According to a recent Institute of Medicine report, four out of five U.S. adults take at least one medication prescription, over-the-counter drug, vitamin/mineral or herbal supplement each week, while nearly a third take at least five different medications. In the hospital, a multiplicity of clinicians and changing care settings exacerbates these numbers. In a study conducted at Mayo Health System in Wisconsin, an estimated 5 percent of hospitalized patients experienced medication errors, 60 percent of which occurred during transitions of care. In a study conducted by Partners Healthcare, half of the patients admitted to a general internal medicine unit had at least one unintended discrepancy, and almost 40 percent of the discrepancies had the potential to cause moderate to severe discomfort or clinical deterioration.

Data collected from hundreds of hospitals by the Institute for Healthcare Improvement (IHI) showed that miscommunication regarding patient medications at key transition points (admission, transfers between care settings and discharge) leads to as many as 50 percent of all medication errors in hospitals and up to 20 percent of adverse drug events.

Medication Reconciliation

According to The U.S. Food and Drug Administration, about 10 percent of all medication errors reported result from drug name confusion. In a study of medication discrepancies at hospital admissions, more than half of patients had at least one unintended medication discrepancy, and nearly 40 percent of these discrepancies had the potential to cause moderate to severe harm. It is a significant problem in need of an effective solution.

One of the most promising solutions is medication reconciliation, a formal process of obtaining a complete and accurate list of each patient’s current home medications — including name, dosage, frequency and route — and comparing medication orders to that list at key points in the care process. Medication discrepancies at these times are common and pose considerable potential for harm to patients.

Medication reconciliation is a consistent process that helps mitigate miscommunication throughout a patient’s hospitalization. The Joint Commission describes the process as follows:

Admission: Develop a complete and accurate list of all medications the patient is currently taking, compare it with the medications being ordered/prescribed and reconcile any discrepancies. During the stay, update the list of medications and repeat comparison/reconciliation whenever changes are made in the patient’s medication regimen as he or she moves through the care continuum.

Transfer: Convey the list of current medications to the next care provider and to concurrent care providers at each transition and at discharge.

Discharge: Give the patient a list of all medications he/she is to take following discharge.

In 2004, medication reconciliation moved center stage as a key component of the highly publicized IHI’s “100,000 Lives Campaign,” which asks U.S. hospitals to commit to changes that would improve patient care and prevent avoidable deaths. Since then, it has evolved from a nice-to-have to a must-do. Several key mandates include:

The Joint Commission’s National Patient Safety Goals. In 2004, the Joint Commission began pushing hospitals and other healthcare providers to use reconciled medication lists whenever patients moved to new settings, services or levels of care. In 2006, a standardized method for medication reconciliation became an accreditation requirement. Medicare-funded healthcare organizations must now disclose their safety records, including how many times specific kinds of errors and adverse drug events (ADE) happened.

The Patient Safety Act of 2005. The first resource available to patients for information on ADEs, ensures quality care by giving the public the information to make informed decisions.

Implementation

From electronic health records (EHR) to computerized physician order entry (CPOE), technology can play an important role in medication reconciliation. However, according to a 2006 study by the Institute for Safe Medicine Practices, a mere 13 percent of U.S. hospitals have computerized systems in place to support the medication reconciliation process from admission to discharge.

Reasons include: Lack of standards, which has slowed development of software specific to all aspects of medication reconciliation and has led many hospitals to create paper-based systems; and: Complexity, due to the many hospital departments and processes involved. Data comes from multiple, sometimes less informed sources, including patients, caregivers, primary care physicians, specialists, outpatient medical records, hospital discharge summaries and community pharmacies. For each patient, the organization must verify medications, dosages and routes at admission; determine which medications to maintain; convert those medications into orders; track changes in the medications through transfers to discharge; convey reconciled lists to subsequent care providers and discharge staff; and then, document what was done for safety/quality review.

How an organization manages medication reconciliation depends on the systems it has, or acquires, as well as its current or proposed processes for collecting, using and communicating information. For some organizations, the solutions are systems designed specifically for medication reconciliation. Others build and add custom applications onto existing clinical information systems, or leverage existing CPOE and EHR systems.

EHRs can aggregate the correct patient information, then make it available across multiple disciplines to inform clinician decision making during admission and discharge processes. CPOE systems automate ordering of inpatient medications during admission and construction of the post-hospitalization medication list during discharge. Together, such tools increase the accuracy and efficiency of the medication reconciliation process.

Regardless of the systems supporting it, medication reconciliation demands process redesign and cultural change. Technology cannot replace the need to design a reliable process or secure buy-in from frontline clinicians.

Improved Patient Care

The key to managing the complexity includes viewing medication reconciliation simply as information management for clinical consistency. The best medication reconciliation systems provide access to complete medical records, automate the steps of the process, compel compliance, aggregate data and help document care. However, the true value of medication reconciliation is its ability to ensure consistency in the manner in which clinicians deliver that care.

As more and more hospitals look to technology and clinical information systems to support care delivery, we can expect to see many changes in the attitudes toward such processes as medication reconciliation. With growing acceptance, this process will become more intuitive, and as such, part of a care provider’s natural workflow.

FEBRUARY 2008