered to the patient are compared to those on the list and any discrepancies or problems are resolved. The list should include over-the-counter medicines, vitamins, and supplements, Ptasinski says.
"When a patient comes into the hospital, whether it's through the emergency department, a direct admit, or through ambulatory surgery, someone on the staff must get an accurate and current list of the patient's medications," she explains. The organization needs to determine which staff member will obtain the list of medications the patient is on.
In the inpatient setting, the list should be included on the patient's medical admission record. Any time new orders or prescriptions are written, whoever is writing the prescription should make sure it is included in the medical record.
Problems have occurred in the past when a patient was admitted to one unit, such as the intensive care unit with medication orders issued, then transferred to another unit where he or she would continue getting the medication ordered in the ICU along with new medications ordered on the unit, Spath says.
Another trouble spot for medication errors is the surgical unit. Sometimes when a patient is discharged after surgery, the surgeon writes, "resume all previous medication" without knowing what they were and without realizing that some could be discontinued after the surgery.
"When patients go home and resume taking one medication, they might not realize that their new medication is the same, but it's either generic or a different brand name. This can cause tremendous problems," Spath says.
This is why whoever is in charge of the discharge process should make sure their patients understand what they should be taking and what they should not be taking, Ptasinski adds.
Before the patient is discharged, someone on the staff, as determined by the organization, should go through the entire list of medications, looking at what the patient was taking before admission and comparing them with what the patient will take after discharge, Ptasinski says.
She suggests that whoever writes the discharge instructions should write, "Do not take this medication," and "Now take this medication instead" to make sure that the patient clearly understands what to take and what not to take.
For more information, contact Patrice Spath, RHIT, health care quality consultant, Brown-Spath & Associates in Forest Grove, OR. E-mail: [email protected].
Case managers should be part of the team that ensures hospitals meet the Joint Commission on Accreditation of Healthcare Organizations' medication reconciliation requirements, says Patrice Spath, RHIT, health care quality consultant with Brown-Spath & Associates in Forest Grove, OR.Subscribe Now for Access
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