Prior to the COVID-19 pandemic, the brisk pace of the emergency department (ED) already made it a tricky place to conduct medication reconciliation. Add to that the highly variable conditions of patients who come through its doors, now coupled with patient surges due to COVID-19 and overwhelmed staff, and it's easy to see why the ED is an environment ripe for medication errors.
Although strategies for reducing medication errors in the ED aren't that much different than in other areas in the hospital, one thing most certainly is: The uncertainty of who will conduct the medication reconciliation (med rec). Perhaps the ED's biggest challenge concerns its high number of rotating staff — some of whom may be well-versed in medications, others not — and the variability of those staff depending on time of day and day of the week.
Let me point out the elephant in the room: Most EDs lack the right people with the right training performing medication reconciliation and doing so correctly at the right time. In most hospitals, ED personnel who end up being tasked with med rec are not well-versed enough in the medications they are discussing with patients, especially more complex and challenging patients. Unfortunately, the resulting medication errors can be disseminated throughout the hospitalization and potentially well beyond discharge.
Obviously, this variance is not good practice. Perform medication reconciliation wrong on the front end and it can become the basis of the medication record throughout the patient's stay and at discharge, and perhaps in future medical encounters.
It's time to focus on fixing the front end to avoid the back-end boomerang of adverse drug events (ADEs). Here are four of the ways EDs can improve their medication reconciliation process. Note: Read through to the end of this blog to learn how hospitals can also improve their MRP discharge performance.
1. Put pharmacy in charge
Due to the number of variables, performing complete and accurate medication reconciliation in the emergency department will always be a complex process. But study data indicates that adverse drug events are greatly reduced when pharmacists or pharmacy technicians lead the med rec process. And clinical leaders whose organization's employ pharmacists and pharmacy technicians and then leverage them in this manner have told us that these team members make a big difference.
In a year-long improvement study, Citrus Valley Health Partners-Foothill Presbyterian Hospital used "best practices" and Lean Six Sigma tactics to train and deploy pharmacy techs to perform medication reconciliation in two hospital emergency departments. The hospital reduced its overall error rate by nearly 40% and increased the accuracy rate for all medications to almost 96%. In addition, a retrospective study of 490 medication orders found that ED pharmacists reduce medication errors by two-thirds.
There is a lot of additional evidence that having pharmacists on the team results in such significant improvements. Read "Pharmacists and Medication Reconciliation: A Review of Recent Literature," "Medication Reconciliation: From Med Wreck to Med Rec – One Hospital's Improvement Story," and "A Pharmacist-Driven Intervention Designed to Improve Medication Accuracy in the Outpatient Kidney Transplant Setting" to learn more.
In addition, given these documented improvements in ED medication safety and cost-effectiveness, the American Society of Health-System Pharmacists recommends inclusion of pharmacists in ED care teams.
2. Document the how and who of the medication list, dosages, and reasons
The first step of The Joint Commission's medication reconciliation process is as follows: "Develop a list of current medications." What on paper looks simple is deceptively complex. To develop such a list requires answers to many questions, a patient interview, and sometimes calls to pharmacies and/or physician offices. When patients are extremely ill, in pain or bleeding profusely, checking these boxes is not always possible or doable in a manner that produces complete and accurate results.
This is where involvement by a pharmacy technician can be of huge value. In addition to documenting the list of prescribed medications, indications, and dosages, the pharmacy tech can document how the patient is/isn't taking their medications as well as who provided the information (e.g., patient, family member, pharmacy). Including this data in the note of patient's medical record can help eliminate confusion about a patient's current medication regimen and adherence while increasing the confidence level of the downstream clinical team. This, in turn, can strengthen the credibility of the overall medication documentation.
3. Document the rationale behind medication changes
In addition to the how and who, explain the why behind medication regimen changes. Was the dry cough from Lisinopril so excessive that the patient's physician switched her to Diovan? Was the initial prescription of Levothyroxine at 50mcg ineffective in reducing fatigue and cold sensitivity so the physician titrated the dose up to 100mcg to improve efficacy? When explaining the why, it's essential to include key details about medications and the prescribed changes, such as dose changes, discontinuation, and drug class switches.
Such a level of detail is often glossed over when the ED is busy. Or if the information is requested, it may not be documented completely. Adding it to the note provides valuable insight to the next clinician in the care chain about a previous provider's thought process. This can help with new medication decisions and is especially useful in environments that experience multiple and frequent patient handoffs.
4. Optimize patient medication reconciliation interviews
Effectively leading patient interviews is a skill that requires the use of open-ended (require more than a one-word answer) and closed-ended questions (can be answered "yes" or "no"). The key is to engage patients in such a way that they provide fuller, more detailed information about their medication regimen. Role playing can help uncover areas where your team needs improvement and identify who requires additional coaching.
In addition, targeted questions can yield better results. Instead of asking, "Which medicines do you take?" ask, for example, questions concerning specific conditions. For example, you might ask, "What do you take for your diabetes?" Certain prompts can help with recall. Example questions: "What do you take when you get a headache?", "What do you take when you have allergies?", and, "Do you put any medicines on your skin?"
The Agency for Healthcare Research and Quality's (AHRQ) has a useful guide for conducting patient medication interviews. It's part of the MATCH Toolkit for medication reconciliation.
Strengthening the Back End
While these four best practices can help a hospital and its emergency department improve medication reconciliation performance, there's still the potential for med rec oversights and mistakes to occur in the ED. Considering the challenges facing EDs today that we highlighted in the beginning of this blog, it's likely an increased potential compared to other departments.
That's why hospitals must also develop strong medication reconciliation practices on the back end. This must include medication reconciliation post-discharge (MRP). We previously noted in a blog answering FAQs about MRP that best practice is to ensure all patients receive an MRP within 72 hours of discharge. However, research shows that this only happens approximately 50% of the time, which unfortunately contributes to the increased risk of patients requiring what would be an avoidable readmission.
MRP brings its own challenges, and some of the best practices we highlight can help hospitals overcome some of these barriers and improve their MRP performance and rate. But for many hospitals and health plans, performing medication reconciliation post-discharge on all discharged patients — which should be the expectation — will be difficult at best and impossible at worst.
That's we at Cureatr have developed a tech-enabled medication reconciliation post-discharge service that has board-certified, clinical telepharmacists performing MRP within 48–72 hours following patients discharge. Our provider and health plan partners are seeing how our MRP service is directly leading to reductions in readmissions and adverse events while also delivering improvements in outcomes, quality scores, patient satisfaction, and financial performance. To learn more about our MRP, solution, schedule a consultation.