Identification and
Explanation of Problem
Today, many medication reconciliation errors can still
occur despite the technology being used.
Without a doubt, medication discrepancies that are not addressed
correctly can result in adverse drug events (Salanitro et al., 2013). “Medication reconciliation has been
acknowledged by several international patient safety organizations such as The
Joint Commission (TJC), Institute for Healthcare Improvement (IHI) and the
World Health Organization (WHO) as important for achieving medication safety” (Almanasreh, Moles, & Chen, 2016,
p. 645). It is critical for all
nurses to fully understand the medication reconciliation process in order to
prevent medical errors from happening at their organization. The doctor signing off on the medication
reconciliation has the responsibility to complete it accurately. In addition, pharmacy plays a significant
role in reducing the chance for a medication error to occur when patients are
being moved to another room within a facility or being admitted from an outside
facility (Smith et al., 2015). When pharmacy is involved with the admission
process for medication reconciliation, “accuracy, cost savings, and patient
safety across all phases and transition points of care were achieved” (Smith et al., 2015, p. 1).
Indeed, medication discrepancies are more likely to occur
with the elderly population when a patient is transferred to a different level
of care (Vargas, Silveira, Peinado,
& Vicedo, 2016). These
reconciliation errors for medication happen in nearly 50 % of the elderly
population at the time of admit and especially when medications are omitted (Vargas et al., 2016). This study showed the contributing causes for
the errors which included having patients that were on a high volume of
previous medications, physicians with fewer years of experience, and patients
with a history of more surgeries (Vargas
et al., 2016). However, with the
technology being used today for the computerized order entry system in
institutions, less errors are being seen (Vargas et al., 2016).
An article provided an example of how easily a medication
error can occur (Manno & Hayes,
2006). Prior to a patient being
transferred from a skilled nursing facility to a hospital, this patient that
was a diabetic received a dose of her scheduled insulin. When the patient arrived to the hospital, she
was given a second dose resulting in a medical error. It was not until an hour later when that the
nurse realized that she had created an error after viewing the patient’s
medication history in full. The
Institute for Healthcare Improvement stated that a lack of communication with
medical patient information on admission and during other transfers for a
patient accounts for 50% of medication related errors in the hospital setting (Manno & Hayes, 2006). Additionally, I have witnessed team members
create medication errors from not entering all the medications ordered
correctly on admission from an outside facility admission.
How to Improve the Situation
The admitting nurse has the responsibility to ensure that
the list of all patients’ medications is obtained correctly. This includes listing the correct name of the
drug, dose, frequency, and route (Manno
& Hayes, 2006). The nurse has to
“compare that list against the physician’s admission, transfer, and/or
discharge orders, with the goal of providing correct medications to the patient
at all transition points within the hospital” (Manno & Hayes, 2006, p. 63). Additionally, the nurse must always confirm the
last time that the patient has received the last dose of each medication. It is important for every institution to have
a protocol in place for that documents and reconciles each medication through
the continuum of services being provided (Manno & Hayes, 2006). The medication reconciliation process needs
to start with the nurse obtaining the patient’s list of current medications and
any other pertinent medication history (Manno & Hayes, 2006). Secondly, the nurse needs to make sure all
medication and doses are correct and clarify any issues that need to be
revised (Manno & Hayes, 2006).
Thirdly, during the reconciliation, any issues need to be resolved and
documented with any new order changes (Manno & Hayes, 2006).
Nurses need to be mindful of how they are asking patients
what medications they are taking. The
key is to ask open-ended questions that include what, why, and when (Manno & Hayes, 2006). It is also important for some of the
questions to be yes or no questions to prevent the patient from becoming
overwhelmed. When the nurse is asking
the patient questions, it is critical to avoid medical terminology (Manno & Hayes, 2006). The nurse has the responsibility to obtain a
complete and accurate list of the patient’s medications which needs to include
any patch medication, cream, eye drops or eardrops, inhalers, shots, mineral
supplements, and vitamins (Manno
& Hayes, 2006). When any
information is unclear, the nurse has the responsibility to check medical
records received on admit, ask the patient to have someone bring in the
medication bottles from home, or call the pharmacy where the patient fills
their prescriptions. Patients should be
educated on filling all medications at one pharmacy. When the nurse is obtaining the history, the
nurse should ask about adverse drug effects and educate the patient about an
adverse effect that is expected versus a true allergy.
Recommendations for Improvement
It is vital for the proper education to be given to all
team members on the use of their organization’s technology and the proper
sequence that needs to occur in order to deliver patient care safely. When a go live occurs for a new system, it is
crucial for there to be many super users available to help answer all questions
timely since staff members are busy trying to take care of their patients
safely and administer medications appropriately. The electronic health record (EHR) being used
at organizations needs to be user friendly to help reduce medical errors. In addition, organizations can see
improvements with having student pharmacists collect and evaluate a patient’s
medication history gathered from where the patient routinely fills his or her
medication and then have a face to face interview with the patient (Smith et al., 2015). In a study, after the student pharmacists
gathered the medication history this way, the student would only contact the
primary care providers when needed (Smith
et al., 2015). Subsequently, this
information gathered by the student would be presented to the medical
pharmacist (Smith et al., 2015). Additionally, any interventions that occurred
involve use of clinical judgement by the pharmacist (Smith et al., 2015). During the study, 290 medication
discrepancies were found (Smith et
al., 2015).
The risk for medication discrepancies can be lowered by
performing a proper medication reconciliation (Salanitro et al., 2013). The Multi-Center Medication Reconciliation
Quality Improvement Study (MARQUIS) occurred at six United States hospitals (Salanitro et al., 2013). The hospitals that participated in the study
had gathered baseline data on each primary result for “the number of
potentially harmful unintentional medication discrepancies per patient, as
determined by a trained on-site pharmacist taking a “gold standard” medication
history” (Salanitro et al., 2013, p.
230). With mentors guiding them,
each location incorporated at least one of 11 best practices to make the
medication reconciliation better. This
study showed the most common discrepancies were related to history errors
versus an actual reconciliation error (Salanitro et al., 2013).
Changes to Benefit Nursing and Improve
Patient Outcomes
Certainly, the reconciliation process for medications is not
an easy one. However, this process is
such a critical part of keeping patients safe in healthcare today. The pharmacy department plays a vital role in
the medication reconciliation process to help reduce preventable medication
errors. With more patients being part of
the healthcare system today, there are also more providers caring for these
patients on an interdisciplinary team and using more technology than ever
before (Smith et al., 2015). Without a doubt, new approaches for the
medication reconciliation process need to occur (Smith et al., 2015). Some studies have shown that medication
omission is the most frequent error occurring (Smith et al., 2015). However, dose optimization is found to be the
most frequent encountered discrepancy (Smith et al., 2015). Organizations need to gather and review clear
information on the occurrence, type, and causative factors for all
discrepancies with medications (Almanasreh
et al., 2016). Ultimately, leaders
need to advance safety measures to lower the risk for any adverse medication
situation occurring.
The advanced-practice informatics nurse works on improving
workflow with the doctors, pharmacists, nurse managers, assistant nurse
managers, charge nurses, and other nurses on each unit to advance patient care
safety and efficiency. In addition, the
advanced-practice informatics nurse needs to determine exactly what is
happening with the medication reconciliation process and to capture the
information correctly with the current workflow for each area in their
organization. It is important to develop
a detailed process map and a high-level map illustrating the major process
steps. When implementing a new system,
the advanced-practice informatics nurse has to train all of the super users and
be available for the go live. Technology today has allowed patients to receive their medication on admission more timely and safely with the automated alerts to the nurse.
References
Almanasreh, E., Moles, R., & Chen, T. F.
(2016). The medication reconciliation process and classification of
discrepancies: A systematic review. British
Journal of Clinical Pharmacology, 82,
645-658. doi:10.1111/bcp.13017
Manno, M. S., & Hayes, D. D. (2006).
Best-practice interventions: How medication reconciliation saves lives. Nursing, 36(3), 63-64. Retrieved from www.nursing2006.com
Salanitro, A. H., Kripalani, S., Resnic, J.,
Mueller, S. K., Wetterneck, T. B., Haynes, K. T., ... Schnipper, J. L. (2013).
Rationale and design of the Multicenter Medication Reconciliation Quality
Improvement Study. BMC Health Services
Research, 13(1), 230.
doi:10.1186/1472-6963-13-230
Smith, L., Mosley, J., Lott, S., Cyr, E. J., Amin,
R., Everton, E., ... Komolafe, O. (2015). Impact of pharmacy-led medication
reconciliation on medication errors during transition in the hospital setting. Pharmacy Practice, 13(4), 1-7. doi:10.18549/PharmPract.2015.04.634
Vargas, B. R., Silveira, E. D., Peinado, I. I.,
& Vicedo, T. B. (2016). Prevalence and risk factors for medication
reconciliation errors during hospital admission in elderly patients. International Journal of Clinical Pharmacy,
38(5), 1164-1171.
doi:10.1007/s11096-016-0348-8
