Patient safety and quality issues seem to have years when they are popular, and then years when they fall out of favor, when other items get all the press. Medication reconciliation is one of those that seems to be off the radar these days, with everyone focusing on readmission reduction or how to combat hospital-acquired conditions. But the issue is still one that is impacting patients, says Mary Beth Mitchell MSN, RN, CPHQ, CCM, SSBB, a patient safety analyst and consultant for the patient safety, risk, and quality group at ECRI Institute in Plymouth Meeting, PA. It is an “error-prone process” and ECRI released a paper on the topic in June to coincide with Healthcare Risk Management week.
“It can be hard to determine its impact, and whether it is increasing or not, or whether people are just more cognizant of reporting it,” she says. “Increased reporting doesn’t mean we haven’t made progress on the reconciliation process itself. Institutions are reporting more near misses on the topic, too. This increased reporting in and of itself is progress.”
What is known is that patients still suffer because of inadequate, improper, or imprecise medication reconciliation in just about every healthcare environment and at just about every point where it should be done, she says. On admission to the hospital, one of the most common problems is not getting an accurate list of medications in use. “It could be because the list you get on transfer to the hospital is not verified against another source,” says Mitchell.
Other reasons for errors might include that the patient is reporting a list that is not checked with a pharmacy or with the doctor, or the doctor is forwarding a list that doesn’t include what the patient is taking as prescribed by a specialist, she continues. A patient might not know the medications they are taking, or can’t report them accurately because of his or her condition. They might not think to include all the non-prescription items they take, or think that supplements and vitamins “count,” Mitchell says. “Intake is one of the most important medication reconciliations you do. Patients make their best effort, but we can’t just rely on them. They might go to many doctors. If they have a list, it might not have been updated. If they bring in all their bottles, they might be bringing in bottles of drugs they haven’t taken in years. You have to be able to verify this list.”
Getting it right on discharge is equally important, says Mitchell. “Helping patients understand what they need to be taking, when and how much, at a time when they might not be as mentally together as you’d like, can be difficult. And you have to help them understand, too, what you do not want them to take any longer.” Make sure that someone is with the patient, listening and taking notes with them. And the written information you provide, Mitchell says, should agree with the drugs the patient will take at home. For example, if the patient will be taking generic drugs, your written instructions should include generic names, not name brands. If they are going to an assisted living situation, then the nurse there will need to verify and do an admission reconciliation, too.
Mitchell says that there are some computer systems which are more patient-friendly than others. If you are using a system that prints out medication instructions, be sure to go over it with the patient and his or her caregivers. If they aren’t patient-friendly, make sure the patient understands what is written and correct anything that is not understandable to the patient.
One thing that is not done nearly enough, she says, is a proactive analysis of the medication reconciliation process. “Where are your gaps? You may look for these when an event occurs, but why wait? Look for where things can fall through the cracks.” She says the increase in near-miss reporting shows proactive thinking, and taking regular looks at processes, breaking them into steps and assessing where there may be vulnerabilities with the frontline staff involved is a great way to avoid not just events, but even near misses.
“Performing an FMEA (Failure Mode and Effects Analysis) is not more complicated than doing an RCA but takes a proactive approach rather than a reactive approach,” she says. Such analyses -- when broken into process steps for admissions, as well as for transitions of care from unit to unit and from hospital to the next mode of care or to home -- is “not as costly and is easier to correct than after a patient is harmed.”
The risk management document that ECRI released in June, which is available to members, suggests actions including the following:
- Get a multidisciplinary team together to identify opportunities to improve medication reconciliation and ways to measure effectiveness of existing and new strategies. Mitchell says a multidisciplinary approach will involve getting people from every entry point to the hospital — the emergency department, direct admissions, and the OR, as well as representatives from nursing and physicians. In some facilities, but not all, pharmacy will also be involved.
- Have a standard approach to the reconciliation process at every transition to a new unit or new level of care. It should be the same thing every single time.
- Make someone accountable for each step.
- Help patients understand the importance of keeping an up-to-date medication list and having it at every healthcare appointment. Mitchell says there are lots of templates available online for medication lists. Having them available to patients, or even filling one out with current medications and giving a few copies to the patient on discharge for him or her to keep at home, in a purse, or with a loved one or whoever has medical power of attorney, is a great way to ensure that they have easy access to a current list when they go to their first post-discharge appointment.
Mitchell also suggests looking at the recent events you have had related to medication. That can help you determine where you have gaps and then get that multidisciplinary team working on how to eliminate them.
ECRI has more information available on medication reconciliation and how to help reduce the problems associated with it in its most recent Top 10 Patient Safety report available at https://www.ecri.org/Pages/Top-10-Patient-Safety-Concerns.aspx.
For more information on this topic, contact: Mary Beth Mitchell MSN, RN, CPHQ, CCM, SSBB, Patient Safety Analyst/Consultant III, ECRI Institute PSO, Healthcare Quality and Insight Assessment Services, Patient Safety, Risk and Quality Group, ECRI Institute, Plymouth Meeting, PA. Telephone: (610) 825-6000.