Sentinel Event Alert: The time for medication reconciliation is now

Most programs will need tweaking, says Joint Commission surveyor

By now, hospitals should have fully developed and implemented a process to comply with 2005’s National Patient Safety Goal (NPSG) 8 of the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL: "Accurately and completely reconcile medications across the continuum of care."

Still, the Joint Commission issued a Sentinel Event Alert in late 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 failure to reconcile medications during these transitions can cause serious patient injuries and even death," the Alert says.

Medication reconciliation isn’t new, says Sonja A. Nisson, PharmD, a Joint Commission surveyor and regional manager of pharmacy and diabetes at Asante Health System in Medford, OR. "We’ve already had two standards in medication management that refer directly to making sure that the patient has a safe and accurate list of medications, and making sure that there is a therapeutic indication for any medication you’re giving. We should be well down the road to this, but it is challenging to do in the overall scope of things." She made these remarks at the American Society of Health-System Pharmacists Midyear Clinical Meeting, held last December in Las Vegas.

The requirement for NPSG 8 for 2006 has two parts. They are:

  • 8a: 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.
  • 8b: Communicate a complete list of the patient’s medications to the next provider of service when a patient is referred or transferred to another setting, service, practitioner, or level of care within or outside the organization.

"Both of these are very difficult things to do, but hopefully, we are well down the path of doing them," Nisson says. Any organization that doesn’t have a process in place will be scored as noncompliant.

"It’s not enough for a manager to tell the surveyor, This is what we implemented.’ The real proof is when we go out to do the tracers," she says. "When we go out to do the tracers, we need to see that this process is being followed 100% of the time." To add to the challenge for hospitals, the Joint Commission’s surveys this year are unannounced.

Nisson gave a quick overview of what the Joint Commission wants to see for hospitals to be compliant with this goal. First, hospitals should do as good a job as they can of getting a list of the medications the patient is on. Second, they should make sure that the list is available to the providers when they order those medications. Finally, when patients are admitted, hospitals should make sure that any medication that’s not ordered was omitted intentionally.

"The long and short of it is that our patients get on the right medications in the beginning," she says.

About 50% of our medication errors today are directly related to communication deficits, as well as about 15% of our adverse drug events, Nisson explains. "This is critical to our patients’ safety."

The Joint Commission has seen a disproportionate number of hospitals piloting their programs in December. Programs piloted last spring and early summer, however, have rarely gone without problems.

"It will take some tweaking," Nisson says. "Get the best you can in place on time and make it a dynamic process."

Although many hospitals are overwhelmed with developing this process, Nisson says, it will get progressively easier over time. It is important to remember to keep the process simple. "We want something that people will use. A multidisciplinary approach is also more effective than one person dreaming up the process."

Studies have shown that once a medication reconciliation process has been implemented, it does save time. In one example, the process saved nursing 20 minutes on its admission assessment. The organization used pharmacists on the discharge end. The process saved it an average of about 45 minutes.