Which steps must the nurse perform as part of the medication reconciliation process?

One of the most challenging aspects of improving medication safety involves ensuring that accurate information about a patient’s medications — what he or she is taking, when, and in what dose — travels with that patient throughout the health care system, and that any changes to that list are shared with other providers. This requires specific steps as well as clear roles and responsibilities. But the first challenge — and it can be a significant one — is getting the initial list of medications right.

Consider the following scenario: You are an emergency department nurse. An elderly patient has arrived by ambulance, pale and short of breath. As a doctor examines her, the EMT hands you three prescription bottles he retrieved from the patient’s kitchen windowsill. You check the computer and find the chart from this woman’s recent hospitalization for congestive heart failure. The five prescriptions she was discharged with and the bottles in front of you are only a partial match. It’s Sunday evening, her doctor’s office is closed, and the prescriptions were filled at two different pharmacies. You ask her what medications she takes, and she says, “a small blue pill after breakfast and two big white ones at bedtime.”

Getting this woman’s medication information right may be critical to her treatment in the emergency department. But it also matters because she’s likely to be cared for in several different departments, and the initial record of this patient’s medications — accurate or not, and whether collected in the ED or when admitted to a unit — will travel with her throughout her hospital stay. When the information is incomplete or inaccurate, there can be discontinuities in care. Without well-designed steps to share medication information and treatment decisions at transition points — when patients are admitted to the hospital, transferred from one unit to another, or discharged —quality and safety are both compromised. In fact, studies show that inconsistent knowledge and record keeping about medications directly threaten patient safety, causing up to 50 percent of all medication errors in the hospital and up to 20 percent of adverse drug events (ADEs).

The most effective solution to this problem is called medication reconciliation, a formal process of collecting and maintaining a complete and accurate list of a patient’s current medications and comparing that list to the physician’s admission, transfer, and discharge orders. Medication reconciliation has been shown to reduce adverse drug events (ADEs). That’s why IHI included medication reconciliation as one of the interventions in the 5 Million Lives Campaign, and why both the Institute of Medicine and the Joint Commission on Accreditation of Healthcare Organizations have identified it as a priority.

Medication reconciliation is designed to avoid the most common medication errors: inadvertently omitting a medication a patient was taking at home during a hospital stay; failing to ensure that home medications temporarily stopped during a hospital stay are restarted when the patient is transferred or discharged; duplicating medication orders either because the patient may already be taking the drug or due to confusion between brand and generic versions of a drug or formulary substitutions; as well as prescribing incorrect dosages. Medication reconciliation involves a three-step process: verification (collecting an accurate medication history); clarification (ensuring that the medications and doses are appropriate); and reconciliation (documenting every single change and making sure it “squares” with all the other medication information). These steps are more difficult than they might appear.

The challenge is exacerbated by the fragmented nature of the US health care system. “The sources of information on medications are scattered in a number of different places,” says Frank Federico, RPh, an IHI Director focused on patient safety and reliability. Federico also co-chaired a statewide patient safety initiative to reduce medication errors sponsored by the Massachusetts Coalition for the Prevention of Medical Errors.

“The physician’s office has records, but they are difficult to keep current, especially if the patient has prescriptions from many specialists,” explains Federico. “The pharmacy has records, but only for the prescriptions filled there. The hospital medical record may be incomplete, considering that most care is administered in the ambulatory setting. And many patients can’t say what they are taking because they are cognitively impaired or their drug regimen is complex.” That a single drug may have a chemical name (often unpronounceable), a brand name, and a generic name simply adds to this already challenging task.

Though it’s important to get accurate information for all patients entering the hospital, it can be particularly important — and challenging — with emergency patients. “Some emergencies may actually be the result of medication interactions or medications taken inappropriately,” says Federico. Moreover, for patients who are admitted to the hospital through the ED, incomplete information can perpetuate mistakes. “If a patient was on four meds at home but the hospital only learns about three, on admission the doctor orders only those three,” says Federico. “Or what if the doctor orders only two of those meds? How will other caregivers know if the medication was intentionally omitted or simply missed? Hospitals need good processes for deciding and documenting what meds to continue or discontinue during hospitalization, and which ones to restart on discharge.”

While information technology such as electronic medical records and computerized prescription order entry systems can play an important role in improving medication reconciliation, software specific to all aspects of medication reconciliation is not yet well developed. Many hospitals are not waiting for it either, but are creating paper-based systems that are achieving great results. Technology isn’t essential, but commitment to the goal and hard work are. 

Not Just Another Project

Eric Alper, MD, Patient Safety Officer at UMass Memorial Medical Center in Worcester, Massachusetts, a participant in the statewide medication safety initiative, says that implementing medication reconciliation is not just another project, because it changes the fabric of the organization, including processes, roles and responsibilities.

“Medication reconciliation requires logistical and cultural change, and repeated process redesign at multiple levels,” he says, “which is why leadership is so important.” Alper says the CEO and chief quality officer at UMass Memorial strongly supported the effort.

Strong leadership is necessary, says Alper, because in most hospitals there is no one designated to be responsible for making sure the patient’s medication list is complete and accurate. “If you asked ten laypeople on the street if they thought this was already being done in their hospital, they’d say yes,” says Alper. “But the question inside the hospital is, ‘Whose job is this?’” Without clear leadership and accountability, he says, the answer will continue to be “no one’s.”

In fact, the job is big enough and complicated enough that it requires teamwork. Nurses are often the ones who start the reconciling process by gathering medication information, but physicians write the medication orders. The tasks are interdependent, and both parties must accept accountability for their part of the job. At UMass Memorial, a large academic medical center, Alper says that residents perform most of the medication reconciliation. “They were already gathering medication lists and writing orders. It made sense to give them primary responsibility for med rec.” But whoever gathers and documents a patient’s medication history must sign their name to the list. Subsequently, nurses verify the list with patients and address any questions that arise.

The process at UMass Memorial was streamlined through the introduction of a new medication reconciliation form — tested and tweaked many times — that combines the medication list and the order sheet, eliminating the need to copy information from one to the other, as had long been the practice. Now the physician can indicate on the patient’s complete medication list which medications to continue during hospitalization and which to suspend, and that form is sent directly to the pharmacy and becomes part of the patient’s record.

Alper says they tested the new form on a small population — those coming in for pre-operative testing — and once the kinks were sufficiently worked out, they spread it more broadly. “We were able to roll it out pretty successfully,” says Alper, though it took a lot of time. “We met with all the residents across hospital departments, and did it repeatedly as the residents rotated through.” Now, he says, up to 80 percent of patients have a medication reconciliation form in their chart, and about 95 percent of patient’s hospital medical records appear to be free of reconciliation errors.

In Top Form

Health care is rife with forms, and the tedium involved in designing them is not why people go into medicine. Daniel Hoffman, MD, speaks for many physicians when he says, “I don’t like bureaucracy and boring details.” But when it comes to medication reconciliation he says, “This has been one of the most rewarding changes we’ve made. It’s made a huge difference.” Hoffman is Administrative Medical Director for Good Samaritan Regional Health Center in Mount Vernon, Illinois, part of SSM Healthcare. The work to improve medication reconciliation was done jointly with another SSM facility, St. Mary’s Hospital, in nearby Centralia, Illinois.

“We used to get accurate admission lists of home medications about 30 to 40 percent of the time. Now we are at about 80 percent on both campuses,” says Hoffman. Reconciliation upon discharge has improved dramatically as well, he says. “We’ve gone from 48 percent reconciled at discharge to 94 percent.”

Hoffman acknowledges that getting there is challenging. “It requires a lot of changes in behavior, especially for physicians,” he says. Several elements are essential for the effort to succeed. “Physician champions are critical,” says Hoffman. “You won’t get there without them. Second, it has to help physicians in their work, as well as being good for patient care. And third, floor staff have to be empowered and willing to hold physicians to the new process. That can be very hard for some employees.”

At the two SSM hospitals, where a multidisciplinary team with representatives from both campuses developed the new process, the focus was on consolidating information about patients’ medications onto a single form used in all settings, regardless of where or why the patient enters the hospital. That medication list is printed and placed in the patient’s chart daily during his or her hospital stay.

Hoffman says this makes physicians’ jobs easier. “All the information is consolidated in one single place, all I have to do is circle yes, no, or hold, sign and date it. When the pharmacy reviews and enters those orders, the computer automatically updates the medication list. Downstream at discharge, I now have a form that helps me address all the medications the patient came in on, which helps me discharge them on the proper meds.” The discharge list is printed with patient-friendly instructions and given to the patient on discharge. Copies are also placed in the patient’s hospital chart and faxed to the patient’s physician.

It sounds simple and straightforward, but it isn’t always, says Monica Heinzman, PharmD, Pharmacy Director for both SSM hospitals. This is where information technology can help. “When patients are admitted, hospitals routinely look to their own formularies for an equivalent drug to whatever the patient was taking at home,” she says. So a patient on cholesterol medication at home may get an equivalent medication in the hospital, but with a different name. This can result in patients taking two drugs for the same thing after they’re discharged. “When the discharge sheet is generated, our program converts medications back to what was originally ordered for patients at home, and that has helped a lot,” says Heinzman.

But of course streamlined processes, effective forms, and efficient technology are only as good as the information they are designed to accommodate. Getting accurate information about patients’ medications in the first place can sometimes be the biggest challenge.

Enlisting Patients

“Our nurses and doctors told us that getting medication information from patients is the most unreliable part of the whole process,” says Mary Urquhart, RN, Executive Director of Nursing at Brattleboro Memorial Hospital, a 61-bed primary- and acute-care hospital in Brattleboro, Vermont. “We knew that in order to do our best with medication reconciliation, we needed to teach the public what we expect of them in terms of their medications.”

So recently the hospital launched a community education campaign that includes articles in the local newspaper and in their hospital newsletter, community forums, and soon, free online access to blank copies of the hospital’s admission medication form. “We want people to fill in their medication information and keep a copy at home or in their purse to bring if they ever come to the hospital, and send a copy to their doctor’s office so they have an accurate list,” says Urquhart.

In many communities, EMTs participate in programs such as Vial of Lifedistributing forms and often special containers or magnets that encourage people to record and keep easily accessible information about their medications. This way an EMT will know where to find the information if a patient is unable to communicate and bring it to the hospital along with the patient.  

Tim Lynch, PharmD, MS, says community education programs such as these are helpful. Lynch is Pharmacy Services Manager at St. Francis Hospital in Federal Way, Washington, a 110-bed hospital that is part of the Franciscan Health System (an affiliate of Denver-based Catholic Health Initiatives). “People are much more educated these days about how to help us help them,” says Lynch. “Patients often arrive with their medications or their list because they’re aware of the importance.” Much of that education is taking place in primary care settings, where many practices are encouraging patients to bring all their medications to every appointment for a quick review. This helps the doctor’s office maintain an accurate and current list of medications.

At St. Francis, Lynch says they are always looking for ways to make it easier for everyone to get accurate information about medications. “We’re currently piloting a tri-fold wallet-sized card to give patients at discharge with all their medications, conditions, and allergies listed on it,” he says. Eventually the plan is to develop it for use in all settings, including the hospital’s primary care clinics.

Even with a printed list, detective work is often required to make sure it’s accurate. Monica Heinzman at SSM recommends the same approach that President Ronald Reagan once advocated in US/Soviet relations: Trust, but verify. “You really shouldn’t just take the patient’s word for everything,” she says. Her colleague Dan Hoffman concurs. “Patients are sometimes reluctant to share information. Maybe they don’t want their primary care physician to know they went to another doctor to get a medication he wouldn’t given them, and they’ve been surreptitiously taking it. We need to educate our patients at every opportunity about the importance of being forthright.” And of course physicians and other caregivers need to create a relationship of trust and respect in which patients are comfortable being honest with them.

Sometimes, to be sure the medication list is accurate, the person compiling it will need to speak with family members or call the patient’s physician, specialists, pharmacy, or anyone involved in prescribing or administering medications to the patient. “And it’s not enough just to get a list of prescription medications,” Heinzman cautions. “To be complete and accurate, it should include over-the-counter meds, herbals, inhalers, everything. And it’s important to know not just what they take, but when and how much, and when they took their last dose.”

Ultimately, of course, the goal of reconciling medications is to reduce adverse drug events. The signs are encouraging. UMass Memorial is beginning to see a correlation between improved reconciliation and reduced ADEs, says Eric Alper.

IHI Director Frank Federico commends organizations that are embracing this challenge, because he understands the commitment it requires. He also understands what motivates them. “Organizations that are working on this don’t do it just to meet national patient safety standards. They do it because it’s the right thing to do for patients. It is part of delivering good patient care. But,” he adds, “that doesn’t mean it’s easy.”

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