Medication Reconciliation: One Organization's Approach

Medication reconciliation is a process that has received increased attention since inclusion by the Joint Commission as a National Patient Safety Goal (NPSG) in 2005. As defined by the Joint Commission, medication reconciliation is the “process of comparing the medications that the patient/client/resident has been taking prior to the time of admission or entry to a new setting with the medications that the organization is about to provide.” The intent of medication reconciliation is to provide continuity of care for patients with regard to medication use as they move across transitions in the healthcare system. Justification for this process is borne out by studies that show, for example, that upward of 50% of patients have discrepancies between the medications that they are taking prior to admission and what is ordered inpatient.

Data from the USP MEDMARX program covering September 2004 to July 2005 indicates more than 2,000 reported medication errors that were attributed to failures of medication reconciliation; 22% of these occurred during hospital admission, 66% during transition/transfer to another level of care, and 12% during hospital discharge.

The Joint Commission NPSG #8 that requires organizations to reconcile medications is composed of two subgoals. Goal 8A requires that the organization, working with the patient/family and with the patient’s primary physician and outpatient pharmacy, if necessary, develop a complete list of the medications that the patient is taking upon entry to the organization. This list must contain over-the-counter and alternative medications, as well as prescription medications. The list must then be compared to the medications that have been ordered by the organization’s providers, and any differences (eg, omissions, changes in dose) must be reconciled, or potential problems (eg, duplications, drug interactions) resolved. Goal 8B requires that the organization provide a complete list of the medications that the patient is to take upon discharge to the next care provider(s).

In 2007, this Goal has been amended to require that patients must also be provided with this list. It is important to note that the NPSG does not apply only to inpatients. Medication reconciliation is expected to occur any time that the patient enters the organization and medications are used, may be modified, or may affect the treatment/service being rendered to the patient. The standard also does not specify who must perform the reconciliation or specify any particular documentation requirements. For inpatient areas, the medication list may be collected by the prescriber, nurse, or pharmacist. Some organizations have used pharmacy technicians for this purpose. Likewise, the process whereby the two lists are compared may be carried out by one of these professionals.

In outpatient areas, other ancillary personnel (eg, radiology technicians) may be involved in the collection of the home medication list. The organization must ensure the competency of those involved in the process to carry out their assigned roles. Medication Reconciliation at Thomas Jefferson University Hospital Thomas Jefferson University Hospital (TJUH) is a 675-bed tertiary care, teaching hospital in Philadelphia, PA. The medication reconciliation processes described below were developed by a multidisciplinary team of members of the medical staff, nursing, pharmacy, hospital administration, informatics, and other ancillary departments that are affected by the NPSG requirements. At TJUH, inpatient orders are placed using a computerized prescriber order entry system (GE HealthCare’s LastWord^®). Within the computerized prescriber order entry (CPOE) system is an outpatient module (RxPad) that documents the patient’s outpatient medications so they can be viewed by any healthcare professional with access to the TJUH patient information system.

Inpatients

For a patient who has no medication history recorded in the outpatient module, the medication reconciliation process begins with the prescriber taking a complete medication history at the time of admission. Physicians are asked to elicit information from the patient regarding prescription, non-prescription, and alternative medications. Each medication is entered into RxPad, which contains a comprehensive database of available medications. When multiple strengths of a medication are available, each dose strength is listed as a separate entity. For each medication, a default dose is built into the system; the purpose of this is to reduce the amount of time required to enter information into the system.

For medications that are not listed in the database, an option for “Non-System Medication” is available. The system allows prescribers to enter a comment for each medication entry, and also includes a field for the indication for use of the medication (this is not presently a mandatory field). If the patient is not on any medications, the provider can select the “No Chronic Medications at the Time of Admission” option. If the patient’s medication history cannot be obtained at the time of admission (eg, a trauma patient who cannot provide history), there is an option for “Unable to Obtain Medication History;” the expectation is that the prescriber or a pharmacist will enter the medication history once it is known. Prescribers cannot proceed to enter inpatient orders into the CPOE system until the medication history has been entered in the outpatient module. For a patient who already has a medication history recorded in the system, the prescriber must review the medications and make any additions.

Once the medications are entered and/or updated, the prescriber must indicate the plan for each on admission. The system will take the prescriber through each medication, and the prescriber will indicate if the medication will be continued, changed, discontinued, or held. The prescriber can also note that the patient is not taking the medication any longer. For those medications that are to be continued or changed, a tentative order is then placed in the CPOE system for the prescriber to review and accept or modify as appropriate. For non-formulary medications that are to be continued, the prescriber is presented with an online non-formulary request form that must be completed (requiring justification for use of the drug) before the pharmacist assesses whether to approve the medication order or recommend an alternative agent.

Medications that are held are placed in an order set that can be accessed when the prescriber is ready to resume

them. Because the success of the reconciliation process is dependent on obtaining an accurate medication history,

nursing staff independently obtain a medication history and compare the information to what the physician has entered in the outpatient module. Any differences are brought to the attention of the prescriber. The outpatient list of medications and the medications ordered inpatient are then sent from CPOE to the hospital intranet, where a pharmacist views both lists side by side and reconciles any differences based on the prescriber’s intention for each medication. The pharmacist then documents any discussion with the prescriber and notes that reconciliation has occurred.

One of the concerns that was initially voiced by the surgical staff at TJUH during conceptualization of the system was that the process of entering all medications and reconciling them would slow down the flow of the surgical schedule. Since most of our surgical patients are seen by a nurse practitioner in our Patient Testing Center (PTC) prior to the day of surgery, our PTC staff has been assigned the responsibility of obtaining the medication history and entering it in the system. On the day of surgery, nurses in the pre-operative area review and update (if necessary) the list with the patient, and obtain the history from any patient who did not come through the PTC. Post-operatively, the prescriber then goes into RxPad and indicates the plan for each medication.

When patients are transferred to another level of care, an order must be placed in the CPOE system to effect the transfer. The prescriber is also required to review all medication orders (as well as other orders), and document that orders have been reviewed and updated. Since orders are not rewritten, as in a paper system, there is no chance that a medication will be omitted, or that a dose will be written incorrectly. Patient care pharmacists review the orders to ensure that prescribers have discontinued medications that may not be appropriate for the area where the patient is transferred.

At discharge, the prescriber once again goes to RxPad and formulates the discharge medication plan. The patient has previously taken are updated to reflect the current date, and any new medications are added. Additional instructions to the patient are included. Prescriptions may be generated from the system at this time. The list is then sent to the hospital intranet. The prescriber then views a document that shows the medications on admission on one side, and the medications to be taken at discharge on the other side. For each medication at discharge, the prescriber must indicate whether the prescription is the same as upon admission, a dose increase or decrease, a schedule change, or a new medication. This information is included on the final discharge medication instructions. We are presently in the process of including the discharge medication list as part of a comprehensive Web-based discharge instruction form.

In the ambulatory practices, we use a form that contains the complete list of the patient’s medications. The form is revised each time that a change is made in the patient’s medication regimen, and a copy is given to the patient. A copy is also mailed to other prescribers who would need to be aware of the change(s). In both the procedural and ambulatory areas, our goal is to eventually use RxPad for maintaining medication histories, so that a current medication history is always available online for TJUH patients.

Conclusion

Implementing a medication reconciliation process has proven to be a challenge for many Joint Commission-accredited organizations. In the first six months of 2006, 38% of surveyed hospitals received a Requirement for Improvement (RFI) in the area of medication reconciliation. However, the efforts should result in the identification of disparities that will prevent the occurrence of medication errors, some of which may adversely affect patient outcome. Within our organization, we have identified numerous instances in which this has been the case.

Organizations should continue to look for ways to make medication reconciliation an electronic process, to ensure

a more efficient and effective overall process. Finally, we must encourage/develop mechanisms for patients to have the list of their medications readily available, so that the medication reconciliation process starts with the most accurate information possible.

Craig S. Senholzi, RPh, MBA, is Medication Safety Coordinator at Thomas Jefferson University Hospital in Philadelphia, PA. Contact him at craig.senholzi@jeffersonhospital.org.