Why It Matters
Steve Meisel, PharmD, CPPS, System Director of Medication Safety for Fairview Health Services/Healtheast Care System, knows medication reconciliation has never been easy. A longtime patient safety leader, in the following interview, he shares why it's still so challenging, how to improve it, and why he wishes we would call it something else.
How long has medication reconciliation been an interest of yours?
I’ve been a pharmacist since 1977, so I’ve been in health care for over 40 years. I first became engaged with this topic when I was a faculty member for IHI’s 2nd Breakthrough Series on Medication Errors and Adverse Drug Events (ADEs). Dr. Roger Resar, then of Luther-Middlefort Hospital in Eau Claire, Wisconsin, said that medication reconciliation was his number one concern because he believed it was a major cause of medication harm. Other faculty members, such as Dr. Lucian Leape and Dr. Don Berwick, were initially skeptical. But I immediately knew that Roger was onto something, although I was unsure if it was fixable. I said “Roger, let me help. If you’re successful, I will bring a team from my organization to visit yours because we’re having the same issues!”
Why is medication reconciliation a perpetually difficult challenge?
The main problem is that for far too long it has been thought of as a technical problem: just find a way to line up lists. What we’ve failed to recognize is that medication reconciliation is a cognitive and adaptive problem; all the lists do is provide an opportunity to take a breath and consider what is right for this patient on this day. It’s akin to a surgical timeout.
What has happened in health care in the last decade or so to make medication reconciliation easier or more challenging?
Technology has certainly made gathering and recording the list(s) easier and more accurate. It has also made it easier to make the lists longitudinal across settings of care. And it has made it easy for physicians to execute by clicking buttons.
But that technology also makes it easier to look at reconciliation as a technical issue; it’s far too easy to let the computer populate lists and click buttons when instead we should be asking, “What medicine should this patient be on?” In addition, the advent of hospitalists is a blessing and a curse. It’s a wonderful innovation and truly makes hospital care smooth and of high and consistent quality. On the other hand, hospitalists don’t always know the individual patients. They tend to be reliant on the lists in the computer and likely to accept what is plausible as opposed to knowing if it is truly accurate.
What are some of the opportunities for improvement?
First, we need to get rid of the term “medication reconciliation.” It harkens back to the days of paper records and lining up a pile of lists. Instead, we should use the term “medication time out.” This term — or something like it — would convey what we’re really thinking.
The other thing we need to recognize is the value of focus. Nurses and doctors have many things to focus on during an admission and discharge; medication therapy is but one of those. The reason the literature shows that pharmacists and pharmacy technicians obtain more accurate admission and discharge lists is not because they are smarter; rather, it is because they can focus. Of course, this work can be very time consuming and requires resources, so we need to demonstrate a good business case for those resources.
Is there a story you can share that helps illustrate the importance of improving medication reconciliation?
There have been a number of events in my organization where medication reconciliation was done perfectly, by the book, but we made the perfectly wrong decision. Each of these has resulted in a readmission for an adverse drug event or untreated medical condition. Each of these examples serves to emphasize the value of the cognitive and adaptive nature of effective reconciliation.
How can improving medication reconciliation complement work many organizations are already doing to reduce readmissions, reduce costs while improving quality, and increase joy in work?
There is no doubt that if you do reconciliation well there will be fewer ADEs, fewer readmissions, and fewer untreated conditions. All of this has an impact on quality and cost. Nobody wants to deliver poor care and everyone wants to maximize the value they bring to patients. By letting doctors be doctors, nurses be nurses, and allowing pharmacists and pharmacy technicians to practice at the top of their licenses, we will improve everyone’s job satisfaction and sense of meaning.
Editor’s note: This interview has been edited for length and clarity.
You may also be interested in: