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