Tuesday, January 7, 2014
Medication reconciliation demands a 'no ifs, ands or buts' list
There’s a universal problem that is plaguing hospitals across the nation. In the midst of all the other challenges in health care, it is a surprisingly under talked about issue. Medication reconciliation. For anyone non-medical reading this, in a nut-shell medication reconciliation is all about clarifying the patient’s home medications when they are admitted to hospital, and then confirming them again—with any changes—upon discharge. According to JCAHO (Joint Commission on Accreditation of Healthcare Organizations) the definition is “the process of comparing a patient’s medication orders to all of the medications that the patient has been taking.” Sounds simple enough? If only that was the case. I’ve found this to be an elusive goal in every single hospital I’ve ever worked in, all the way from rural hospitals to major academic teaching centers. I’m yet to see this seemingly simple process fully mastered.
It all essentially boils down to these questions: How can we best confirm what a patient’s exact home medications are when they are admitted to hospital? And how can we ensure that this list is again clarified during any in-hospital transfers and upon discharge?
Here’s the process that currently occurs. When a patient is admitted to hospital, the doctor takes a complete history and performs a physical examination (hopefully by then we are confident of the diagnosis). Part of the history taking is to obtain the patient’s full home medication list. Some reasons why this is so difficult and haphazard include:
• Physicians are typically only able to dedicate a handful of minutes to this task, since it forms only a relatively small part of the history and physical;
• The patient is not sure about exactly what medicines they take. This is an extremely common scenario, and it can understandably get very confusing for some elderly patients who are on a dozen or more medications;
• No easy access to the patient’s regular medication list from external sources. Lack of a universal computer system which is connected to the patient’s primary care doctor or pharmacy. After hours (the majority of the time when people are admitted to hospital), the admitting doctor will find it difficult to contact these other places;
• Different medication lists. Often 3 or more different ones from the primary care physician, prior hospital records, and the patient themselves;
• The patient doesn’t actually take the medications that have been prescribed to them; and
• Upon discharge, after some of the medications have been changed, the new list is not properly reconciled with the original one on admission.
I’ve lost count of the number of times an anxious relative feels the need to clarify their loved ones’ medications after they’ve already been admitted to hospital. I always feel very bad when this happens, because it shouldn’t fall on their shoulders to be left telling us. We may not be able to account for patients who are not taking what they should be, but we should at least be able to say with certainty exactly what they are supposed to be taking. Neither should the solution rest with relying on patients to give us a complete medication list; that isn’t likely to work any more than a car service center expecting a customer to know all the details of their last repair work.
Getting this right is important for a number of reasons. First and foremost, it’s a huge patient safety issue. Medication errors were first brought into the national spotlight in 1999, with the Institute of Medicine’s landmark report, To Err is Human: Building a Safer Health System. At that time, it was estimated that about 100,000 deaths per year were because of hospital errors. Latest statistics suggest that this figure may be even higher, as much as a staggering 400,000 per year according to a recent study in the Journal of Patient Safety. This would make them the third leading cause of death in the US.
While these statistics include all hospital errors, medication errors are top of the list. The Institute of Medicine estimates that the average hospitalized patient is subject to at least one medication error per day, of which more than 40% are thought to be the result of poor reconciliation. Alarmingly, 1 in 5 of these will cause harm to the patient. It is therefore very dangerous to have any confusion surrounding the patient’s medications.
New technology has the potential to greatly help solve this problem, especially if medication lists are clarified within one central computer system. The federal government’s Meaningful Use policy adds extra incentives to do this. Unfortunately, because hospitals have rushed to comply, not enough thought has been put into the underlying processes. Simply putting everything on the computer doesn’t automatically make everything okay if it’s the wrong list in the first place! It isn’t all about just complying with Meaningful Use. Computerized medication reconciliation is a classic example of a great idea, which simply takes too long on our currently available cumbersome computer systems. Far more accurate right now would be to have a laminated list of the correct medications that was kept in a secure part of the chart.
Many studies have looked into who the right person is to perform the reconciliation task. Is it always the doctor? In some hospitals, it’s even the ER nurse that is given the responsibility. Several studies have in fact shown that pharmacists are the professionals best equipped to do this, since their whole expertise and focus is on reviewing medicines. In my experience, this is very true, and I’ve been fortunate enough to work with some great pharmacists in my time as a hospital medicine doctor. It’s typically the pharmacy that acts as a backup anyway for physicians when they write any medication orders. Frontline doctors are well used to communicating with pharmacists on a daily basis (usually after receiving an informational message on their pager). Some ways that hospitals can successfully utilize pharmacists in the medication reconciliation process are as follows:
• Have a pharmacist stationed in the ER dedicated to documenting a complete and thorough medication list for every patient admitted to hospital (there may need to be more than one pharmacist for busier EDs). If the cost of employing these extra pharmacists is a problem for hospitals, think of the patient safety and saved “doctor time;”
• This pharmacy-generated list should be made part of the computerized record, and instantly available to the admitting doctor; and
• The pharmacist should again review the medications and go over any changes with the patient upon discharge. This can be targeted to more complex patients if staffing is an issue.
Many hospitals are finally realizing the importance of medication reconciliation and putting significant resources into solving the problem. Doctors, pharmacists and administrators have to work closely together to drive this quality improvement. The first goal should be to have a definite process in place whereby the accurate list is known on admission—to put it bluntly, a “no ifs, ands, or buts” medication list. By doing this seemingly simple thing, we will be taking a huge leap forward into the new health care era.
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.
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Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
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Suneel Dhand, MD, ACP Member
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