JCAHO alert addresses medication errors

Reconciliation prevents mistakes

More than 10% of all sentinel events reported to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) relate to medication error; but in home care, more than 13% of sentinel events relate to medication error.

According to the Joint Commission, in a Sentinel Event Alert issued in January 2006, 63% of the medication errors that resulted in death or serious injury were a result of a communication breakdown. Half of the communication breakdowns would have been avoided with effective medication reconciliation, according to report authors.

To reduce errors related to medication reconciliation, the authors recommend:

  • 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.
  • Reconcile medications within specified time frames (within 24 hours of admission; shorter time frames for high-risk drugs, potentially serious dosage variances, and/or upcoming administration times).
  • Adopt a standardized form to use for collecting the home medication list and for reconciling the variances (includes both electronic and paper-based forms).
  • Develop clear policies and procedures for each step in the reconciliation process.

As part of its current National Patient Safety Goals, the Joint Commission also 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.

Resources

To see a full copy of the Sentinel Event Alert, go to www.jcaho.org and choose "Sentinel Event Alert, Issue 35: Using medication reconciliation to prevent errors" in the "headline news" section.

The Institute for Healthcare Improvement's web site includes a section on medication reconciliation review, including samples of a reconciliation tracking tool and a medication reconciliation flow sheet. Go to www.ihi.org, click on "topics" on the left navigation bar, choose "patient safety," then choose "medication systems." Under "medication systems," click on "tools," then choose "medication reconciliation" to see a list of forms and tools that can be used for medication reconciliation.