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Medication reconciliation: It takes a village

Since being identified as one of the Joint Commission’s national patient safety goals in 2005, medication reconciliation has gotten a lot of publicity, both positive and negative. In March 2009, SHM organized a group of key stakeholders for a one-day meeting in Chicago to discuss the issues preventing widespread implementation of an effective medication reconciliation process. I was fortunate to be part of that group. Since then, we have had numerous conference calls to update and discuss these issues further, and the SHM plans to release a white paper on the topic in the next several months.

The first overwhelmingly consistent opinion shared by the group was that we needed to further clarify and define the process and goals. What constitutes a “medication”? When should medication reconciliation occur? Who should be responsible? How do we keep it patient-centered? How do we integrate the varying levels of electronic documentation present across any one system? These were all questions we asked and attempted to answer.

I have worked with many hospitals and health systems and seen medication reconciliation performed with varying degrees of enthusiasm and accuracy.

The process can be relatively uncomplicated and consist of a simple form, completed at admission and discharge, which quickly becomes a “task” rather than a “tool.” While satisfying some Joint Commission requirements, this type of system falls well short of what we need to ensure that patients remain safe from medication errors and adverse drug events (ADEs).

At the opposite end of the spectrum is a system that requires full participation and “buy-in” not only from the medical staff, but also from nurses, pharmacists, and patients and their families. Such a comprehensive system involves gathering and verifying the information at every level of care, and it is both time-consuming and labor-intensive. It does however, in most instances, accomplish the goals of such a program.

How do we balance the needs for efficiency in the process and the goals of ADE prevention to provide safe, cost-effective and timely patient care? The bottom line is that it takes a village to reconcile medicines. To truly accomplish the goals of a medication-reconciliation program, we need fundamental commitment from all key participants.

This has to start at the hospital level, with full education of the nursing, pharmacy and medical staff in not only what processes to put in place but also in program goals. Medication reconciliation has to be more “goal oriented” (such as patient safety) and less “task-oriented” (such as filling out a form).

We also need to recognize that any forms we fill out are merely tools designed to accomplish a very important end. The process needs to cross disciplines, all of which need to share responsibility for the process. We also need a commitment to go the extra mile to ensure data are accurate because bad data in equals bad data out. That means making phone calls to nursing homes, pharmacies and/or families.

We also need a clear set of metrics to collect, analyze and report, including the number of ADEs and readmissions for medication-related reasons. These data should be made public and should be a source of pride for an entire hospital when paying attention to all the details involved in medication reconciliation proves effective.

Hospitalists are clearly in a position to take a leadership role in this process. Like other hospital quality and patient safety projects, we are increasingly being tasked to design, implement, monitor and improve these initiatives. Some of these are more within our scope than others, but this one clearly hits home. Consider taking the lead on this program in your institution, and watch closely for the official white paper from the SHM task force in the near future.