Eye on ethics: Are you ready to reconcile medications?

There is still inadequate communication among pharmacists from different practice settings about patients' medications. Pharmacists should take ownership of medication reconciliation.

A Wherever pharmacists work, each practice setting has its own patterns of medication use and requires particular professional skills. Patients may be transferred among several settings within a lifetime. In 2005, the Joint Commission set patient safety goals, including the medication reconciliation process, which attempts to catch errors made when patients move from one setting to the next. If the patient requires continuous care no matter what the setting, why has the medication reconciliation process focused only on hospital-based care? And why aren't pharmacists in charge of this process?

Community pharmacists frequently receive a long list of discharge orders, presented by a patient's family member. Often, that person doesn't even know which drugs the patient has at home. Patients admitted to long-term care are often discharged from the hospital on 20 or more medications; many patients are diagnosed with methicillin-resistant S. aureus, AIDS, and other conditions or diseases that require complex care. Generated within the closed system of a hospital, discharge orders may reflect "in-house" protocols and abbreviations that may be misinterpreted by those working outside the hospital.

The Joint Commission's patient safety initiatives emphasize working to provide the patient with a current list of medications and instructions upon discharge, but the critically ill or incapacitated patient cannot be his or her own advocate. Failing to review orders before discharge leaves the patient open to errors, which may take hours or even days for the next pharmacist to resolve and may partially disable the care process.

Pharmacy as a whole still needs to repair this huge gap in patient care. The lack of coordination between practice settings also affects hospital pharmacists. Patients admitted to the hospital from home may also lack complete medication profiles, and the hospital staff may have to piece together the profile through patient and family interviews, calls to multiple pharmacies, and by sorting through the drugs the patient brings to the facility.

It may be time for pharmacists to sign off on complex or unusual discharge orders when the patient is sent to another care setting. That would signal that a pharmacist has reviewed the orders and provide an easily reached contact in case clarification is needed. This step would also save time for physicians, preventing much of the convoluted clarification process. And the pharmacist's extensive knowledge of products, interactions, and the wide range of medication options available would save both patients and their physicians time and money.

The medication reconciliation process revolves around the list of drugs that a patient is prescribed and must involve all pharmacists who care for the patient with complex care. Ironically, the term reconciliation usually applies to relationships between people, not pieces of information. Though every R.Ph. is legally self-responsible for the work done for each patient, it is very rare for a patient to receive medications and review from just one pharmacist in one setting. The relationships and the communication between pharmacists in all settings need to be reconciled to better serve the patient.

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Dr. Charles Lee
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