Medication reconciliation: a safeguard for patient safety
BACKGROUND
ACCORDING to the Institute of Medicine’s Preventing Medication Errors report, the average hospitalised patient is subject to at least one medication error per day (Institute of Medicine. Preventing medication errors. Washington, DC: National Academies Press; 2006). This confirms previous research findings that medication errors represent the most common patient safety error.2 More
than 40 per cent of medication errors are believed to result from inadequate reconciliation in hand-offs during admission, transfer, and discharge of patients. Of these errors, about 20 per cent are believed to result in harm. Many of these errors would be averted if medication reconciliation processes were in place. Medication reconciliation is a formal process for creating the most complete and accurate list possible of a patient’s current medications and comparing the list to those in the patient record or medication orders.
DEFINITION
According to the Joint Commission5: Medication reconciliation is the process of comparing a patient’s medication orders to all the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions in care include changes in setting, service, practitioner, or level of care.
PROCESS
This process comprises five steps: (1) develop a list of current medications; (2) develop a list of medications to be prescribed; (3) compare the medications on the two lists; (4) make clinical decisions based on the comparison; and (5) communicate the new list to appropriate caregivers and to the patient.
Recognizing vulnerabilities for medication errors, numerous efforts are underway to encourage all health care providers and organisations to perform a medication reconciliation process at various patient care transitions. The intent is to avoid errors of omission, duplication, incorrect doses or timing, and adverse drug-drug or drug-disease interactions. The Joint Commission added medication reconciliation across the care continuum as a National Patient Safety Goal in 2005.6 The Institute for Healthcare Improvement (IHI) has medication reconciliation as part of its 100,000 Lives Campaign.
A comprehensive list of medications should include all prescription medications, herbals, vitamins, nutritional supplements, over-the-counter drugs, vaccines, diagnostic and contrast agents, radioactive medications, parenteral nutrition, blood derivatives, and intravenous solutions (hereafter referred to collectively as medications). Over-the-counter drugs and dietary supplements are not currently considered by many clinicians to be medications, and thus are often not included in the medication record. As interactions can occur between prescribed medication, over-the-counter medications, or dietary supplements, all medications and supplements should be part of a patient’s medication history and included in the reconciliation process.
IN-PATIENT
For a newly hospitalised patient, the steps include obtaining and verifying the patient’s medication history, documenting the patient’s medication history (instituting a channel for the return of unwanted/unused medicines), writing orders for the hospital medication regimen, and creating a medication administration record.
At discharge, the steps include determining the postdischarge medication regimen (and creating avenues for the return of unwanted/unused medicines), developing discharge instructions for the patient for home medications, educating the patient, and transmitting the medication list to the follow-up healthcare provider.
OUT-PATIENT
For patients in ambulatory settings (Outpatient), the main steps include for new patients obtaining and verifying the patient’s medication history, documenting a complete list of the current medications (and creating a channel for the return of unwanted/unused medicines), and then updating the list whenever medications are added or changed. Patient counselling is important in identifying previous medications, current medications, and discontinued medications.
INFORMATION TO
CAPTURE-MEDICATION
RECONCILIATION
Contact details for relevant healthcare professionals; Known allergies and reactions to medicines or ingredients and the type of reaction; Current medicines (name, strength, formulation, dose, timing and frequency, route of administration, indication); Changes to medicines and the reason for changes (medicines started, stopped medicines, dose changes); Date and time the last dose of any medicine was taken, including specific instructions to support their administration; Information about any medicine given less often than once a day – weekly or monthly medicines; information given to the person, family members or carers; when the medicine should be reviewed or any monitoring; any other relevant information, for example smoking status, alcohol intake
MANAGEMENT INFORMATION SYSTEM & DIGITAL TECHNOLOGY
The adoption of a very sound, comprehensive hospital management information (supported by digital technology) system is critical in storing, retrieval data on the patient (Kramer JS, Hopkins PJ, Rosendale JC, et al. Implementation of an electronic system for medication reconciliation. Am J Health Syst Pharm 2007; 64:404-22)
CHALLENGES
There are patients where medication reconciliation is usually a challenge: stroke patients, accident victims, the elderly, persons with co-morbid conditions and several medications, educational background, cultural beliefs, and persons with disabilities.
The readiness of health workers (an enabling work environment) to adopt medication reconciliation and the availability of an effective management information system and digital technology could also constitute a challenge.
CONCLUSION
Medication reconciliation should be seen as key safeguard for patient safety. This reconciliation is done to avoid (among others) medication errors such as omissions, duplications, dosing errors, or drug interactions.
DR. EDWARD O. AMPORFUL
CHIEF PHARMACIST
COCOA CLINIC
