Patient safety calls for going beyond the walls’
If your hospital had a completely paperless system, and all institutions in your community could communicate with one another electronically, then compliance with the Joint Commission on Accreditation of Healthcare Organizations’ medication goal would be a breeze.
Unfortunately, this is a pipe dream for most organizations.
"Without a single electronic medical record that is accessible for all health care providers, how do you communicate from one institution or level of care to another?" asks Kim Shields, RN, clinical systems safety specialist at Abington (PA) Memorial Hospital. "It is going to be quite some time before everybody is operating at that level of technical sophistication. So the challenge is, what do we do in the meantime? We are struggling with this, as I’m sure are other institutions."
Of all the Joint Commission National Patient Safety Goals, quality professionals agree that the requirement to reconcile a patient’s medications across the continuum of care is their biggest challenge.
"By far, this is the toughest goal," Shields points out. "For many goals, it’s just a matter of committing to doing them. But this is not something we have full control over, because it involves providing and receiving accurate medication information beyond the walls of our institution. That’s what makes it so difficult."
Still, Shields says the goal is moving in the right direction, to get health care providers "thinking outside their silos" and focusing on patient safety across the continuum of care.
The complexity of the health care system adds to the difficulty of compliance, says Marie Mercier, APRN-BC, CNS, lead clinical nurse specialist at NorthEast Medical Center in Concord, NC.
"The success of this goal will take a lot of communication and collaboration across all health care settings," she says. "This is definitely the most challenging goal for our organization."
Tackling standardization of the medication reconciliation process requires a performance improvement approach — "plan, do, check, act," says Patrice L. Spath, BA, RHIT, a health care quality specialist with Forest Grove, OR-based Brown-Spath & Associates.
The quality department staff may be involved in measuring compliance with the hospital’s procedures and evaluating measurement results to identify improvement opportunities, she says. "Quality managers should be involved in facilitating improvement teams and measuring the effectiveness of pilot projects."
The first hurdle to overcome is helping people understand that this is not a new requirement — the Joint Commission is just asking that the reconciliation process be performed consistently, notes Spath.
"While medication reconciliation may seem like something new, caregivers have been doing it for years — we just haven’t called it by that name," she says.
Identifying the owner of the process is a challenge because so many different caregivers are involved in medication reconciliation.
"The process owners in the emergency department may be different than in the intensive care unit," Spath explains.
Organizations must determine who ultimately is responsible for reconciling a patient’s medications in each different care setting. "Establishing accountability for the process is especially important for enforcing and measuring compliance," she says.
To comply with the goal’s requirements, consider the following:
1. Start small.
NorthEast’s strategy is to begin with a single inpatient adult medical unit and expand the process throughout the organization, Mercier says.
This is based on the work of the South Carolina Hospital Association and the Massachusetts Coalition for Patient Safety, which use one patient, one nurse, one physician, and one unit as a pilot for process changes, she adds.
"The patients on this floor are seen by hospitalists and discharged back to their primary care provider," Mercier notes. "This seems to be the best population to start with, since most patients are chronically ill and take multiple medications. Therefore, communicating information is even more critical and challenging."
2. Improve communication within your organization.
You must create a user-friendly process that does not require significant staff time or add unrealistic documentation burdens, Spath says. Here is what is required:
- At the time of admission to the hospital, someone must find out what prescribed medications the patient has been taking at home. The name of each medication, dosage, frequency, and route must be documented.
"This can be particularly challenging if the patient is unable to assist in creating this list, either because of their illness or language barriers," notes Spath.
- The home medications must be compared to what the physician has ordered for the patient.
- When patients are transferred among units in the hospitals, a similar reconciliation must occur — with medications the patient was taking while in the previous unit compared to the medications ordered for the current unit.
- At discharge, someone needs to compare all medications that the patient has taken in the hospital with what the physician orders for the patient at discharge.
Consider creating a medication form that includes space to document the reconciliation process at each phase in the patient’s hospitalization, Spath advises.
Since patients enter the hospital through various entry points, staff at each point must be trained in how to use this form, she adds.
"This can be an enormous undertaking, and that’s why many hospitals should start small. It is best to do pilot projects in just one or two units and refine the process with feedback from physicians and staff," Spath points out.
Don’t roll out process changes throughout the organization until those involved in the pilot are satisfied with both the forms and the procedure, she advises.
At Abington Memorial, a new computer system (Sunrise Clinical Manager 3.5 XA, manufactured by Boca Raton, FL-based Eclypsis) recently was implemented, allowing for immediate access to the patient’s hospital electronic medical record, which facilitates timely review and medication reconciliation.
Patients’ medication information moves with patients as they transfer within the institution, allowing physicians and nurses to add information along the way. "We aspire to use one communication tool throughout the hospital — it’s key for everybody to be working off the same documentation," says Shields.
The discharge instruction sheet is faxed to the patients’ primary care physician and involved specialists as a way of passing the baton with accurate patient information to the next health care provider. For patients transferring to an extended-care facility, a computerized printout is sent, which legibly lists patients’ discharge medications, says Shields.
3. Measure your compliance.
You need to determine whether the required documentation is present in the patient’s record, Spath says. "The form developed by the hospital for medication reconciliation should be present in patient records and should be used by caregivers as defined by hospital procedures," she says.
You also need to determine the percentage of medications that are actually reconciled, which can be calculated by dividing the total number of medications on the list by the number for which there is evidence of reconciliation, such as a check mark or other notation, Spath explains.
At a minimum, measurements should be taken on admission and on discharge, and if patients are transferred within the facility, measurement also should occur at that time, Spath advises. "Evaluating every patient record would be an enormous data collection task, so most hospitals only review a sample of charts from each unit," she says.
This review can be done on closed records or concurrently by quality department staff, case managers, or nursing supervisors, Spath says.
At NorthEast, open chart review is done to capture compliance on admission, and closed chart review measures compliance at time of discharge, to see if the patient’s medication list was sent to the next level of care.
"Initially, data will be collected concurrently by the patient safety committee members working on this project," Mercier notes. "After the process is up and going, I suspect retrospective review will be done."
4. Make patients more accountable.
Although organizations must do everything they can to ensure seamless communication about patient medications between health care facilities, part of the onus must fall on the patients themselves or a designee to provide correct medication information, Shields adds.
"The new JCAHO goal has challenged us to assure our patients understand the importance of being the historian of the medication they take, particularly since many patients have multiple health care providers prescribing medication," she says.
The organization currently is developing a system to reconcile medications for patients who arrive at the institution, Shields notes. "Part of our plan includes patient accountability. Including the patient as a member of the health care team is critical for achieving compliance with this goal."
The following are being implemented:
- A Partnering for Patient Safety program will be offered to the community. It will stress the importance of patients and their advocates knowing the medication and doses they take.
- At discharge, patients are given medication cards and advised to keep the card current and with them at all times.
- A one-page Partnering for Patient Safety education sheet was developed, outlining what patients can do to help ensure a safe experience during their hospital stay.
- Patients are encouraged to register with the Turlock, CA-based nonprofit organization MedicAlert, so that medical information, allergies, and DNR status could be accessed in a worldwide database. "We need to provide patients with tools to help them keep track of what medication they take," Shields explains.
It’s important to collaborate with health care providers outside your organization, she adds. "We are working toward the important goal of providing safe patient care across the health care continuum," says Shields.
NorthEast Medical Center plans to work with the North Carolina Hospital Association to endorse a statewide form for patients to keep up with their medication list, since compliance with the goal depends on patients and families to provide a correct and current list.
"Communication and collaboration is something we in health care need to improve on," Mercier adds.
[For more information on reconciling a patient’s medications, contact:
• Marie Mercier, APRN-BC, CNS, NorthEast Medical Center, 920 Church St., North Concord, NC 28025. Phone: (704) 262-4746. E-mail: firstname.lastname@example.org.
• Kim Shields, RN, Clinical Systems Safety Officer, Abington Memorial Hospital, 1200 Old York Road, Abington, PA 19001-3788. Phone: (215) 481-4378. Fax: (215) 572-9087. E-mail: KShields@amh.org.
• Patrice L. Spath, BA, RHIT, Health Care Quality Specialist, Brown-Spath & Associates, P.O. Box 721, Forest Grove, OR 97116. Phone: (503) 357-9185. E-mail: email@example.com. Web: www.brownspath.com.]