# Medication Reconciliation Strategies

Effective Medication Reconciliation Strategies

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### Overall Goal:

To establish and implement the finest medication reconciliation process across the continuum of care to achieve superior patient safety.

### Specific Objectives:

1. Define medication reconciliation.
2. Articulate the steps involved in medication reconciliation process.
3. Identify potential barriers with appropriate resolutions related to the implementation of medication reconciliation process.
4. Enumerate best practices on how to conduct a comprehensive medication history taking.
5. Name website information resources if needed.

### Introduction and Background

Hospital processes such as admissions and disharges seems simple but yet so complex events because it involves numerous handovers among professional care givers and several changes to patients' medical plan. Unfortunately, this increases the chances of communication breakdown which can result to the occurence of medication error. Medication errors are one of the leading causes of injury to hospital patients, with approximately two out of every 100 patients admitted to the hospital experiencing a preventable adverse drug event (ADE) (Rogers et al., 2006). Hospital costs related to adverse drug events is estimated to be about \$3.8 million per hospital per year (Varkey et al., 2006). The Institute of Medicine reports that up to 1.1 million preventable adverse drug events occur in the United States annually. Medication errors have been reported to be responsible for as many as 98,000 deaths each year in the United States (Caglar et al., 2008). Up to 27% of all hospitals prescribing errors can be attributed to incomplete medication histories at the time of admission (Tam et al., 2005). The UK National Patient Safety Agency (NPSA) suggested that 900,000 incidents harm or nearly harm NHS inpatients in the UK annually, 12-20% of these incidents are related to medication errors occuring most commonly in the are of prescribing, dispensing, or administration (Fertleman et al., 2005).
In response to this patient safety concern, the Joint Commission for Accreditation of Healthcare Organization (JCAHO) mandated with full implementation in 2006, the development of a process to accurately and completely reconcile medications across the continuum of care (Poon et al., 2006). Preventing adverse drug events (ADE's) is the impetus behind the concept of medication reconciliation.In order to support the patient safety and improve the quality of care, treatment and service; it is crucial for an institution to have a medication reconcilistion process in place.

### Definition of Terms

• Medication Reconciliation-is the formal process for creating the most accurate and complete list possible of all pre-admission medications for each patient and comparing the physicians's admission, transfer, and/or discharge orders against that list. Discrepancies are brough to the attention of the physician and, if appropriate, changes are made to the orders and any resulting changes in orders are documented.
• Adverse Drug Event- any response to a drug which is noxious, unintended, and which occurs at doses normally used in humans for the prophylaxis, diagnosis, or therapy of disease.
• Inpatient Pharmacist- pharmacist who performs standard pharmacy service such as ward medication review and discharge counceling.
• Medication Reconciliation Pharmacist- pharmacist who's promary role is to collect, verify, document, clarify and reconcile medications.

### Steps Involved

The process starts when the patient is admitted to the hospital, continues whenever the patient is transferre to a different level of care, and occurs again when the patient is discharged from the hospital. Remember to involve patient in every step of the process!!!!
1. Verification
2. Clarification
3. Reconciliation

• When the patient is admitted, comprehensive medication interview is conducted to collect a list of the medication the patient is taking. **This can be done by:
1. patient/family/representative's interview
2. inspection of the medication bottle/containers
3. review patients most recently updated list on e-chart.
4. Contact community pharmacist or physician as needed.
• Compare all the informations collected
• Document in a standard designated part of the chart (i.e PTA)
• Prior to Admit list of medication will be utilize to generate admission orders
• Reconcile PTA medication list with new admission orders

At Transfer

• When trasferring the patient from one level of care to another, the physician should compare the pre-admission medication list with the current medication orders and generate transfer orders
• Pharmacist-comprehensive reconciliation will be done to ensure accuracy
• Discrepanies will be clarified and reconciled with the ordering physician

At Discharge

• Anticipated discharge will be communicated with the team to facilitate faster, smmother dicharge process
• Discharge orders will be written day before discharge by medication reconciliation pharmacist
• PTA medication list, current medication list will be reviewed before discharge orders are made
• On day of discharge, discharging physician will review discharge orders and authorize, modify pre-written orders
• Discharging nurse will discuss the instructions and provide a copy of the discharge orders and encourage to always carry a copy of the medication list with them at all times.

### Best Practices

Although the adequacy of pharmacy personnel remains a challenge, evidence have shown that a pharmacist-comprehensive medication history taking is the most accurate method of conducting a medication reconcilation (Chantelois et al., 2003). Here are some tips how to best conduct a medication review:
• Interview the patient-
• using open-ended question (What do you take for your high blood pressure?)
• using closed-ended questions (Do you take medication for your high blood pressure?)
• inquire about prescription medications, OTC, sample medications, herbals, vitamins, health supplements
• Obtain the name, strength, formulation, dose, frequency, route of medication
• If patient cannot recall or unable to provide medication history
• Interview the family or caregiver or someone available
• Call someone over the phone to try to gather information- if possible
• Call the patient's community pharmacy/physician- remember that the patient may be the best source of information
• Obtain previous medical records
• Encourage patient's participation in the design of a process (i.e. design of a medication list/card)
• Blanket reinstatement of pre-hospitalization medication are not allowed at any time.

### Barriers to Implementation

Medication Reconciliation process cannot be implemented without potential drawbacks. The goal is to develop the best and most accurate list possible.
• Mistaken Perceptions/Paranoia
• create culture of safety
• create a non-punitive environment
• learn from mistakes
• Senior leadership needs to "buy-in" to assist in the provision of resources
• Encourage teamwork
• Physician and staff participation
• encourage inputs
• Engage physician and staff in designing the process
• positive initial experience with the process
• share pertinent data or examples to motivate/convince them
• keep the team/staff goal-centered
• Communication breakdown
• open and honest communication between stakeholders
• continuing education and support
• Ownership of the responsibility
• Assign expert as supported by evidence if feasible
• design and implement policy
• Establish accountability among stakeholders
• Fear of Change
• utilize Kotter's theory of change
• establish sense of urgency
• develop a guiding coalition
• create and communicate the vision
• provide empowerment to act on the vision
• plan for and create short term wins
• count improvement and keep moving forward
• institutionalize approach
• Attempt PDSA method

### Summary and Conclusion

The Joint Commission mandated that health care organizations had to have process implemented to promote medication safety. It is crucial for every institution to identify and adopt a system that will abide to the patient safety goal. The collaborative effort of the health care team is undeniably valuable-given a clear definition of role, organizational standards, hightened accountability and innovative technology, but placing the medication expert (pharmacist) as the front runner of the process might not be an unpleasant choice as well.

# Web Resources

Prepared by M Pragasa--Mdpragasa 20:00, 1 December 2009 (UTC)