Answers to improved medication reconciliation lie with pharmacists

November 19, 2007

Two out of 10 hospital pharmacists know of incidents in which inadequate policies have led to patient harm, an exclusive Drug Topics survey concluded.

Overall, most hospital pharmacists think their institutions do a good job reconciling patients' medications. But two out of 10 know of incidents in which inadequate policies have led to patient harm, an exclusive Drug Topics survey concluded.

In many cases, the policies failed to catch a duplication of medication or missing doses, the survey found. In other instances, medications were omitted or there was no follow-up. And several respondents blamed their hospital's shoddy medication reconciliation policy on inadequate staffing.

"It was done late in the evening when staffing was less than earlier in the day," one pharmacist wrote. "Patients being admitted during shift changes resulted in late med reconciliation, or it not being done at all." Another health-system R.Ph. simply stated, "took too long to reconcile home meds."

Drug Topics conducted the nationwide survey of hospital pharmacists Sept. 27 through Oct. 10. The survey was sent to 12,105 subscribers of the magazine, and 640 pharmacists responded.

Joint Commission criticism

Seven percent of those who responded said the Joint Commission found fault with the way their hospitals handled medication reconciliation, the process by which healthcare practitioners obtain and document a complete list of a patient's current medications upon admission to a hospital or healthcare facility. A complete list of the patient's medications should ideally be given to the next healthcare provider upon the patient's discharge or transfer to another facility.

The Joint Commission has included medication reconciliation in its list of National Patient Safety Goals for the past several years. The process also is endorsed by the Institute for Healthcare Improvement.

When asked to explain how the Joint Commission found fault with their hospital's medication reconciliation policy, many pharmacists responded with a simple "not being done." Others said additional steps were needed in outpatient areas, while some said their program was not far enough along.

"Our policy didn't include reconciling home meds upon admission with home meds to be taken after discharge," one pharmacist explained. "It does now, but remains the problem area."

"Inconsistent following of the policy," wrote another health-system R.Ph. "Some providers are very good, some not; also questioned certain verbiage in notes."

Still others said the Joint Commission faulted their policies because they were not uniformly followed throughout the hospital or because physicians were not active enough in the process.

Seventy percent of respondents said their hospitals allow patients to bring in their own medications. Among those pharmacists, 53% noted they have run into problems identifying patients' medications.

Possible solutions

When asked for suggestions to improve the patient handoff process at their hospitals, respondents proposed a better communication process, more accurate drug information, and increased involvement from pharmacists.

"Better communication with the patient to verify that he understands the medication changes that have been made," wrote one pharmacist. Others challenged doctors, nurses and pharmacists to be more communicative with one another, while some felt there should be more interaction during shift changes and at patient transfers.

One pharmacist even placed the responsibility of improving the process on the patient: "A better understanding for patients as to what they are expected to provide to caregivers."

And many said technology could help. "Have forms available electronically that can be used to collect the information, update it when needed, and carried forward from one facility to another (transferred electronically to the next provider of care)," commented one respondent. "This will eliminate a lot of work collecting the same information over and over again."

"Electronic records," agreed another pharmacist.

More than half of the pharmacists who responded to the survey—53%—said their hospital uses tools such as software or electronic health records to help them with medication reconciliation.

Of the pharmacists whose hospitals do not use software or electronic health records, 21% said their facility has plans to adopt new technology in the next year to help improve the medication reconciliation process. Forty-six percent said they were not sure whether their hospital would adopt new technology in the coming year.

"In a perfect world, and hopefully someday, we'll get there, an electronic health record would help a lot," said Allen Vaida, Pharm.D., FASHP, executive VP of the Institute for Safe Medication Practices. "That record would be available to different healthcare professionals throughout the continuum [of care], but we're not there yet."

Medication reconciliation process at hospitals suffered relapse in 2006

The nation's hospitals did a poor job last year reconciling patients' medications. And the problem seems to have gotten worse.

A new report from the Joint Commission concludes that only two-thirds of American hospitals reconciled medications, down from 99.9% in 2005. There was a similar drop in reconciling medications across the continuum of care, including at discharge: 72.5% of the nation's hospitals consistently did so last year, a drop of 27.2% from 2005, according to the report, Improving America's Hospitals: The Joint Commission's Annual Report on Quality and Safety 2007.

"This is a test of hospital competency in redesigning care processes," said Joint Commission President Dennis O'Leary. "It's seemingly simple to get the list of medications from where the patient was to where the patient is going. But in fact it is a terrible challenge."

Medication reconciliation proved to be one of the biggest challenges for hospitals last year, the report states. The Commission identified nine issues that were most difficult for hospitals to meet, and medication reconciliation was the second-most problematic, recording a 54% compliance rate. Only one issue proved to be more difficult for hospitals to meet than medication reconciliation: improving the effectiveness of communication among caregivers. That issue had a 42% compliance rate, the report stated.

Other difficult issues for hospitals last year included the proper and safe storage of medications; ensuring that medication orders are written clearly and transcribed accurately; proper pain assessment; improving medication safety; managing safety risks; and keeping a "complete and accurate" medical record of all patients served.