In 2006, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) started the new year with a mandate for accredited organizations to implement an innovative initiative: Medication Reconciliation. The mandate attempted to address the ~1.3 million iatrogenic adverse events that occur annually, many of which are related to medication.
Medication reconciliation is an effective process to reduce errors and harm associated with loss of medication information, as patients transfer among community-based and hospital providers. It may prevent up to 70% of all potential errors and 15% of all adverse drug events.1
Medication reconciliation involving the patient should occur at all interfaces of care (handoffs) and on admission to and discharge from ambulatory, emergency and urgent care, long-term care, home, or inpatient services. It is not entirely a new requirement?it has been a less prominent component of JCAHO's Medication Management standard.2
The process of comparing a patient's medication orders with all the medications the patient has been taking often has surprising results. Reconciliation can prevent medication errors (omissions, duplications, dosing errors, or drug interactions; see sidebar3,4).
JCAHO mandates the process at every care transition if new medications are ordered or existing orders are rewritten. The commission defines care transitions as changes in setting, service, practitioner, or level of care. The specific steps are presented in the Figure.
Certain types of orders are renowned for their propensity to cause errors and associations with adverse drug events.5 For this reason, the Joint Commission's Medication Management standard (MM.3.20) specifically forbids "blanket" orders, such as "Resume preop medications."
Rationale for Reconciliation
JCAHO's sentinel-event database includes >350 medication errors resulting in death or major injury. Root cause analysis identified breakdowns in communication as significant factors, completely or in part, in 63% of those errors. Clinicians could have prevented approximately half of them using effective medication reconciliation.
The Institute for Safe Medication Practices (ISMP) has published samples of errors reported pursuant to failed communication.4 ISMP included the following:
?Duplicate orders for insulin and other medications being given when the patient's medication history or medication administration record followed the patient only hours later
?Poor handwriting leading to lookalike- name drugs being prescribed
?Infusions ordered by flow rate, with a higher concentration of medication administered and consequent overdose
?Patients cutting tablets inappropriately when doses were halved by mistake
Identifying Causes of Medication Errors
The interfaces of care (admission to, transfer within, or discharge from a health care facility) are replete with opportunities for error.3,6 Up to 77% of all patients may be discharged with inadequate medication instructions.7
The US Pharmacopeia's (USP) MEDMARX reporting program captures errors involving medication-reconciliation failures. Examining the 2011 reconciliation errors reported between September 2004 and July 2005 reveals that 66% occurred during transition or transfer to another level of care, 22% occurred during admission to a facility, and 12% occurred at discharge.8 MEDMARX tracks types of errors and indicates that the majority involve improper dose or quantity, followed by omission error and prescribing error. Usually, analysis finds that performance falling short of expectations, transcription errors, documentation deficits, communication failures, and work-flow disruption are involved.
All health care facilities must create a process for reconciling medications at all care interfaces. The process must include reasonable time frames for completing reconciliation. Experts recommend using standardized forms for the patient's list and the reconciliation step. Every party in this process should employ reconciliation tracking tools and medication-reconciliation flow sheets.9,10 Patients and responsible physicians, nurses, and pharmacists all have roles, which should be defined in policies and procedures.
Pharmacy technicians also can help. One hospital reduced potential adverse drug events by 80% over 3 months by having pharmacy technicians obtain patients' medication histories before scheduled surgeries.5
When health care extenders such as technicians are invited into the process, the key is providing the training and experience necessary for them to become competent in the process, and then assessing their competency periodically. In fact, all health care providers need continuing training and competence assessment.10 Some facilities also involve case managers, depending on the case management model they use.11,12 The reasoning is that case managers can be a safety net for patients, especially if they round with clinical pharmacists, because they often follow the patient's entire stay.
Pharmacists involved in this process may find that some hurdles continue despite a year's experience. Some facilities have failed to define the interfaces in which reconciliation is necessary and may need to redefine when a patient handoff occurs.13,14
At admission, collaborating with patients to create an acceptable list can be undermined by poor staffing levels, lack of focused attention, and patients who are unable to explain what they take.15 Some tactics can help, such as linking medications with the conditions they are prescribed for, and prompting patients with questions such as, "Does that medication have a CR or an XL after its name?" Providers also can ask for the name of the patient's outside pharmacy or pharmacies.16 In addition, some physicians may be uncomfortable reconciling medications prescribed by specialists, especially if they lack knowledge in the specialty area.13
The lists may become lost in the jumble of the clinical record unless the facility or practice designates a visible and readily retrievable location for them in the paper or electronic record.14 Names of medications may be collected successfully, but the information may lack the drug frequency, route, and time the patient took the last dose. Standardized forms can help staff members remember to solicit this information.2
Medication reconciliation is an ongoing responsibility, and it cannot be assigned to one specific point in the health care continuum. When providers receive a list of discharge medications from a facility, they must invoke the reconciliation process? despite the fact that the originator already should have performed medication reconciliation.
Although the patient has reconciled the list he or she sent against the list of medications he or she received during his or her tenure there and against the original medication provided at patient entry to the organization, it must be checked at the receiving organization.10 Medication reconciliation is one area where the goal is to increase rather than decrease redundancy.
JCAHO reports high levels of compliance with this requirement among facilities, but it indicates that noncompliance is most likely at discharge.2 On discharge from the facility, in addition to communicating an updated list to the next provider of care, each clinician or care provider must give the patient the complete list of medications that he or she will be taking after discharge from the facility, as well as instructions on how and how long to continue taking any newly prescribed medications. The patient should be encouraged to carry the list with him or her and to share the list with any providers of care, including primary care and specialist physicians, nurses, pharmacists, and other caregivers.
Ms. Wick is a senior clinical research pharmacist at the National Cancer Institute, National Institutes of Health, Bethesda, Md. The views expressed are those of the author and not those of any government agency.
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4. Institute for Safe Medication Practices. Building a case for medication reconciliation. Medication Safety Alert. April 21, 2005. Available at: www.ismp.org/MSAarticles/20050421.htm. Accessed December 24, 2006.
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8. USP Patient Safety CAPSLink. October 2005. US Pharmacopeia. Available at: www.usp.org/patientSafety/newsletters/capsLink.
9. Institute for Healthcare Improvement Web site, section on Medication Reconciliation Review, samples of a reconciliation tracking tool and a medication-reconciliation flow sheet. Available at: www.ihi.org.
10. Massachusetts Coalition for the Prevention of Medical Errors Web site. Available at: www.macoalition.org.
11. Help your hospital meet the new medication reconciliation requirements. Hosp Case Manag. 2006;14:161-164.
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13. Varkey P, Resar RK. Medication reconciliation implementation in an academic center. Am J Med Qual. 2006;21:293-295.
14. JCAHO looking closely at medication reconciliation. Hosp Peer Rev. 2006;31:65-67.
15. Haig K. Medication reconciliation. Am J Med Qual. 2006;21:299-303.
16. Sullivan C, Gleason KM, Rooney D, Groszek JM, Barnard C. Medication reconciliation in the acute care setting: opportunity and challenge for nursing. J Nurs Care Qual. 2005;20:95-98.
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