Medication reconciliation is back on the front burner. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has expanded its existing National Patient Safety Goal on medication reconciliation for 2007.
The 2006 NPSG for medication reconciliation called for a complete list of meds when a patient is transferred to another facility or another level of service. Starting next January, patients must also be given a medication list at discharge. "We were not aware originally that the medication list had to be clear and understandable to the patient or the caregiver," said Carol Ptasinski, JCAHO senior director of standards interpretation. "We found that many organizations were transferring medication lists but not giving the list to patients or caregivers at discharge. We needed to be more specific."
A 2006 survey found that 83.5% of hospitals were giving discharge drug lists to patients. That compared with 97.7% of long-term care providers and 90.8% of all providers. The problem seemed to be confusion about exactly what JCAHO expected, Ptasinski explained. Too many hospitals believed that medication reconciliation meant reordering all of the medications patients were taking before admission.
"The more complex the organization, the more confusion there seems to be," Ptasinski continued. "They want to make sure they are consistent across all of the different inpatient, outpatient, ambulatory care, day surgery, and other units. Medication reconciliation is going to be a National Patient Safety Goal for quite a while."
Keeping the focus on medication reconciliation is a positive move for patient care, said Kasey Thompson, director of the ASHP's' Center on Patient Safety. "My sense is that there are still challenges in medication reconciliation. Some hospitals are still working the bugs out of the system."
Hospitals use one of two methods to reconcile mediations: paper systems and electronic systems. Some institutions create their own forms or systems, others gravitate toward commercial products, Thompson said.
On the electronic side, some vendors use claims data to generate medication lists. Healthcare informatics provider Cogon Systems, for one, pulls medication-related data from other hospital systems. "We are system-agnostic," said Tony Basel, clinical systems consultant for the Pensacola, Fla., firm. "Whether it's an admitting system, emergency department, pharmacy, computerized physician order entry, or anything else, as long as it can output in HL7 [a standardized data format], we can work with them."
Many hospitals have been reconciling medications for years, Thompson said. Meeting the NPSG may have brought changes in documentation, but not in daily practice. Other institutions waited until late 2005 to launch reconciliation systems. Hospitals that waited tended to have problems when the initial 2006 NPSG deadline arrived Jan. 1, Thompson said.
Northwestern Memorial Hospital was already reconciling medications in 2004, when JCAHO first announced its intent to require the practice in 2006. Hospital researchers published a study in 2004, reporting that while nurses and physicians are integral to the medication reconciliation process, pharmacists are key players in reducing medication errors.
That conclusion hasn't changed, said lead author Kristine Gleason, research pharmacist coordinator on Northwestern's patient safety team. The most important element in medication reconciliation is working with patients to ensure that their drug list is complete and accurate. "Patients have always gotten a drug list here," she said. "It goes back to how accurate that list is. When patients go home, they need to understand changes to what they were taking before admission, as well as any new drugs." Northwestern developed an electronic reconciliation system linked to the institution's electronic medical record system. "We had to go electronic," she said. "No one looks at a paper history around here anymore."