Published in the May 2006 issue of Today’s Hospitalist
In January of this year, the Joint Commission began requiring hospitals to implement some sort of system to reconcile medications. To underscore the importance of that new goal, the agency in January issued a sentinel event alert urging hospitals to take action to get accurate medication histories from their patients.
The alert pointed out that a stunning 63 percent of reported medication errors that resulted in death or serious injury were due to breakdowns in communication, and that half of those errors could have been avoided with an effective medication reconciliation process.
That’s why the Joint Commission is calling on hospitals to develop a process for obtaining and documenting a complete list of patient medications. The goal applies not only to admission, but any transition points during a patient’s stay.
While cataloguing all of a patient’s medications may seem daunting, a number of hospitals have done just that. In Massachusetts, for example, a group of 50 facilities “more than 75 percent of the state’s acute care hospitals “have been participating in an effort known as the Reconciling Medications Collaborative.
In the January 2006 issue of the Joint Commission Journal on Quality and Patient Safety, researchers reviewed the lessons that the Massachusetts hospitals have learned in creating medication reconciliation systems. They provide some valuable insight into the thorny issues surrounding medication reconciliation, from who should initiate the process to who should be responsible for finding and correcting problems.
How the process works
The key to medication reconciliation is the document that physicians and nurses use to track medication histories. UMass Memorial Medical Center in Worcester, Mass., one of the hospitals that participated in the Massachusetts collaborative, has developed a medication reconciliation form and accompanying process that is so successful that it has been adopted by a number of hospitals.
Eric Alper, MD, a hospitalist at UMass Memorial and a co-author of the journal article, explains that while his hospital’s form has undergone many changes over the last few years, it is effective because of its simplicity. It devotes most of its space to lists of medications patients are taking.
(The form is online.)
At UMass Memorial, physicians enter information about the drugs patients are taking onto the medication reconciliation form. A nurse then scans the form into the hospital’s computer system and forwards it to the pharmacy, where it is entered into the pharmacy information system. The medication list then makes its way into the chart.
The process is relatively straightforward, but it raises some interesting questions about exactly who is best suited to initiate a patient medication history: physicians or nurses. While the article points out that most of the hospitals in the Massachusetts project had nurses initiate the process, not everyone agrees with that approach.
Dr. Alper, who is also the patient safety officer at UMass Memorial, says when admission nurses at his facility have begun the medication reconciliation process, the results were far from perfect. The problem? By the time a nurse talked to patients on the floor, he explains, the hospitalists had already seen the patient in the emergency department, taken a history and written admission orders.
“It created some duplication of work in terms of gathering the medication history,” Dr. Alper says. “It’s a little redundant to have a nurse gather a medication history, write it on the medication reconciliation form and then compare it to the orders that a physician has already written.”
“We felt it would be better for the reconciliation to take place up front and to have our hospitalists do most of the medication reconciliation,” he explains. “It seems like getting the person who’s going to be the one prescribing the medication to take some involvement in that process makes the most sense.”
Dr. Alper adds that the goal should be to gather a complete medication list as soon as possible. “If you can do that at the triage desk in the emergency department,” he says, “that helps the next person along the line. You don’t have to go back to the patients every 10 minutes and ask what medication they’re taking.”
Benefits for hospitalists
Leading the medication reconciliation process may mean more work for hospitalists, but Dr. Alper says that they also stand to benefit the most from having complete medication information.
“Because we work on a shift system,” he explains, “we’re frequently taking care of patients we haven’t admitted, and we are frequently discharging patients we didn’t admit. Having a clear, complete record of what patients were taking when they came into the hospital is really essential in terms of being able to know what to do as the patient leaves the hospital.”
Before UMass Memorial implemented a medication reconciliation program, Dr. Alper says, he would write down the patient’s medication list in the history and physical section, a daunting task for patients with upwards of 15 medications. He would often have to write the same list again in the patient’s order sheet.
“Now when I admit a patient,” he explains, “I complete the medication reconciliation form to indicate what medications should be discontinued or changed. I don’t need to rewrite the entire list somewhere else.”
As physicians are ultimately responsible for which medications a patient receives, Dr. Alper is a firm believer that physicians, not nurses, are in the best position to perform medication reconciliation. He acknowledges, however, that at community hospitals that have no regular physician presence “institutions where there are no hospitalists or housestaff “nurses may be the only staff who can lead medication reconciliation.
But hospitals that have a full-time physician presence, he adds, should give the responsibility to physicians. And no group is better suited to the task than hospitalists.
“When I go around the country talking to people about this, I always tell them to go speak to their hospitalists first,” Dr. Alper explains. “Hospitalists recognize that gathering a complete medication history, making the necessary medication changes and sending patients home on the right medications is one of the most important interventions that we do.”
Who should reconcile problems?
Another issue hospitals setting up medication reconciliation efforts are encountering is who is responsible for finding and fixing problems in patients’ medication histories. While UMass Memorial has given physicians the lead for creating medication histories, nurses are charged with reviewing the medication lists. If they find a problem, they contact the physician.
Dr. Alper says that although the system was designed to make everyone responsible for medication accuracy, problems can develop when no one steps up and takes ownership of medication discrepancies.
“One of the problems generally with this type of initiative is that physicians haven’t wanted to take ownership of the process,” he explains. While hospitalists tend to recognize the value of medication reconciliation, outpatient physicians and specialists in the hospital who don’t have to follow patients throughout their stay in the hospital may not have the same appreciation.
“Ambiguity regarding who is responsible for the process can lead to the sense that this is not my job, that someone else should be doing this,” Dr. Alper says. “A risk of this process is that it’s easy to become disengaged or think it’s someone else’s work, when they’re really the ones who are ultimately responsible.”
Formularies and bad information
As patients are often the only one who really know what medications they are taking, gathering a complete and accurate medication list can be quite challenging. Dr. Alper estimates that only about half of his patients or their family members are a reliable source of information.
One special challenge that providers are faced with is the substitution of home medications for the drugs on the hospital formulary. “When they come into the hospital, patients frequently are switched from the statin they were taking to another statin on the hospital formulary,” Dr. Alper says. “The reconciliation process helps to make sure that they get switched back to the drug they were taking when they came in because that’s what their health plan covers. It also makes sure they don’t wind up receiving two drugs of the same class.”
Another concern is catching flawed information in electronic systems. Dr. Alper says that in an ideal world, physicians would have access to a complete, continuously updated database of medications that crosses all providers. Even when this kind of information is available, he notes, it’s still important to double-check information that’s in the system when patients are admitted. Again, there’s no better source than the patients themselves to assess for recent changes and adherence.
“If the primary care physician’s system says the patient is taking one thing,” he explains, “there’s a tendency to trust that information. But what if they went to the cardiologist last week and they’re no longer taking that drug? We need to make sure that we actually invest the time with patients and do the reconciliation with them.”
Edward Doyle is Editor of Today’s Hospitalist.