Published in the November 2007 issue of Today’s Hospitalist
Consider this case file from Maryland’s department of health: An 80-year-old patient is prescribed ramipril on admission for his hypertension and heart failure.
His discharge summary, however, reveals that the patient was mistakenly given the sulfonylurea Amaryl instead of ramipril “an error that is not picked up, because no one reconciles the patient’s medications at discharge. After discharge, the patient is first found to be obtunded, then hypoglycemic. He is re-admitted, but later dies from complications related to the initial episode of hypoglycemia, which was caused by the accidental dose of Amaryl.
The case is a good example of this disturbing reality: What hospitalists don’t know about reconciling medications can hurt their patients, or at least compromise their care. Despite well-documented benefits of medication reconciliation and the strong endorsement of such efforts by national groups like the Joint Commission, hospitals are struggling mightily to fully implement reconciliation initiatives.
According to speakers at the “Medication Reconciliation Dilemma” session at the Society of Hospital Medicine (SHM) meeting, high hurdles repeatedly crop up between planning and implementation.
“Developing the process is easy,” noted co-presenter Eric Howell, MD, a hospitalist at Johns Hopkins Bayview Medical Center in Baltimore, “but the multiple barriers make implementation hard.”
To underscore the types of problems that hospitalists can expect to encounter, Dr. Howell discussed what did “and didn’t “work during a medication-reconciliation initiative at his own facility.
A working definition
Dr. Howell and co-presenter Brian Clay, MD, assistant professor of medicine at the University of California, San Diego’s hospital medicine division, offered a definition of medication reconciliation from the Institute for Healthcare Improvement (IHI), which made it one of the six planks in IHI’s “100,000 Lives” campaign. Reconciliation is the process of “identifying the most accurate list of all medications a patient is taking “including name, dosage, frequency and route” “and then using that list to guide drug choice and usage anywhere within a health care system.
The IHI calls for comparing the list of current medications against a physician’s admission, transfer and/or discharge orders.
Medication reconciliation also got a strong push in 2005, when the Joint Commission made it the centerpiece of its annual patient safety goals. Those goals called on hospitals to develop and document a process for obtaining a complete list of patients’ medications on admission; compare that list to hospital-provided medications; and communicate that list, in writing, at every transition in care.
According to Dr. Howell, fully 99% of hospitals in 2005 responded to the Joint Commission’s call to put a medication reconciliation process in place. But a year later, the Joint Commission found that only 62% had fully implemented one. The SHM’s 2006 survey on medication reconciliation showed even less compliance, said Dr. Clay.
“Only 48% had fully implemented medication reconciliation,” he noted, “and 11% were still in the planning stages.”
The recognition that medication reconciliation is underutilized is frustrating, both presenters agreed, given the evidence behind its benefits.
“We know that the vast majority of adverse events are adverse drug events,” Dr. Howell told attendees. “Even the more recent studies suggest that about one-third are preventable or ameliorable.” He cited decade-old landmark studies that identified failure to properly reconcile medications at handoff as a leading cause of adverse drug events.
The problem is that hospitals encounter substantial barriers, both logistical and cultural, on the road to reconciliation, said Dr Clay. The chief barriers cited by those responding to the SHM survey included patients’ lack of knowledge of their medications (cited by 87% of respondents); unavailability of the medication list (80%); no access to outside records (63%); formulary differences across providers or institutions (59%); and the time it takes to obtain and document medication lists (53%).
Dr. Clay also cited what he saw as one of the survey’s most telling findings: “a striking lack of pharmacist involvement.” Only 5% of respondents reported that pharmacists were involved in obtaining or documenting medications, and only 6% said that pharmacists had a role in reconciling medications. Even fewer “2% “reported that hospital pharmacists were involved in discharge instructions regarding medications.
The Hopkins’ experience
Dr. Howell used his own institution’s experience to illustrate some of the roadblocks cited by survey respondents. Johns Hopkins Bayview started its efforts in 2004, he recalled, but soon found that faculty and staff were “either unaware or uninterested in the problem.”
It wasn’t until the medical center conducted a failure mode and effects analysis that identified both barriers to implementation and physician champions that the initiative gained steam. Getting the support of physician champions who are “on the front line” of medical care is so critical, Dr. Howell said, because they are more likely to get buy-in from physicians than a hospital administrator.
Physician champions can pass along the needed message in a way that other physicians can understand, he pointed out. In part, that means focusing on concepts like data and patient impact, which are powerful motivators for physicians.
The medical center first elected to use a paper format, devising a two-part form: an admission sheet that listed outpatient medications, and a discharge sheet listing then-current medications. The discharge sheet included designated slots to indicate which medications had been reconciled, as well as check boxes for medication status: “no change,” “stop” and “new.” The discharge form also included a check box to indicate whether physicians had reviewed all medications with the patient.
The hospital decided to roll out the initiative on a busy unit as a test, then throughout the hospital once the kinks were worked out. While the paper discharge list was an instant hit, the admission sheet was used only intermittently because physicians were more accustomed to using a paper form, a factor that Dr. Howell said stymied full reconciliation. Even when physicians wanted to use the sheet, they often complained that it was missing from the chart.
Patient-literacy issues were another significant barrier. And some physicians either complained about the extra time required to do reconciliation or simply used the popular H&P list in lieu of a new one.
The team undertook several modifications to address those barriers. To ensure the form made its way into the chart, for instance, unit secretaries were educated about its importance.
To increase physician engagement, John Hopkins Bayview’s quality improvement team gathered data on individual physicians’ use of the medication-reconciliation form and shared those data. Compliance on using the admission reconciliation form jumped from 29% to 71%, Dr. Howell reported, while use of the discharge reconciliation form went from 72% to 95%.
The issue of how much time it took to reconcile medications was somewhat resolved, he recalled, once the forms became more available. And team members opted for a low-tech solution to overcome the cultural issue of physicians reporting to the H&P medication list: They placed a large sticker that said “USE THE MED REC LIST” over the H&P medication area.
A big breakthrough for compliance was deciding to place the admission and discharge forms side by side, to avoid one of the most common problems encountered in reconciling medications: tracking down an accurate initial list and verifying its contents, while comparing that list to discharge medications.
“You really need both components to be successful,” said Dr. Howell, “and it helps to have them side by side.”
The medical center has since embarked on electronic medication reconciliation. That format holds out the promise of doing away with duplicate medication lists from both nurses and physicians.
But electronic reconciliation comes with its own headaches. For one, it’s hard to visually manage a long list of drugs.
Then there’s the practical issue of fitting admission, inpatient and discharge medications on a single screen. “The structure of an electronic format doesn’t always facilitate workflow,” Dr. Howell pointed out.
Delivering real gains
Despite those barriers, one big hurdle “the lack of physician buy-in “is no longer a problem. As a result, Dr. Howell indicated, the initiative is starting to deliver real patient-safety gains.
He urged hospitalists whose organizations are making little progress toward full implementation to take the lead and tap the growing body of resources.
“Either be a champion or find one,” he said, adding that hospitalists don’t need to “re-invent the wheel” when resources are readily available. Finally, he advised hospitalists to move sooner rather than later, as the pressure on hospitals that don’t have a good system in place will likely intensify.
“There’s some indication,” he said, “that the Joint Commission will soon raise the bar on this.”
Bonnie Darves is a freelance writer specializing in health care. She is based in Chadds Ford, Pa.
Medication reconciliation fast facts
To gauge where hospitals are implementing medication reconciliation, the Society of Hospital Medicine (SHM) in 2006 surveyed close to 300 hospitalist groups. Here are some survey findings:
- Implementation. Community teaching hospitals and non-teaching community hospitals were more likely than academic centers “at 57%, 49% and 35%, respectively “to have implemented medication reconciliation.
However, academic centers were ahead of the curve in using computerized reconciliation processes, said Brian Clay, MD, assistant professor of medicine in University of California, San Diego’s hospital medicine division. (Dr. Clay was a co-presenter of a session on medication reconciliation at SHM’s annual meeting this year.) Among academic centers, 27% (vs. 9% of community teaching hospitals and 7% of private facilities) had an electronic reconciliation process in place.
- Format. Among respondents, 47% had implemented medication reconciliation using a paper format. Only 11% used a solely computer-based format, while 31% used a combination of paper and electronic formats.
- Process steps and provider roles. Physicians were primarily responsible for reconciling medications at admission, updating the medication list at discharge and communicating that information to the next provider. Nursing or shared RN/MD roles included obtaining and documenting the home medication list, and providing current medication information to the patient at discharge.
“In most institutions, it was clear that medication reconciliation was viewed as a shared responsibility,” Dr. Clay said. That can be a problem, he pointed out, because it may mean that “no one is actually responsible” for managing the task.
- Hospitalist engagement. Among respondents, 36% reported that hospitalists assumed an active role in medication reconciliation design and implementation. An additional 24% were involved in a peripheral or consultative capacity.