Some whos, hows, whens, and whys of reconciliation

Process requires real change, says JCAHO surveyor

Medication reconciliation is a requirement of the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL. Many hospitals, however, still are bogged down in details of developing and implementing this process. A Joint Commission surveyor recently gave some tips on navigating the rough waters.

The first part of the accrediting body’s National Patient Safety Goal (NPSG) 8 is: "Implement a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization and with the involvement of the patient. This process includes a comparison of the medications the organization provides to those on the list."

One of the first questions is who should obtain this medication list, says Sonja A. Nisson, PharmD, a Joint Commission surveyor and regional manager of pharmacy and diabetes at Asante Health System in Medford, OR. Nisson spoke at the American Society of Health-System Pharmacists Midyear Clinical Meeting, held last December in Las Vegas.

This is not necessarily pharmacy’s responsibility, but Nisson recommends that pharmacy be involved. She sees a couple of hazards of making it a pharmacy job. "One is that it is difficult to get everyone’s ownership if it is a pharmacy job. This is really a medication management issue. The second one is that if a pharmacist isn’t available all the time, a pharmacist-driven process will fail."

The person responsible for this task should have "sufficient expertise." Suggestions for this person include the triage nurse in the emergency department, the admission nurse, the admitting physician, the nurse with the primary responsibility for the patient, or the caregiver — a physician or nurse — who sees the patient first.

Next is the question of when this should take place. The answer is on admission or as soon as possible thereafter. The Joint Commission recommends:

  • Prior to the next prescribed dose.
  • A target of six to eight hours. The target is four hours for high-risk medications and/or circumstances.
  • Prior to the physician writing admit orders.

The requirement is within the time frame of the initial assessment. "By definition in hospitals, that is within 24 hours," Nisson says.

Next is the question of how this should take place. One way is for the patient to complete a questionnaire. Another is to have interview questions on the back of a form. Patients or their relatives can also bring a bag of their medications into the hospital for identification. Finally, hospital staff can call physicians and pharmacies that service the patient.

Strive for "reasonable" completeness and accuracy. "People want to develop something that is just right. They spend a lot of time [wondering if it will work in this area and that]. Don’t let perfect stand in the way of good," Nisson says. "Go with those areas where it will work the majority of the time. Take on what is doable. See how that works and adjust it for the other areas."

Nisson often sees three or four lists when she reviews records. "You have a list that is in the medication history. You have a list that somebody did in a cursory way on admission. You have the doctor’s initial order. You have a partial grocery bag that a relative brought in with a list of what they think they are taking. Getting this integrated into a systematic approach with one list is really important for success."

Don’t accept lists without questioning the patient or relative, Nisson says. Also understand that the list is a dynamic document.

"Involve the patient in this when you can. If you get more information on day two, then add that information on day two. We want [this list] to be something that means something."

Also, she continues, one of the worst things hospitals can do in this process is telling staff that they are reconciling medications because it is required by Joint Commission. "We are doing it for patient safety."

The list should be placed in a highly visible location in the patient’s chart and include dosage, drug schedules, immunizations, and allergies or drug intolerances. Some hospitals make the list a different color so it stands out.

Reconciliation: Address discrepancies

The next step is reconciliation, the most important component of the first part of the goal. Reconciliation means comparing the medication list against the physician’s orders, and identifying and bringing any discrepancies to the attention of the physician.

Look for differences between what the patients were taking when they came in and what they are taking now, Nisson says. Were the differences intentional? "Of course, there are some things that patients take at home that they don’t need to take or may not even be appropriate to take at the hospital."

Any resulting changes in orders should be documented, "Otherwise, the reconciliation piece is a process,’ Nisson says. "It is not a documentation piece."

She then gives an example of how a Joint Commission surveyor might look at the reconciliation process. A patient, for example, might have a list of drugs that he brought in. He also has physician orders, and the two are not the same.

"First I talk with the nurse taking care of the patient to see how the reconciliation process worked. Sometimes one of the problems is that this nurse knew it. [He or she] left a message at change of shift and it dropped off in communication. Sometimes the nurses say, Yes, we did that.’"

The surveyor will then talk with the patient, who doesn’t understand why he isn’t getting this medication. "We can call and see — did the physician intend for the patient to be on this medication? We can back into this that way. In some instances, we can do it by interview." Nisson suggests hospitals trace the medications through their own systems as well.

It’s also best if the physician can use the list to write orders. "If you do that on the front, it will save a lot of work on the back end," she suggests.

Who should be responsible for reconciling the medications? The task needs to be assigned, Nisson says. "If everybody thinks anybody can do it, nobody will."

Any clinician with the background and experience necessary can handle this, she explains. Often a registered nurse has the primary responsibility to ensure completion of the process. The nurse contacts physicians and passes off unreconciled medications at shift change. Physicians, however, are ultimately responsible for their patients, she says, and may be the best choice.

The medication reconciliation should take place as soon as hospitals have a reasonably complete list. "Certainly don’t let it go because you don’t know about the very last med," Nisson says. Get the parts you can and catch up to the others later.

In hospitals, both the data gathering and the reconciliation need to be completed within 24 hours. "Make your best effort to do that," she says.

A standardized reconciliation form may be one of the best ways to begin. Nisson recommends examples available on the web site of the Massachusetts Coalition for the Prevention of Medical Errors (www.macoalition.org).

Don’t expect, however, to download a form, tweak it to get it through your forms committee, run it through your pharmacy and therapeutics committee, slap it on the chart, and tell everyone you are going to do it.

"This is not easy," Nisson says. "Difficult things can still be the right thing to do."

The process is difficult because it requires real change in the way hospitals work. "When you are actually working with it, the changes that are required become evident for what you need to do."

Nisson cautions that when hospitals change how they do things and are gathering information for medication management, they will create new risk points. "Be sure you look at those risk points and make sure you are addressing them."