When asked what medications they take regularly, patients offer a wide variety of responses:

“It’s a little white pill. I think.”

“The dose? No idea.”

“I can’t pronounce the name of it.”

“No, I don’t know what it’s for.”

“I’m supposed to take it in the morning. Oh, and at night, too. I think. A nurse or somebody told me, when I was being discharged from the hospital, to change the way I take it.”

As a result of this confusion, patients may be given drugs they aren’t supposed to get and may not receive those they need. But a growing number of hospitals now see this confusion and information gap as a systems failure that health care providers — not patients — have the responsibility to fix. The stakes are high. Adverse drug events (ADEs) can and do result from wrong or incomplete information about the medications patients are taking.

Preventing ADEs is the impetus behind the concept of “medication reconciliation.” It was developed by Jane Justesen, a nurse at Luther Midelfort-Mayo Health System in Eau Claire, Wisconsin, as part of an IHI initiative. Among other things, Justesen’s team at Luther Midelfort pioneered the tools and forms needed to create, update, and reconcile a patient’s medication record during hospitalization — starting at admissions right through to returning home.  [See the "Medication Reconciliation" area in the Tools section for more information on tools developed by Luther Midelfort.]

IHI subsequently made it a standard feature of its ongoing work and Lucian Leape, a pre-eminent patient safety expert and IHI fellow, arranged for it to be tested on a statewide basis in Massachusetts.

Enter the Joint Commission on Accreditation of Health Care Organizations (JCAHO). It has adopted medication reconciliation as part of its National Patient Safety Goals.  

In 2005, JCAHO will survey this goal, but full compliance is not expected until 2006. As Paul Schyve, Senior Vice President of JCAHO, says, “as important as everybody agrees this is, it isn’t easy” to implement a process that prevents medication error.

But the reasons to have an accurate patient medication record at every stage of inpatient care are compelling: patients who have an ADE are nearly twice as likely to die as those who do not experience an ADE [Classen DC, Pestotnik SL, Evans RS, Lloyd JF, Burke JP. Adverse drug events in hospitalized patients. Excess length of stay, extra costs, and attributable mortality. Journal of the American Medical Association. 1997;277:301-306]. In 1993 ADEs caused almost 1,200 deaths among hospitalized patients [Phillips DP, Christenfeld N, Glynn LM. Increase in US medication-error deaths between 1983 and 1993. The Lancet. 1998;351:643-644]. ADEs account for more than 6 percent of malpractice claims [Rothschild JM, Federico FA, Gandhi TK, Kaushal R, Williams DH, Bates DW. Analysis of medication-related malpractice claims. Causes, preventability, and costs. Archives of Internal Medicine. 2002;162:2414-2420]. It is especially critical to have an accurate record at the so-called transition points in care — when patients are admitted, discharged, and transferred between units. Forty-six percent of all medication errors occur at these junctures. 

Implementing medication reconciliation may pose a challenge, but the concept behind it is simple. At every step of the process of being cared for in a hospital, beginning with admission, patients (or a competent proxy) should be asked what medications they take, at what dose, and how often. This information is then placed in an accurate, definitive record. After verifying and clarifying the information, anything a patient receives is reconciled against the record to ensure that nothing is prescribed that shouldn’t be or omitted.

Dr. Roger Resar, Senior IHI Fellow, Mayo Health System, has extensive experience with the process. He says, “Everybody thinks they’re doing medication reconciliation already,” but usually the process is not standardized and the methods that are used are far from adequate. And at least two other obstacles exist, says Resar. Staff members sometimes don’t communicate with each other — especially a problem for admissions occurring in the middle of the night or at other times when staff might be stretched — and continual arguments go on about who is responsible for collecting the information. Resar recommends starting small, making a trial run on one patient, on one day, using one nurse and one form, with the goal of getting the best list possible. He also suggests undertaking the process at admission first, before devising a process for discharge, because time invested on the “front end” actually saves time in the long run. Resar says it’s important to make nurses and pharmacists responsible for the verification and clarification steps, and physicians for reconciliation.  

Medication reconciliation is a team effort. Frank Federico, Director and Patient Safety expert at IHI, encourages including patients in the reconciliation process.  “Patients can play a vital role in medication reconciliation by carrying a list of the medications they are taking.  Having this information available can help make the reconciliation process more efficient and effective. Imagine how much work and rework can be eliminated when a patient presents with a list at the physician’s office or when admitted to a hospital.”  Federico points out that many organizations, such as McLeod Health in South Carolina, are working on forms or cards that can easily be used by clinicians and patients.

There are many difficulties inherent in medication reconciliation:  questions about who is responsible for obtaining the information; who has the expertise to ensure reconciliation, especially in complex, multidisciplinary care; the limits of knowledge about interactions of drugs with vitamins, minerals, and herbal supplements; and how to implement the process in highly specialized settings. Dana Jenkins, an Associate Vice President for Organizational Performance at Roswell Park Cancer Institute in Buffalo, New York, highlights the unique challenges medication reconciliation poses for a cancer hospital, where some types of patients — those undergoing bone marrow transplant, for example — might be seen at a “transition point” every day for a year. Reconciling medications with such frequency is clearly unworkable. Thus, a one-size-fits-all process is neither possible nor desirable; effective, efficient procedures must evolve to meet the specific needs of individual institutions and in many instances, the unique needs of patients engaged in ongoing treatment for a disease.

When it comes to administering medications, the stakes are indisputably high. But the opportunity to decrease adverse events and improve outcomes makes medication reconciliation a critically important task.