Study Shows Importance of Effective Medication Reconciliation
A recent study from Brigham and Women’s Hospital in Boston illustrates some of best tactics hospitals can use for improving medication reconciliation.
Updating and verifying a patient’s medication lists and orders is critical to ensuring patient safety and optimizing care, but it can be challenging in a hospital environment, says lead author Jeffrey L. Schnipper, MD, MPH, research director of the Brigham’s Division of General Internal Medicine and Primary Care, a professor of medicine at Harvard Medical School, and principal investigator of the second Multi-center Medication Reconciliation Quality Improvement Study (MARQUIS2). The recent work is a new analysis of data from the second study.
The first lesson from the study is the importance of taking the best possible medication history in the ED before the patient is admitted, Schnipper reports. The information obtained in the ED tends to be more accurate and complete.
“Once the patient is upstairs, the admission orders have been written. It’s much harder to take a history at that point, and then retrospectively fix the admission orders that were based on incorrect history that was originally taken,” Schnipper explains. “Getting it right the first time and doing it as early as possible before the admission orders are written is the goal, which generally means doing it while the patient is still in the emergency department. That is really key.”
Another important finding is a best-possible medication history in the ED should be combined with discharge medication reconciliation, especially in the highest-risk patients. At discharge, this is usually by a pharmacist to reduce discrepancy rates, especially for those that are going to be harmful to patients.
“We know when patients leave the hospital, they’re going to a less monitored setting. Mistakes that are made at that point may not be detected for a while until they cause patient harm,” Schnipper says. In the ED, the medication history can be taken by pharmacy technician rather than a pharmacist, he notes.
Improving medication reconciliation can require systemwide interventions, Schnipper says. These may include improving the medication reconciliation module in the electronic health record, better access to preadmission medication sources, and training providers on how to take the medication history.
“The two things that we found most successful were making changes to the electronic health record, and then doing what we call ‘measure-vention,’ which is basically catching errors in real time and fixing them before they reach the patient,” Schnipper explains. “A few sites were particularly good at that. It does take resources to do this well, but these errors are occurring every day in our hospitals — and at quite alarming rates. The only reason we don’t notice them more often is that we’re not good enough in measuring.”
For most hospitals, applying the lessons from the study probably would require hiring more pharmacy technicians. In some markets, it is harder to find those employees than others. Many hospitals are employing dedicated transition of care pharmacists (TOCs), Schnipper says.
“What’s interesting about this group of people is that they are in some ways easier to hire than your typical inpatient pharmacist because the skill set that you need to be a quality control pharmacist is often the skill set that community pharmacists have — the ability to know medications really well, talk to patients, counsel them,” Schnipper notes. “We’ve actually had an easier time hiring TOC pharmacists. We recently hired 20 new TOC pharmacists, and they’ve all been from the community setting and are really enjoying the job.”
- Schnipper JL, Reyes Nieva H, Yoon C, et al. What works in medication reconciliation: An on-treatment and site analysis of the MARQUIS2 study. BMJ Qual Saf 2023 Mar 22;bmjqs-2022-014806. doi: 10.1136/bmjqs-2022-014806. [Online ahead of print].
- Jeffrey L. Schnipper, MD, MPH, Research Director, Brigham’s Division of General Internal Medicine and Primary Care, Boston. Email: [email protected].
A recent study from Brigham and Women’s Hospital in Boston illustrates some of the best tactics hospitals can use for improving medication reconciliation. The first lesson from the study is the importance of taking the best possible medication history in the ED before the patient is admitted.
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