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Helping to ensure safer transitions in hospitals

A patient receives Pamelor (nortriptyline) in the hospital instead of the Panlor (acetaminophen, caffeine, dihydrocodeine) he takes at home. A patient is transferred from an extended-care unit to a medical unit, and her medication administration record is not in the chart; she receives her morning doses of warfarin, levothyroxine, metoprolol, amlodipine, and sertraline before it is realized that she had already taken her medications earlier that morning. A 7-year old child is brought to the hospital unconscious a week after being discharged; her parents gave her both the previous and new prescriptions for Dilantin (phenytoin). What is the common denominator in these medication errors? Health care providers failed to communicate about medication use at transition points in care.

DRUG ERRORS ARE COMMON

More than 1.5 million Americans are injured every year in American hospitals by adverse drug events (ADEs), and the average hospitalized patient experiences at least one medication error each day.¹ Poor communication of medical information at transition points, admission, transfers to another service or care setting, and discharge is responsible for as many as 50% of all medication errors and up to 20% of adverse drug events in the hospital.²

Medication errors at the time of hospital admission are common, and some have the potential to cause significant harm. Studies have found that the majority of patients admitted to hospitals had at least one discrepancy between their medication history and their admission orders. Though most discrepancies were judged to have little chance to cause serious harm, almost two out of five discrepancies had the potential to cause moderate to serious harm to the patient.³

A Joint Commission National Patient Safety Goal instituted in 2005 requires all hospitals to reconcile medications across the continuum of care. Hospitals across the country continue to be challenged by Patient Safety Goal #8 (see the sidebar). However, some important lessons are emerging in how to effectively and efficiently perform medication reconciliation and improve hospital safety.

MEDICATION RECONCILIATION

Medication reconciliation is the process of creating the most accurate list possible of all medications a patient is taking—including name, dosage, frequency, and route—and comparing that list against the admission, transfer, and/or discharge orders, with the goal of providing correct medications to the patient at all transitions within the hospital.² Essentially, the process has three steps (see the algorithm):

• At admission, collect a list of the current medications, including prescription, OTC, herbals, and supplements. Reference the list when writing admission orders.

• Compare the home medication list, the current medication orders, and the transfer orders at each transition. Assess whether each medication should be continued, resumed, or discontinued.

• Upon discharge, review the patient’s home medication list and current medication orders, and compare them with the discharge medication orders to ensure that medications are appropriately continued, resumed, or discontinued. Provide the complete, up-to-date list and any necessary education to the patient. Communicate the list to the next provider.

A multidisciplinary team approach is needed to plan, implement, and monitor the medication reconciliation process. The Joint Commission’s goal does not specify who is to do the reconciliation. However, successful organizations involve representation from all departments involved in medication processes—doctors, PAs, nurses, pharmacists, other staff with roles in the process, and most importantly, the patient. Comprehensive medication histories resulting from a team effort routinely obtain more information than physician-acquired histories.⁴

Hospitals should establish a standardized process to collect and document information about all current medications. The process should address when medication reconciliation should be performed, what information is collected, who is responsible for completing and updating the list, and where and how it should be documented.

It is important to establish a single section in the chart for patient medication and allergy histories. A consistent, highly visible location should be used, which is easily accessible to all clinicians referencing or writing drug orders. Documentation by all care providers—physician, PA, nurse, or pharmacist—will help ensure the information is current.⁵

Hospitals should identify and focus on high-risk medications and patients. Three drug categories account for 50% of preventable ADEs: anticoagulants, opiate agonists, and insulin therapy.⁶ Some organizations direct more effort toward patients considered high-risk for medication discrepancies or for ADEs, such as those with a high number of medications, patients with multiple chronic conditions, the elderly, and young children.

Health information technology (HIT) can assist medication reconciliation in a number of ways. Health information exchange systems can obtain medication use histories from sources outside the hospital, such as local retail pharmacies, insurance carriers, and outpatient practices. HIT can generate home and active medication lists at each transfer point and at discharge as well as automatically forward the lists to the next provider. Clinical decision support solutions can enhance the reconciliation process by aiding medication history verification and preventing errors associated with therapeutic substitutions to match the hospital formulary.⁷

IMPROVED PATIENT SAFETY

Early reports from hospitals demonstrate a positive impact from medication reconciliation. Various medication reconciliation strategies have resulted in an 80% decrease in medication discrepancies for patients scheduled for surgery⁸ and a greater than 50% reduction in admission and discharge discrepancies in an inpatient family medicine unit.⁹ A successful reconciling process can reduce the work associated with the management of medication orders. The time invested at admission can reduce clinician work at transfers and discharge.¹⁰

Medication reconciliation is not only about compiling lists of medications but also about evaluating the information on the list. We encourage PAs to take an integral role in ensuring that the list is complete, evaluating the information, discussing it with the patient, and communicating it to the next provider. Every stage in the process is an opportunity to optimize the medication regimen and improve the patient’s understanding of the condition and its treatment. Every stage can help to reduce medication errors and improve patient safety. JAAPA

The 2007-2008 members and staff of QCC include Michael Doll, MPAS, PA-C; Michael Ellwood, MBA, PA-C; Joseph English, PA-C; Robert McNellis, MPH, PA; and James M. Taft, PA-C. This article was written by James Taft.

REFERENCES

	1.	Committee on Identifying and Preventing Medication Errors. Preventing Medication Errors: Quality Chasm Series. Aspden P, Wolcott J, Bootman JL, Cronenwett LR, eds. Washington, DC: The National Academies Press; 2007.
	2.	Improvement report: reducing ADEs through medication reconciliation. Institute for Healthcare Improvement Web site. http://www.ihi.org/IHI/Topics/PatientSafety/MedicationSystems/ImprovementStories/Reducing+ADEs+ Through+Medication+Reconciliation.htm. Accessed February 4, 2008.
	3.	Cornish PL, Knowles SR, Marchesano R, et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005;165(4):424-429.
	4.	Tam VC, Knowles SR, Cornish PL, et al. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. CMAJ. 2005;173(5):510-515.
	5.	WHO Collaborating Centre for Patient Safety Solutions. Assuring medication accuracy at transitions in care. Patient Safety Solutions. May 2007;1(6). http://www.jcipatientsafety.org/fpdf/presskit/PS-Solution6.pdf. Accessed February 4, 2008.
	6.	Winterstein AG, Hatton RC, Gonzalez-Rothi R, et al. Identifying clinically significant preventable adverse drug events through a hospital’s database of adverse drug reaction reports. Am J Health Syst Pharm. 2002;59(18):1742-1749.
	7.	Moore G. Using clinical decision support to improve medication reconciliation. Patient Safety & Quality Healthcare. Nov/Dec 2006. http://www.psqh.com/novdec06/reconciliation.html. Accessed February 6, 2008.
	8.	Michels RD, Meisel SB. Program using pharmacy technicians to obtain medication histories. Am J Health Syst Pharm. 2003;60(19):1982-1986.
	9.	Varkey P, Cunningham J, O’Meara J, et al. Multidisciplinary approach to inpatient medication reconciliation in an academic setting. Am J Health Syst Pharm. 2007;64(8):850-854.
	10.	Rozich JD, Howard RJ, Justeson JM, et al. Standardization as a mechanism to improve safety in health care. Jt Comm J Qual Saf. 2004;30(1):5-14.