How to improve medication reconciliation

The ProblemMedication reconciliation—comparing a patient's medication orders to all medications the patient has been taking—helps to avoid medication errors such as omissions, duplications, dosing errors and drug interactions. The Institute for Safe Medication Practice estimates that 50 percent of medication errors and 20 percent of adverse medical events could be eliminated with proper medication reconciliation.For CCRMC, CEO Jeff Smith, MD, recognized in late 2004 that the hospital's current quality improvement methodologies from the 80s and 90s were insufficient to achieve higher levels of improvement. With this level of executive sponsorship, Steven Tremain, MD, chief medical officer, was asked to develop a team to help redesign clinical processes. A top priority of redesign was meeting the requirements for medication reconciliation. Director of ancillary services Stephanie Bailey was asked to lead a team in the rapid development of a medical reconciliation process that would quickly be adopted by physicians and nurses and establish a standard for ongoing process improvements.The Solution

CCRMC set out to establish a reliable process for medication reconciliation at all points of hospital-based care. At the same time, CCRMC sought to develop a repeatable process and an organizational mindset for continually developing and improving clinical activities and systems—quickly and effectively.

The medication history seemed complete, but something wasn't quite right. So Eric Poolman, MD, MBA, asked the family to bring in the patient's pill box. He'll never forget what he found.

"One of the compartments of the pill box also had plastic beads in it, the kind you use to string a necklace," says Poolman, chief of hospital medicine at Northwest Permanente in Oregon. The patient's medication list, as provided by the family, was indeed complete and up-to-date. But Poolman's careful efforts at medication reconciliation—inspired by his concerns about the elderly patient's memory—uncovered a potentially dangerous situation.

"Even though the family and patient vouched for the fact that she was taking her medications exactly as prescribed, the medication review led to us getting a good sense of what was going on and ultimately convinced the family that we needed to do more for the patient," Poolman says.

Reducing medication errors through careful reconciliation efforts has been a focus for hospital medicine physicians since at least 2005, when the Joint Commission first required all accredited organizations to develop, test, and implement medication reconciliation processes.[1] Yet, obtaining and maintaining an accurate record of a patient's medications remains a challenging endeavor, even in the age of electronic medical records (EMRs).

Here are seven strategies that hospitalists are using to improve medication reconciliation and reduce harm.

1. Building Relationships With Emergency Department Physicians

According to a 2013 study published in Medical Care,[2] nearly 82% of unscheduled hospital admissions come through the emergency department (ED). ED personnel are usually the first to ask patients about their medication history, making this interaction a crucial one to the overall process of medication reconciliation.

"Historically, there was very little effort put into assuring the accuracy of that list because it doesn't really impact emergency care all that much," says Rohit Uppal, MD, president of the hospital medicine division for TeamHealth and a practicing hospital medicine physician with the Memorial Healthcare System in Florida. To improve trust, collaboration, and efficiency, Uppal schedules regular meetings between emergency medicine physicians and the hospital medicine group.

"When you get people meeting face-to-face, you build trust. It also allows us to find opportunities to help one another—Gosh, if I do this extra thing, it makes your work life easier, and in exchange, I can do this for you," Uppal says. As a result, patients are now coming to the floor with more accurate medication histories.

2. Using Pharmacy Technicians to Compile Medication Histories

Going through a paper bag full of prescription bottles is time-consuming. So is trying to decipher a tattered, handwritten list of meds. Neither is a good use of a hospitalist's time. "If you bog down doctors and nurses with clerical tasks, you're negatively impacting their productivity and ability to really manage quality and safety," Uppal says.

Both Memorial Healthcare System in Florida and Northwest Permanente use pharmacy technicians to gather patients' initial medication histories. Technicians compare medication lists provided by patients and families to EMRs, noting any discrepancies or changes. If needed, pharmacy technicians also call patients' pharmacies to gather prescription data. Hospital medicine physicians then review the collected information and work to clarify any discrepancies.

3. Tapping Into Prescription Databases

Many EMRs now integrate with large databases of prescription fill data. These databases—which include prescription fill information from participating pharmacies—can be a goldmine of information, but they're not a panacea. If your patient gets medication from a pharmacy that's not included in the database, you may not be able to access their information.

Further, prescription fill data don't tell you the whole story. "A lot of filled prescriptions aren't taken," Uppal says.

After reviewing the medication history, hospitalists sit down with patients and family caregivers to focus their understanding of the patient's medication use. With a best possible medication history in hand, "this can be a much deeper conversation from the start," Poolman says. "We can talk directly about patients' concerns about medications and clarify discrepancies that may have crept in, such as changes in the medication dose."

These tailored conversations also help hospitalists determine patients' health literacy levels. "When you're asking patients about their medication, you really get a sense of their understanding," Poolman says. "There is a huge difference between the patients who tell you, 'I take two of those little green pills' and a patient who is able to talk about the dose of the beta-blocker they're taking." This knowledge helps hospital medicine physicians more effectively discuss plans of care with patients and families.

"There's a lot of local customization that can be done to EMRs," says Jeffrey Schnipper, MD, MPH, a hospitalist and director of clinical research at Brigham & Women's. Hospitalists can (and should) collaborate with information technology specialists to increase the utility of the medical record in promoting medication reconciliation. For instance, it's possible to add a section to document the quality of the initial medication history, flagging any areas of concern. It may also be possible to highlight high-risk medications so that they receive careful follow-up.

At Northwest Permanente, "transition pharmacists are part of the team that works at the point of discharging the patient," Poolman says. Because discharges—to home or to continuing outpatient care—are a high-risk time for medication errors, engaging high-level professionals to review and discuss discharge orders is an efficient use of resources, Poolman says.

"If the transition pharmacists see something on the final list of medications that is not intuitive to them, they will reach out directly to the discharging physician," he says. A pharmacist, for instance, may note that the patient's metoprolol dose was decreased slightly during hospitalization and check to see if the physician intends to continue the lower dose or resume the patient's previous dosing.

Schnipper and others have been researching—and systematizing—best practices for medication reconciliation. The Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS),[3] launched in 2011 with a grant from the federal Agency for Healthcare Research and Quality, included six hospitals; the MARQUIS 2 study involved 18 hospitals and has evolved into the MARQUIS Collaborative, a Society of Hospital Medicine program designed to help hospitals improve medication reconciliation processes.

"We saw a 30% to 60% reduction in the unintended discrepancies in orders in the MARQUIS studies," Schnipper says, noting that investments in medication reconciliation make financial sense as well. "Hospitals save approximately $2 to $3 for every $1 spent on medication reconciliation improvements," he says.

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Cite this: 7 Strategies to Improve Medication Reconciliation - Medscape - Sep 07, 2018.