Published in the January 2005 issue of Today’s Hospitalist
The task sounds like a given: When patients enter the hospital, a list of all the medications they have been taking is entered into the chart. Doctors and nurses caring for those patients refer to the record when deciding what drugs to order, what therapies to stop, and what to include on their discharge instructions.
Patient safety experts, however, say that the experience of Melissa Bartick, MD, is more typical. “Sometimes,” says the hospitalist at Nashoba Valley Medical Center in Ayer, Mass., “I wouldn’t even find out until the patient had been here for four days and was now going home that he hadn’t been getting an important medication he had been on at home the whole time he was in the hospital.”
Whenever Dr. Bartick tried to draw attention to the problem to nurses and other physicians, she quickly encountered resistance. “Nobody could agree whose job it was to obtain the admitting med list and make sure it is accurate,” she explains. “Nobody was invested in it.”
That attitude is beginning to change, experts say, largely because the Joint Commission on Accreditation of Healthcare Organizations has added “medication reconciliation” to its list of accreditation requirements. As a result, physicians and nurses around the country are beginning to pay attention to the medications that patients are taking when they enter “and leave “the hospital.
Because many inpatients are already taking multiple medications ordered by numerous physicians and obtained from several pharmacies, medication reconciliation has also become a top patient safety goal for groups like the Boston-based Institute for Healthcare Improvement (IHI).
“It’s one of the serious issues that arises at the point of handoff,” explains Paul M. Schyve, MD, senior vice president of the Joint Commission. “On the surface, medication reconciliation sounds like a simple thing, but when you start to look at how you do it, you realize this is complex.”
Three common mistakes
Medication reconciliation, which is also sometimes called preadmission medication verification or medication coordination, seeks to fix three extremely common “and sometimes fatal ” types of drug mistakes that happen during handoffs in the care process: omitting a medicine, failing to restart a medicine that has been withheld from a patient, and double-dosing.
The process usually requires three discrete steps. First, someone must undertake the time-consuming job of compiling an up-to-date medication history. Second, medication orders must be written. Third, because steps one and two often occur independently, someone has to reconcile the two processes and make sure nothing was missed.
This process forces hospitals to make changes in the way they operate explains Gina Rogers, director of the Reconciling Medications Collaborative of the Massachusetts Coalition for the Prevention of Medical Errors. First, she says, the home medication list has to be put in one, easy-to-find place in the chart. Then someone “a nurse, the doctor or someone in the pharmacy ” has to physically reconcile the orders with the history.
“That means one at a time,” Ms. Rogers explains. “Was medication A on the list ordered and in the same dosage? If not, is there a note from the physician saying it was put on hold or discontinued or changed? If there is no notation, you have to call the physician and find out why.”
Sometimes this process “particularly steps one and three, compiling the list and reconciling it “can be protracted. “But when someone tells me this is so time consuming,” Ms. Rogers says, she responds with a simple question: “Why weren’t you doing this already? It’s not safe for your patients if you don’t do this.”
“I think the time complaint is a red herring,” she adds. “It should be part of your standard way of doing business.”
Potential for harm
Studies support her argument. Despite what many clinicians may think, there are often great disparities between a patient’s pre-admission medication list and the orders that are written during hospitalizations. Although many of these errors are caught before they hurt patients, some will inevitably slip through the safety net.
When researchers sampled 204 patient charts at Northwestern Memorial Hospital in Chicago, for example, they found that more than half had “discrepancies in their medication histories and admission medication orders.” According to lead author and pharmacist Kristine M. Gleason, 22 percent of these discrepancies “could have resulted in patient harm during hospitalization, and 59 percent may have resulted in patient harm if the error continued beyond discharge.”
(Her research was published in the Aug. 15, 2004, issue of the American Journal of Health-System Pharmacists.)
“The most common discrepancy requiring intervention was an omission,” Ms. Gleason says, such as forgetting to order a blood pressure medication. In the hospital, she adds, because patients are continually being monitored, a problem caused by that omission will probably be picked up and corrected. “That omission will have a bigger impact at home because they are not getting continuous monitoring,” she points out.
In fact, experts agree that a common cause of hospital readmissions are medication errors following discharge. Patients are either taking too much medicine “often because they are taking both a newly prescribed medicine and a similar drug they already had at home “or because a necessary home medicine is not restarted after a hospitalization.
Both types of errors “missed or duplicated medications during a hospital stay and at discharge “are easily corrected by medication reconciliation, explains Roger Resar, MD, a pulmonary/critical care physician and consultant at Luther Midelfort-Mayo Health System in Eau Claire, Wis., and a senior fellow at the Institute for Healthcare Improvement.
Dr. Resar is credited by patient safety experts for focusing the attention of the health care safety movement on the need to account for, verify and reconcile medications at all health care transition points. In his view, the medication list is one of the balls that’s all too often dropped during handoffs.
(A description of the work on medication reconciliation done by the Institute for Healthcare Improvement and Luther Midelfort is online.)
“If you fail to do the medication reconciliation on admission, a guardian angel called ‘your nurse’ can pick it up,” Dr. Resar explains. “But when you don’t do the medication reconciliation on discharge, there is no one to help you.”
Dr. Resar credits a front-line nurse with alerting him to the problem about five years ago. Like other physicians, he recalls, he was skeptical that it was really a problem. After all, he figured, emergency room nurses, intake nurses and admitting physicians each take a medication history from the patient. They must know all the drugs and dosages their patients have been taking.
So Dr. Resar decided to conduct a little study of his own. He looked at 10 of his patients and found that, after discharge, eight were “taking not only the medications I sent them home with, but the medications they had been taking before they came in.”
A larger study at Luther Midelfort discovered that “there are at least two to three discrepancies in medications that need to be clarified, verified and reconciled during an average patient’s hospitalization,” Dr. Resar says. Some are minor, such as prescribing a different dose of a drug, for instance, or omitting a birth control pill. Others are potentially dangerous, such as failing to restart blood thinners.
“It’s pretty scary,” he notes. Consider the patient whose Coumadin was never restarted after discharge, or the patient who goes home on digoxin but also is told to resume home medications, which includes Lanoxin.
“We have a pretty good idea now that somewhere around 15% of adverse medication events are actually related to failure to reconcile at the interfaces,” Dr. Resar says.
After Luther Midelfort introduced its reconciliation program, the number of drug problems found in chart audits plummeted by 80%, according to Dr. Resar. The system calls on everyone involved with the admission process, but primarily nurses, to work together to compile as complete a list as possible of the patient’s pre-admission medications.
Dr. Resar emphasizes that the words “as complete as possible” are key. Everyone has to realize the list may never be perfect and not give up as a result.
The patient’s physician then uses this list as an order sheet. The doctor must state clearly what is to be done with each medication. This order sheet/medication reconciliation form is then sent to the pharmacy, which calls the physician if some medication isn’t accounted for.
Luther Midelfort has found that it takes nurses an average of 11 minutes to create a medication list for each patient. (For some patients, the list can be created in one minute, while it can take up to 45 minutes with others.) Nurses must sometimes telephone multiple sources, such as family members, the patient’s other doctors, local pharmacies and pharmacy benefit managers to sort through the myriad of medicines and to tease out proper dosages.
Over the entire hospitalization, however, the time spent tracking down a medication history pays big dividends. With a complete list in hand, physicians can more easily order medications for a patient’s hospitalization. That same list can be used to decide which drugs should make it into the discharge instructions.
“The physicians love it, because it saves them so much time,” Dr. Resar says. “Before this, physicians and nurses were running around at discharge trying to figure out what medications the patient should go home on.”
This explains why many hospitals have taken on two projects concurrently: medication reconciliation and improving discharge instructions. In fact, some hospitals came to the idea of medication reconciliation by first looking at problems with discharge.
For instance, Destiny Pattillo, RN, BSN, who has headed up the medication reconciliation safety project at McLeod Health in Florence, S.C. “a project that now has been expanded statewide “began by trying to figure out a way to stop physicians from writing blanket orders, like the notorious discharge instruction to “continue home meds.”
“Everybody wanted to start on the discharge,” Ms. Pattillo says. “I said, ‘If we are not going to get it right coming in the door, we are not going to get it right leaving.’ ”
The power of a form
Over the last two years, a few dozen hospitals around the country have tackled the topic of reconciling medications, and many different models are evolving. About 50 hospitals in Massachusetts, including Dr. Bartick’s, have addressed the issue with help from Ms. Rogers’ group. (Project descriptions and sample forms are available online.)
Dr. Bartick says that with the authority of the state coalition behind her, Nashoba Valley Medical Center finally came around to her way of thinking. Like Dr. Resar, she discovered that the key to getting nurse and physician buy-in to change the way they collect, record and share medication histories was to make the reconciliation form function as an order form as well as a medication history.
“Once it became an order form, people took the med list more seriously,” Dr. Bartick explains. “People are much more conscientious about making sure that the form is accurate. What people hadn’t realized was that the triage list that the emergency department nurse wrote down was going to end up as orders.”
In addition, she says, making the list function as an order form means doctors and nurses all have a stake in getting the list right. Because every page requires a physician’s signature, the doctors pitch in, making additional calls and confirming information when needed.
But what really helped sell the new process to everyone was the fact that having only one form “a medication reconciliation/ order form “means the information only has to be written down once, not several times in several different places throughout the chart as before.
Eric Alper, MD, a hospitalist at UMass Memorial Medical Center in Worcester, Mass., who has worked on medication reconciliation at his hospital through the Massachusetts Coalition’s collaborative, says that the units in his hospital that adopted the new consolidated form saw another important change: The legibility of orders improved.
The role of hospitalists
This is where hospitalists come in, says the Massachusetts Coalition’s Ms. Rogers. “In our projects,” she explains, “where the hospitals have had real success, the hospitalists have been key.”
Perhaps most importantly, explains Ms. Rogers, hospitalists understand “the issue of information transfer at discharge. They know the patient’s primary care physician doesn’t know what has been going on. They have a much better sense of the lack of continuity that goes on.”
She adds that because hospitalists tend to be younger, they tend to be the physicians in the hospital who learned about patient safety during training. They also, she says, are less tied to the old ways, and are more willing to do something differently. “That’s huge,” she notes.
When physicians do protest, explains Dr. Bartick from Nashoba Valley Medical Center, a quick chart review can do the trick. “We had one doctor who told our quality manager that he didn’t think the form was worthwhile,” Dr. Bartick recalls. “He didn’t have a problem, and he didn’t want to use it.”
That’s when someone suggested auditing the physician’s charts to see how many medications were missed in his patients. “He agreed,” she says, “and now he uses the form. He didn’t think he needed it, but then he saw he was just like everyone else.”
Deborah Gesensway is a freelance writer in Toronto, Canada.