The brisk pace of the emergency department (ED) makes it a tricky place to conduct medication review and reconciliation. Add to that the highly variable conditions of patients who come through its doors, and it’s 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 crapshoot of who conducts the medication reconciliation (med rec). The ED’s big challenge is the high number of rotating staff, some 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 doing the right medication reconciliation at the right time. In most hospitals, the personnel doing med rec are not nearly well-versed enough in the medications they are discussing with patients, especially complex patients. And the resulting medication errors are perpetuated throughout the hospitalization and beyond discharge.
This variance is NOT good practice. Do it wrong on the front end and it becomes the basis of the medication record throughout the patient’s stay and at discharge.
It’s time to focus on fixing the front end, to avoid the back end boomerang of adverse drug events (ADEs).
1. Put pharmacy in charge
Due to the number of variables and unknowns, med rec remains a complex process improvement area. But study data indicates that ADEs are mostly eliminated when pharmacists or pharmacy technicians lead it. And clinical leaders whose organization’s employ them told us that they have made 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 evidence that having pharmacists on the team results in significant improvements such as these. Read some of it HERE and HERE.
And, given the improvement in ED medication safety and cost-effectiveness, the American Society of Health-System Pharmacists and the Institute of Medicine’s Committee on the Future of Emergency Care recommend 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: Develop a list of current medications. What on paper looks simple is, in reality, deceptively complex. To ‘develop the list’ requires many questions, a patient interview, and sometimes calls to the pharmacy or physician offices. When patients are extremely ill, in pain or bleeding profusely, it’s not always possible.
This is where the pharmacy tech can be a 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 - patient, family member, pharmacy? Having this data in the note can eliminate confusion and increase the confidence level of the downstream clinical team. Which in turn can strengthen the credibility of the medication documentation overall.
3. Document the rationale behind medication changes
In addition to the how and who, explain the why behind medication regimen changes. This includes dose changes, discontinuation, drug class switches, etc. 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?
This level of detail is often glossed over when the ED is busy. Or if it is asked, it’s not 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 with many patient handoffs.
4. Optimize patient interviews
Effectively leading patient interviews is a skill that requires the use of both open-ended (require more than a one-word answer) and closed ended questions (can be answered “yes” or “no”). The key is to probe in such as way that patients provide fuller information about the medications they are taking. Role playing can uncover areas where your team needs some improvement and identify who needs coaching.
Specific questions yield better results. Instead of, “Which medicines do you take?” ask, for example, what the patient takes for a specific condition: “What do you take for your diabetes?” And certain prompts can help with recall: “What do you take when you get a headache?” “What do you take when you have allergies?” Or, “Do you put any medicines on your skin?”
Contributing Source: https://www.tandfonline.com/doi/full/10.1080/21548331.2015.1023159
Medication Reconciliation: From Med-Wreck to Med Rec - One Hospital’s Story, Cooperative of American Physicians, May 4, 2015, Catherine Miller, https://www.capphysicians.com/articles/medication-reconciliation-one-hospital-improvement-story
 Strategies for Reducing Medication Errors in the Emergency Department, Weant KA, Bailey A, Baker S, Open Access Emergency Medicine, July 23, 2014, https://www.dovepress.com/strategies-for-reducing-medication-errors-in-the-emergency-department-peer-reviewed-article-OAEM