Medication Reconciliation Blog

 

 

 

 

Medication Reconciliation Blog

Meagan Carpenter

Jacksonville University

 

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