ED Accreditation Update

Meds reconciliation summit promises more clarification

Since the implementation of National Patient Safety Goals (NPSGs) dealing with medication reconciliation in 2005, The Joint Commission has received a steady stream of feedback from the medical community. Emergency medicine experts and organizations, in particular, have complained that the goals were unclear and made compliance difficult. In response to this feedback, The Joint Commission convened a one-day summit on Sept. 27, 2007, to address the issue. According to The Joint Commission, compliance rates reveal that compliance with two goals has proven to be difficult for many health care organizations:

  • comparing the patient's current medications to those ordered while under the care of the health care organization (Goal 8a);
  • communicating the patient's medications to the next provider of service and giving the medications list to the patient at discharge (Goal 8b).

Compliance is 'complicated'

Noncompliance rates for these requirements — 18.9% for Goal 8a and 14.2% for Goal 8b for 2006 — remain much higher than desired.

"Fairly soon after implementation, it became evident this was going to be difficult for institutions; it entails a variety of organizational system and process changes," notes Peter B. Angood, MD, The Joint Commission's vice president and chief patient safety officer. "Our regular field monitoring feedback showed pretty quickly how complicated [compliance] was, so we went ahead with convening the summit to bring together by invitation a wide variety of professional organizations and experts with a particular interest and focus on this issue to solicit further feedback, input, and suggestions."

According to The Joint Commission, the consensus of the summit was that while medication reconciliation improves patient safety, more guidance on implementation is required. Additionally, NPSG 8a needs clarification, particularly in regard to the information that should be included on a medication list, the appropriate times and settings for taking medication information (as well as information about allergies, etc.), and how to handle temporary changes to a medication list.

Skepticism remains

Not all of the organizations accepted these conclusions at face value. For example, Denise King, RN, MSN, CEN, newly elected president of the Emergency Nurses Association, was not ready to accept even the initial premise of safety.

"We need to look at that," says King, who is a senior consultant with Blue Jay Consulting of Orlando, FL, where she fulfills interim ED leadership assignments. "There are individuals out there who are convinced [medication reconciliation] does not improve safety and could actually lead to unsafe situations in some cases." For example, she suggests, a patient who comes into the hospital environment does not always know what they are taking, in what dosages, or why they are taking it.

"We may have an incomplete or inaccurate list, but this is nevertheless sent out by the hospital later as accurate," she says. "We do not want to work under the assumption it will improve safety." In fact, King says, The Joint Commission could consider not even having a medication reconciliation requirement.

Having been in ED nursing for 20 years, King says that every hospital ED already did medication reconciliation to some degree anyway. "We always asked patients what they were taking when they came in, so this is not a completely new concept," she says. "What we're struggling with is the depth and degree of what The Joint Commission wants."

Angood recognizes the complexity of obtaining an admission list of patients' meds as "one of the recurring themes" of the summit. "Related to that is the question of whether or not obtaining a full and complete list is necessary for all encounters, regardless of acuity of setting or the appropriateness of the patient, and whether it should be required for everyone," he says.

Consistency sought

King would like to see more consistency in accreditation. "There's been a lot of inconsistency in how the goal is surveyed," she asserts. "I have seen some surveyors who will hold you to the letter of the standard, while others will not do it so strictly."

In the current environment, she continues, when one facility gets surveyed, that information spreads to other facilities. "That becomes the new 'word on the street," she says. "So, when another survey is handled differently, that leads to inconsistencies."

Angood agrees, to a point. "Inconsistency between surveys has been a recognized issue for us," he concedes. "We do our best to make sure there is fairly good consistency, but it will never be perfect."

Nevertheless, he insists, the degree of consistency has improved a lot in the last few years. In fact, at press time, he was planning to participate in a meeting with surveyors. "We will be discussing all of the National Patient Safety Goals tomorrow morning, but you can be sure medication reconciliation will get a lot of attention," Angood shares.

Sources

For more information on medication reconciliation, contact:

  • Peter Angood, MD, Vice President and Chief Patient Safety Officer, The Joint Commission, Oakbrook Terrace, IL. Phone: (630) 792-5000.
  • Denise King, RN, MSN, CEN, President, The Emergency Nurses Association. Phone: (360) 330-8935.