More than 15 years after The Joint Commission established medication reconciliation as a National Patient Safety Goal, adverse drug events remain a significant problem. It's been estimated that preventable medication errors affect more than 7 million patients and cost almost $21 billion annually across all care settings. In addition, about 30% of hospitalized patients have at least one discrepancy in their discharge medication reconciliation and medication reconciliation post-discharge (MRP) within 72 hours of discharge is only occurring for about half of all patients.
Why is medication reconciliation such a struggle? I've observed that, instead of adequately addressing what is clearly a broken process fueled by handoff miscommunications (The Joint Commission estimates that 80% of serious medical errors involve transfer miscommunication between caregivers), med rec has essentially become an EHR-directed process. This does not — in any way, shape, or form — deliver the level of patient safety that patients and their families are expecting from care providers.
If medication reconciliation were truly a priority goal in our healthcare institutions, adverse drug events and other incidents causing patient harm would be much lower. But they're not. I realize there are a plethora of important issues to tackle, but it's time to bump medication reconciliation up much higher on the list. This is not only for the safety of patients (although that's good enough reason on its own) but also the amount of downstream financial penalties and costs associated with avoidable medication errors that are causing providers to waste revenue and time.
We asked physician leaders from health systems and physician organizations to share their thoughts about what works and doesn't work in their facilities. Here are seven takeaways from this research, synthesized with some best practices from literature and recent efforts and initiatives on our end to help improve med rec.
1. Start the medical reconciliation process before the patient shows up
For scheduled visits and surgical procedures, add a reminder to the patient's appointment confirmation text or phone call that they should bring a list of current medications to the appointment. You can also include a prompt in your patient portal to request that patients review their meds list prior to the appointment.
Some clinics ask patients to photograph all their pill bottles so the clinician can review and discuss the medications during the visit. The chief medical director of a practice in the Northeast tells patients to take a picture of the bottle and label of every prescription, over-the-counter medication, supplement, herbal, and vitamin they are taking with their phone and bring those pictures to their appointment. Her catchphrase with patients during visits: "Where are your medication pictures?"
You can also consider conducting a medication list review over the phone or via telehealth prior to the appointment. Direct an admissions nurse, or clinic staff in a medical office, to contact high-risk and polypharmacy patients several days before their appointment and discuss current medications and adherence over the phone or telehealth platform. Staff should document discrepancies and all other issues of concern.
2. Put pharmacists in charge of medication reconciliation
Various studies show that medication list accuracy increases and adverse drug events decrease when pharmacists — sometimes supported by registered nurses — manage the reconciliation at each transition point. The physicians we interviewed whose health systems have employed pharmacists and pharmacy techs to conduct med rec said that accuracy has improved.
The American Society of Health-System Pharmacists, in its statement on the pharmacist's role in medication reconciliation, notes, "ASHP … believes that pharmacists, because of their distinct knowledge, skills, and abilities, are uniquely qualified to lead interdisciplinary efforts to establish and maintain an effective medication reconciliation process in hospitals and across health systems."
3. Decouple medication reconciliation from rooming tasks
In a busy office, putting medication review on the shoulders of busy clinic support staff almost assures it will be rushed, and thus done inaccurately or incompletely. It's time we rethink this all-too-common workflow.
We'll never get to a truly safe process if we expect these staff to attempt such a serious and focused conversation as one about medications. Whatever information they quickly gather and document for the physician to review will be missing something much of the time. At best, busy support staff they will perform the aforementioned EHR-driven process, checking boxes on a screen to satisfy a requirement instead of taking the time working to identify those medications that may have been prescribed outside of the system or by specialists using a different EHR system.
4. Educate and involve patients in medical reconciliation
Inform patients about how important it is to maintain a current and accurate medication list. Using posters, handouts, and verbal prompts at check-in can help get the message across, as can information included in appointment preparation materials, including those provided on your website. If a patient's medications were not pre-reconciled by phone or via your portal prior to the visit, print the list of medications from the EHR at check-in and ask patients or family members to review and revise the list.
The Massachusetts Coalition for the Prevention of Medical Errors developed a "Med List" as part of its initiative to improve patient education and the accuracy of patients' medication information. As the Institute for Healthcare Improvement (IHI) notes, "To promote patient safety and reduce the growing incidence of medication errors in the office setting, this patient medication list was created for patients and their families to carry with them to medical appointments. This medication list (Med List) helps patients and their families track medication history, and also helps providers reconciled medications during medical visits." The resource can be downloaded for free. An IHI account, also free, is required.
5. Be militant about medication reconciliation consistency
Medication reconciliation is not a process to be taken for granted. The stakes are too high, and the safety consequences too significant. The medical director of one clinic we spoke with established a protocol for uncontrolled diabetics, whereby they are scheduled for monthly appointments and called in between to talk about diet, exercise, and adherence. A thorough med rec is completed at every visit.
When the practice saw significant benefits to this high-touch care, they applied it in the same way for chronic obstructive pulmonary disease (COPD) and other chronic disease patients. The medical director notes that providers and rotating residents follow the procedure exactly as it's described. "Even when I've known the patient 20 years, I don't break protocol," this medical director told us. "Things change. And there is no excuse for being sloppy."
6. Leverage medication reconciliation resources
I highlighted the Massachusetts Coalition for the Prevention of Medical Errors' Med List earlier. That's far from the only resource available that can help organizations strengthen their medication reconciliation process and performance. In a recent blog, we identified 10 other med rec resources, including medication reconciliation and medication reconciliation post-discharge forms, a tracking tool, eBook, road map, and webinar. These are all available as complimentary downloads and worth reviewing to see if they can help your organization.
But there may be no better way to improve medication reconciliation performance than by…
7. Bringing on a medication reconciliation partner
Even by following all of these and other medication reconciliation best practices, one key obstacle to med rec success will not be effectively addressed: Clinicians have long struggled with accessing their patients' current, comprehensive medication list that includes drug information from all prescribers and retailers. Even if clinicians had the information required to perform a thorough medication reconciliation, prescribing doctors are typically not trained nor do they have the time to optimize patients' medication therapies. The good news is that now these barriers have been addressed with Cureatr's comprehensive medication management (CMM) services, powered by the Meds 360° platform.
When organizations partner with Cureatr, they receive complete patient medication information along with high-touch interventions performed by board-certified pharmacists that help ensure medication reconciliation and MRP are performed consistently, correctly, and completely. The results: better care coordination across providers and settings, leading to improved patient medication adherence and decreased adverse events and readmissions. Learn more about how Cureatr's CMM services are helping organizations nationwide with medication reconciliation and other critical medication management responsibilities by clicking here to schedule a call with a Cureatr CMM specialist.