SDS Accreditation Update

Alert addresses medication errors

Reconciliation prevents mistakes

More than 10% of all sentinel events reported by organizations accredited by the Joint Commission on Accreditation of Healthcare Organizations relate to medication errors, and in ambulatory and office-based surgery organizations the rate is almost 8%.

Miscommunication can be fatal

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

Because his surgery center conducts the preoperative evaluation and gathers information on the patient’s medications by telephone three days prior to surgery, it is important that the nurse making the call is good at gathering medication information, says Geoffrey Hibbert, RN, director of nursing at the Center for Special Surgery in Greenville, SC. "Not only is that first telephone call our chance to make a positive impression on the patient, but we also need to make sure we get the most accurate information," he explains.

The nurse who handles his pre-op evaluations is an RN with more than 18 years of experience, Hibbert reports. "She asks about prescription medications, vitamins, over-the-counter medications, and herbal supplements," he explains. As she talks to the patients about other medical conditions that may exist, she will ask them what they are taking for that condition, in order to make sure no medications are missing from the list, Hibbert adds.

After talking with the patient, the nurse reviews the list of medications for potential interactions with drugs administered during surgery, makes sure all allergies are noted in the chart, and consults with the anesthesiologist if she has questions about a medication’s potential risk for interaction, says Hibbert. Even if the pre-op nurse does not notice any potential problems, the surgeon and the anesthesiologist review the medication list prior to the day of surgery, he says.

"Our medication information is collected on a standardized form that is placed in the same location in every patient’s chart," Hibbert points out. This standardization means that staff member at each phase of care do not have to search for the information, he adds.

At University of North Carolina Health Care System in Chapel Hill, an electronic medical record is used to capture all of the preoperative information, including detailed lists of prescription medications, over-the-counter medications, vitamins, and herbal supplements that the patient may be using, says Larry Mandelkehr, CPHQ, director of performance improvement. The electronic record and the paper chart that follows the patient through the outpatient surgery process are standardized so that medication information appears in the same place in the chart for all patients, he adds.

Cover medications at discharge

Upon discharge, patients received detailed discharge instructions that explain what new medications are being prescribed, how much to take, when to take, and how to take the medications, explains Mandelkehr.

"The discharge instructions also include when their last dose was administered and when they should take the next dose," he says.

This information is important because patients may not be aware that a pain medication was given to them in the recovery room and that they can take their next dose four hours from that point as opposed to four hours from their discharge time.

"Patients and their caregivers are also given instruction on over-the-counter or herbal supplements they should avoid," says Hibbert. "If a patient is taking a medication that contains acetaminophen, we don’t want the patient to take an over-the-counter acetaminophen for a headache, so we explain what is in each medication."

Hibbert’s facility will not release a patient until the family caregiver has been given discharge instructions, he says. "Although we prefer that the caregiver be in the facility to take the patient home when we are ready to discharge, it doesn’t always happen. If patients have to wait any time, even up to several hours, for a family member to pick them up, we don’t let the patient leave until we have presented discharge instructions to the caregiver as well."

Not only do patients get to hear the discharge instructions again, but staff members can be sure that instructions have been given to someone who has not been under anesthesia and is fully alert, he adds.

The key to an effective medication reconciliation process is to involve all areas in the development, suggests Mandelkehr. Physicians, nurses, pharmacists, and information technology staff members working together will generate a lot of ideas that can be considered, he says. One item that his facility is investigating is software that can be used to identify potential drug interactions at the initial stage of obtaining medication information, he says.

"Technology can’t replace the knowledge of our clinicians who gather and review medication information, but it can act as a backup to ensure patient safety," he adds.

When reviewing your reconciliation process, be sure to build a lot of checks and balances, suggests Hibbert. "When something bad happens, it doesn’t happen because of one mistake, it happens because a lot of mistakes along the way were made," he says. "We triple- and quadruple-check our records by requiring everyone who comes into contact with the patient to check medications and other items such as surgical site, so that we can catch errors in our information before they affect the patient’s safety."


For more information on medication reconciliation, contact:

  • Geoffrey Hibbert, RN, Director of Nursing, Center for Special Surgery, 209 Patewood Drive, Suite 300, Greenville, SC 29615. Telephone: (864) 527-7700. E-mail:
  • Larry Mandelkehr, CPHQ, Director of Performance Improvement, University of North Carolina Health System, 101 Manning Drive, Chapel Hill, NC 27514. Telephone: (919) 966-0488. E-mail:

The Institute for Healthcare Improvement web site includes a section on Medication Reconciliation Review, including samples of a reconciliation tracking tool and a medication reconciliation flow sheet. Go to, click on "topics" on left navigational 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.

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