JCAHO issues sentinel event alert on medication accuracy

Aims to reduce errors in medication reconciliation

The nation’s largest hospital accreditation organization has issued a new warning aiming to reduce harmful incidents arising from inaccurate delivery of medications. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued a new Sentinel Event Alert in January that urges intensified attention to the accuracy of medications given to patients as they transition from one care setting to another or one practitioner to another.

The alert specifies that medication reconciliation should occur whenever a patient moves from one location to another location in a health care facility (for example, from a critical care unit to a general medical unit); or from one health care facility to another or to home; and/or when there is a change in the caregivers responsible for the patient. When effective medication reconciliation does not occur, patients may receive duplicative medications, incompatible drugs, wrong dosages, or wrong dosage forms, among other potential errors. The medication reconciliation process also provides an important opportunity to assure that the patient is receiving all medications necessary to his or her care and to eliminate any medications that are no longer needed by the patient.

The U.S. Pharmacopeia in 2005 received more than 2,000 voluntary reports of medication reconciliation errors, and a 1999 Institute of Medicine report estimated that more than 7,000 deaths occur each year in hospitals alone due to medication errors. JCAHO’s sentinel event database also identifies medication errors as one of the most frequently occurring threats to patient safety. The database reveals that 63% of the reported medication errors resulting in death or serious injury were due to breakdowns in communication, and approximately half of those would have been avoided through effective medication reconciliation.

The fact that medication reconciliation errors continue to occur, despite repeated warnings and rigorous standards, prompted the Joint Commission to issue the new alert on medication reconciliation to the more than 15,000 health care organizations it accredits. 

"A systematic approach to reconciling medications must be the foundation for all efforts to prevent drug errors," says Dennis S. O’Leary, MD, JCAHO president. "As challenging as this effort may be, it will be well worth the investment for caregivers and patients alike."

To reduce the risk of errors related to medication reconciliation, JCAHO recommends that health care organizations:

  • Put the list of medications in a highly visible place in the patient’s chart and include essential information about dosages, drug schedules, immunizations, and drug allergies;
  • Reconcile medications at each interface of care, specifically including admission, transfer, and discharge. The patient and responsible physicians, nurses, and pharmacists should be involved in this process;
  • Provide each patient with a complete list of medications that he or she will take after being discharged from the facility, as well as instructions on how and how long to take any new medications. The patient should be encouraged to carry this list and share it with any caregivers who provide any follow-up care;

In addition, as part of its current national patient safety goals, the Joint Commission also specifically requires that each accredited health care organization:

  • Implement a process for obtaining and documenting a complete list of the patient’s current medications upon admission. This includes a comparison of the medications the organization provides to those on the list. The patient should be asked to describe or confirm any prescription medications, over-the-counter medications, vitamins, herbs or other supplements that he or she takes;
  • Communicate a complete list of the patient’s medications to the next service provider when the patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization.

The warnings about medication reconciliation are the latest in a continuing series of Sentinel Event Alerts issued by the commission. Much of the information and guidance provided in the alerts are drawn from the sentinel event database, which includes detailed information about both the adverse events and their underlying causes. The complete list and text of past issues of Sentinel Event Alert can be found on the Joint Commission web site at www.jcaho.org.