Just how important is medication reconciliation? A regularly referenced survey shows that hospital-based pharmacists considered medication reconciliation "… to be their most important role in improving care transitions." There's good reason for this sentiment: Every year, 7,000 to 9,000 Americans die due to a medication error. Medication errors also contribute to thousands of patients experiencing adverse drug events and billions of dollars in avoidable costs annually. These and other statistics should motivate providers to best ensure they are properly performing the necessary medication reconciliationThe steps to complete medication reconciliation may seem, on the surface, to be straightforward. Yet we know through numerous studies, such as this study of Pennsylvania hospital data, that serious events related to the medication reconciliation process occur — and occur quite regularly. We also know that the medication reconciliation process is often delayed or skipped entirely. All discharged patients should receive a medication reconciliation post-discharge (MRP) within 72 hours of discharge, but statistics show that MRP is only occurring with half of these patients. Why is that the case?
Steps to Complete Medication Reconciliation
Let's review what are considered the five fundamental medication reconciliation steps and highlight some of significant challenges associated with each of them.
1. Develop a list of a patient's current medications
The first step is perhaps not only the most important but also the most challenging of the medication reconciliation steps: documenting all a patient's current medications. If even a single medication or critical detail about a medication (e.g., dosage, frequency, route of administration) is omitted from this list, the risk of an adverse drug event increases and the ability to effectively and appropriately complete the remaining medication reconciliation steps decreases.
Here are just some of the reasons why developing a current medication list can prove so difficult:
- Patients are taking more medications than ever. As the number of medications grows, so does a patient's ability to recall all their medications and associated details. Consider that a study published in 2012 showed that only 36% of patients were able to provide a medication list that matched their pharmacy-prescribed drugs. This figure has likely declined as medication regimens have continued to grow in complexity.
- Patients are taking more non-prescription drugs, including over-the-counter drugs, vitamins, herbals, and dietary supplements. These should be included on a patient's current medication list.
- Patients often see multiple specialists who prescribe medications, so there may not be a single provider source with a current medication list.
- Patients often fill medications at multiple pharmacies, which may now include those operating online. A pharmacy is only likely to have records for those medications that were filled there.
- A drug may have multiple names associated with it (i.e., brand, generic, chemical). Some drug names can be easily confused with others.
- Cognitive impairment issues can make medication regimen recollection by patients more challenging.
- Electronic health record (EHR) systems are often missing data from providers and facilities not connected to that EHR.
2. Develop a list of medications to be prescribed
This step may seem easy, but that brings with it a potential for mistakes. A false sense of confidence can encourage the rushed completion of responsibilities and corner cutting. As an Academy of Managed Care Pharmacy article notes, these are just some of the ways preventable prescribing errors occur:
- Illegible handwritten prescriptions
- Incorrect selection of drug or dose
- Oral transmission of prescriptions can lead to sound-alike name confusion
- Drugs with similar-looking names can be incorrectly dispensed when prescriptions are handwritten
3. Compare the medications on the lists
This is essentially the "reconciliation step" in the medication reconciliation process. The comparison of the lists helps ensure discrepancies can be avoided and red flags can be identified, such as omitted medications, therapeutic duplications, dosing errors, drug-drug interactions, and drug-disease interactions.
Considering that any of these issues can put a patient's health and wellness at risk, why is this step sometimes missed or not completed appropriately? Some of the top reasons include the following:
- Time: As we previously noted in our medication reconciliation guide, "Clinicians sometimes spend less than 15 minutes with a patient during an appointment and can lack the time necessary to perform proper medication reconciliation."
- Unclear roles and responsibilities: If there is confusion about who is supposed to perform medication reconciliation, the likelihood that it will occur decreases.
- Lack of timing clarity: Similarly, confusion about when medication reconciliation must be performed (e.g., medication reconciliation post-discharge) increases risks.
- Poor communication: When a patient or a patient's information is not effectively handed off at transition points, errors are more likely to occur. This can include a failure to pass along new medication orders that would then necessitate medication reconciliation.
4. Make clinical decisions based on the comparison
This is another one of the medication reconciliation steps that can suffer due to time issues. When those performing medication reconciliation lack the adequate time and resources to effectively complete the process, decision-making is likely to be rushed or cut short.
One aspect of medication management that can be negatively affected concerns efforts around deprescribing, which, as we previously noted, "… has become one of the most effective ways to safely decrease inappropriate and unnecessary polypharmacy."
Unfortunately, as a Health Affairs article states, "In many cases, medication reconciliation has devolved into a box-checking exercise to comprehensively catalog all medications a patient is taking, but the process may not make efforts to decrease the number of medications or stop potentially harmful drugs."
5. Communicate the reconciled medication list to the patient and appropriate caregivers
If the preceding four medication reconciliation steps are completed, this final step is typically completed in some fashion. At a minimum, a patient is usually provided with the revised medications list. But even this can experience problems. They include the following:
- Providers may rush their review and discussion of the list with the patient, potentially stifling a patient's willingness to ask questions.
- A rushed discussion may cause a provider to miss warning signs of an increased likelihood for medication non-adherence.
- A rushed review may also lead to a missed opportunity for a discussion around medication adherence. As we previously noted, "Medication reconciliation and adherence are not divorced discussions, and the additional few minutes can make a huge difference in the patient's outcome."
Communicating the revised list to appropriate caregivers is essential to reducing the likelihood for future medication reconciliation shortfalls. However, it too can be neglected if processes and systems that deliver the reconciled medication list directly into their EMR workflow are not in place that help make uptake by the provider simple and fast. Any obstacles for efficient, effective communication are likely to motivate providers to delay or even bypass completion of this final medication reconciliation step.
Better Ways to Complete Medication Reconciliation Steps
At Cureatr, we understand the importance of medication reconciliation and the current challenges facing providers in completing their essential medication reconciliation steps. That's why we offer a range of solutions, including the Meds 360° medication management system that can lower medication reconciliation times by up to 70% and MPR tech-enabled clinical pharmacy service powered by Meds 360° that can help organizations achieve a 100% MRP completion rate. To learn more about how Cureatr is supporting organizations in their efforts to strengthen medication reconciliation processes, contact us today!