Innovation at Its Best: Medication Reconciliation

The elderly woman went home from Contra Costa Regional Medical Center (CCRMC) in Martinez, California, with a new prescription for blood pressure medicine. While she’d been an inpatient, she’d gotten started on the new anti-hypertensive drug. However, soon after being discharged, the woman reappeared in one of the hospital’s ambulatory care clinics complaining of severe dizziness. Her primary care physician figured out that the woman was taking the blood pressure medicine that had been prescribed in the hospital on top of an earlier prescription she’d been using at home for the same thing. The combination of the two drugs had caused her blood pressure to plummet. This incident occurred because the hospital discharge process failed to communicate to the patient that she should stop taking her previous blood pressure medicine.
Regrettably, her story wasn’t unusual, says Stephanie Bailey, MPH, CCRMC’s Director of Ancillary Services, “at least not back then.” It was 2005, says Bailey, “and we didn’t realize how broken our medication reconciliation system was. We’ve changed a lot since then.”
Medication reconciliation is the process of obtaining and maintaining an accurate and detailed list of all prescription and non-prescription drugs a hospital or ambulatory care patient is taking, including dosage and frequency, throughout a health care encounter. For a patient being admitted to the hospital, or being seen in an outpatient clinic, the idea behind “med rec,” as it’s sometimes called, is to link the best medication list possible to any subsequent physician orders and to ensure that the patient receives only what’s safe, and truly intended.
While techniques and policies for medication reconciliation can vary widely from one facility to another, depending on factors such as size, staff awareness, and electronic vs. paper records, the need and opportunity for reconciliation occurs at each fresh point of contact with a patient, especially these three:
  • Admission: When all the medications someone is taking at home are newly inventoried, documented, and reconciled with other medication records that may be on file and any new prescription orders from an admitting physicians.
  • Transfer: When clinicians review previous medication orders in light of new orders or plans of care, resolving any conflicts, changes or omissions and documenting the resolution.
  • Discharge: When clinicians again review and update all medications the patient was taking at home, incorporating new prescriptions to ensure that all medications are clearly noted for continuation or discontinuation and that recommended changes are explained,
Admittedly, the ongoing demands of patient care can frustrate even the best intentions. It’s not always clear who, precisely, is ultimately responsible for ensuring an accurate medication list. If roles aren’t clearly assigned, the process can effectively become no one’s priority. Patients are not always reliable sources on their own drug regimens. Compiling an accurate inventory may require time-consuming cross-checks with outside providers, such as a patient’s pharmacist or primary care physician. Also, it’s extremely challenging to maintain an accurate medication list throughout transitions in care because, depending on the patient’s journey, there can be multiple handoffs to new caregivers and settings, and multiple opportunities for some crucial piece of information to slip through the cracks.
Contra Costa Regional Medical Center (CCRMC)
The 141-bed suburban San Francisco Bay Area county hospital, where the elderly woman mistakenly took two different blood pressure prescriptions post-discharge, reduced its rate of unreconciled home medications on admission and discharge from 25 percent to 1 to 3 percent within two years. The hospital now encourages patients to carry a wallet card listing all their medications or to bring them along in a paper bag. Stephanie Bailey, who led the project, cites three main reasons for the stunning improvement at CCRMC: “Our physicians led the effort. We designed work flows so that there would be less work, not more, for everyone except the pharmacy staff. And we designed low-tech solutions that we could weave into the existing work flow.”
Also key to CCRMC’s success has been revamped forms, both paper and electronic. At admission, the paper medication reconciliation form also doubles as the physician order form for medications. It contains three boxes — continue, discontinue, modify — one of which must be checked. If no box is checked, or if the hospital pharmacy receives no form for a patient, a pharmacy technician investigates the oversight.
The pharmacy keeps each patient’s record updated in its own computer system, and patient transfers trigger a pharmacy-generated paper form of current medications that again require a physician’s scrutiny and sign off. “Nurses just love that,” says Bailey, “because the physicians used to just write ‘continue previous orders,’ which required the nurse to go back to the chart to figure out which meds the patient was receiving prior to transfer. Now they’re right on the form.”
Reforming how medication reconciliation is handled during discharge has encountered some challenges. As with transfers, the clinical system used for medications produces a paper med rec form that lists all current in-hospital medications, plus the at-home list captured during admission. The physician uses both lists to compile discharge medications instructions, and the discharge nurse transcribes all the updated information onto a patient-friendly form. Initially, the pharmacy was asked to create the patient-friendly version, but “that turned out to be more labor-intensive than we realized,” says Bailey. “They couldn’t keep up without adding staff, which we couldn’t do.” Bailey acknowledges that transcribing by hand creates room for mistakes. “We’re working on finding a better way right now. Our goal is 100 percent accuracy throughout our process.”
Fairview Northland Medical Center (FNMC)
The 55-bed Princeton, Minnesota, community hospital is part of Fairview Health Services, which includes four clinics where nearly all FNMC’s physicians also work, treating many of the same patients. Nonetheless, when the hospital’s pharmacy director, Bruce Thompson, MS, RPH, conducted a review of patient pharmacy records in 2004, he found outdated antibiotic prescriptions, medications listed under both brand and generic names, and other inaccurate record keeping that could easily lead to errors. A close inspection of admission forms revealed an average of 2.7 inaccuracies and/or omissions per patient. “We knew we had a lot of cleaning up to do,” says Thompson.
One sticking point: the clinics had electronic patient records, but the hospital used only paper. Thompson realized he’d need to lobby for connectivity, but it might take a while. “We’re a small hospital so relationships are especially important,” he observes. Meanwhile, during 2005 and early 2006, the hospital pharmacy produced its own improved paper forms for admissions, transfers, and discharges and added new services, such as faxing up-to-the-minute physician-signed and dated medication lists to a discharged patient’s community pharmacy or nursing home, and adding allergies, allergic symptoms, and the medical reason for each medication to each record. The changes were well received, but electronic interface with the clinic system remained elusive.
In mid-2006, Thompson and his team launched a renewed effort under the banner “Moving from Med Wreck to Med Rec.” The breakthrough came in January 2007, when FNMC began using an electronic admission form generated from the clinics’ patient records. Transfer and discharge forms are still paper, but hospital pharmacists review discharge medications, update the clinic records, and provide the patient with an accurate take-home list.
“We still have a way to go,” says Thompson, “but now there is just one medication list per patient, across our system. In inpatient areas, we have steadily improved to the point where our reconciliation is now above 97 percent.”
Seton Health, St. Mary’s Hospital
In 2004, a state quality review at the 196-bed community hospital in Troy, New York, found a medication problem related to discharge. “When we looked into it,” says Kathy Lee, MA, RN, Clinical Mentor for Nursing Education, “we discovered that, when patients were discharged, physicians reviewed their in-hospital medications but not always the ones they took at home. As a result, 86 percent of the discharge medication lists contained one mistaken piece of information and 42 percent contained two or more.”
The hospital seized on this opportunity to improve its med rec processes, starting in-house and eventually spreading throughout Seton Health, which encompasses 20 local clinics, by initiating major changes to make sure that a patient’s medications are accurately reconciled at every encounter, including ambulatory procedures and outpatient visits. The new process requires that a medication record, including the name and phone number of the patient’s pharmacy and where/how the medication information was obtained, be created as part of an initial health history that follows the patient through subsequent encounters. “Any time we interact with a patient, we ask for a complete list of current medications, which we check against what we already have and which the clinical staff reviews prior to treatment. Then we update, as necessary,” says Lee. Fortunately, she says, “all our records are electronic, no paper. That’s a huge advantage because it’s much easier to replace old information with new information and transfer it throughout the system than it would be with paper.”
Education has been another vital part of the effort. Posters were placed in the physician lounges touting the importance of medication reconciliation; “ambassadors” — nurses, pharmacists, and information technology staff — met one-on-one with physicians to review the new standards; and the hospital sponsored a continuing clinical education program on medication safety. Patients, too, were informed via a public forum on medication management. To help them stay on top of their own needs, discharged patients now receive a wallet-sized card listing current meds in a durable plastic sleeve. “Our community newsletters also emphasize the importance of knowing what medicines you take,” says Lee.
Compliance with the new processes has grown steadily, from 41 percent in 2006, to 88 to 96 percent in 2007, depending on the clinical service. In 2008, the hospital is looking at medication outcomes to improve medication safety, says Lee.
IHI’s Frank Federico, RPh, a Director who has helped hospitals adopt better medication safety practices, has identified several key lessons:
  • Medication reconciliation should be patient centered.
  • There must be agreement as to the elements of medication reconciliation; this is the foundation to building a reliable process.
  • Use of standardization and simplification are a must.
  • Engagement of staff at the front line is essential; this means those who have to do the work: physicians, nurses, and pharmacists.
  • Engagement of administrative and clinical leadership is critical for all else to succeed.
Medication reconciliation is one part of a comprehensive plan to improve patient safety. Federico notes that some have challenged this work, insisting that collecting a medication list is difficult. His response: “In most cases, how can you provide good care if you do not know what medications the patient is taking? Focus on doing what is right for the patient, and the rest will follow.”
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