On the surface, the concept of medication reconciliation seems quite simple. It can be defined as “…the process of creating an accurate list of medications a patient is taking” and involves answering three straightforward questions: “What medications are my patient taking?”, “When are they taking them?”, and “How strong is their dose?”
This seemingly simple process serves a critical role in ensuring patient safety and preventing harm from medications or adverse drug events (ADEs). In fact, medication reconciliation has been included as one of the Joint Commission’s National Patient Safety Goals since 2005.
Medication reconciliation has proven to have a decidedly positive impact on patient outcomes. In a report issued by the Agency for Healthcare Research and Quality (AHRQ), several studies are referenced highlighting medication reconciliation’s potential to reduce ADEs. One such study that examined medication reconciliation improvement efforts rolled out over a seven-month period showed that these efforts successfully decreased the rate of medication errors by 70% and ADEs by more than 15%. Effective medication reconciliation and medication management are foundations for reducing readmissions, cutting unnecessary medical costs, increasing patient safety, and supporting the greater achievement of health goals.
So, if medication reconciliation sounds so simple, why are medication-related errors such a major issue?
Despite its straightforward definition, the realities of medication reconciliation are far more complex. Medication-related errors, which are often linked to an incomplete or inaccurate medication lists, impact more than 7 million people in the United States annually and cost approximately $21 billion annually across all care settings. AHRQ also reports that more than half of patients have one or more unintended medication discrepancies at hospital admission.
In this post, I will discuss a few reasons why performing a complete and accurate medication reconciliation often presents significant challenges for healthcare providers.
1. Patients are often unreliable sources of information regarding their own medications
In an article published by the Institute for Healthcare Improvement, Mary Urquhart, RN, executive director of nursing at Brattleboro Memorial Hospital, is quoted as saying, “…getting medication information from patients is the most unreliable part of the whole [medication reconciliation] process.”
This problem is even more prevalent with elderly patients. An article published by the American Pharmacist Association, citing data from AHRQ, notes that more than 60% of adults in the United States older than 65 years take at least five medications each week (commonly referred to as polypharmacy) and 15% take at least 10 (commonly referred to as excessive polypharmacy). It is not surprising that recall can be an issue. A study published in The Gerontologist of elderly patients visiting clinics specializing in care of the elderly found these patients failed to recall nearly half of their medications recorded in the chart. Other factors that can contribute to patient confusion about their medications and regimen include frequent changes to medications and multiple prescribers.
2. Everyone is responsible for medication reconciliation — thus, no one is
During market research conducted here at Cureatr, we spoke with dozens of clinicians and found that there was no consistent owner of the medication reconciliation process. The person or people responsible varies based on the place of service.
In the emergency department, for example, medication reconciliation is sometimes performed by the physician, sometimes by the nurse, and sometimes by the pharmacy technician.
In the doctor’s office, medication reconciliation could be the responsibility of an admitting nurse or physician. Without a consistent owner who is held accountable for the process across care settings, the likelihood of inaccurate or incomplete medication information greatly increases.
We witness this shortcoming firsthand when evaluating the consistency of patients receiving medication reconciliation post-discharge (MRP). While 100% of patients should receive an MRP within 72 hours of discharge, statistics show that only about 50% of patients do. As Cureatr CEO Richard Resnick states, MRP is vital because the discharge from the hospital to the home is one of the most dangerous transitions of care for all patients and particularly those with complex medication regimens.
"CMS sets the target for completed MRPs at 80%, but it really ought to happen 100% of the time since over 50% of discharges have at least one medication error," Resnick said. "A [health] plan is financially dinged when they miss that mark, and yet the plan doesn't have total control over whether it happens. It's the provider who is supposed to perform the reconciliation.
"Unfortunately, providers are doing it about half of the time. Even though the plans are pushing providers to perform the MRP and giving them incentives to do so, it's still not occurring regularly. Providers are too busy, there's too much workload challenge, there's not enough data — these and other reasons are why MRPs are not happening consistently for each and every patient."
Fortunately, solutions now exist to that can significantly increase the frequency of MRPs.
3. EMRs come up short on medication reconciliation
Nearly all electronic medical record (EMR) systems now have and continue to refine functionality intended to help streamline and standardize medication reconciliation processes. Most EMRs have what is commonly referred to as a “checkbox” function to reconcile patient medications that have been discontinued, changed, or added.
This function prompts clinicians to check a box next to each medication listed in the patient’s chart while conducting the medication review. In a perfect world, this process would be sufficient for reconciling medications. In reality, these features may only satisfy regulatory requirements, while data quality, usability, and workflow issues can pose significant risks to patient safety.
4. Medication information gaps exist everywhere
Most healthcare providers are acutely aware that medication lists within their EHR, even if accurate, likely only represent those medications ordered within the four walls of their enterprise. They are equally aware that the type of interoperability required to completely connect the dots of a patient’s medication history across the care continuum doesn’t exist. The time thus required to verify all medications for even a moderately complex patient isn’t practical given the overwhelming volume of patients clinicians typically handle on a daily basis.
Raising the Bar on Medication Reconciliation
The good news is that despite these and other challenges affecting medication reconciliation and medication reconciliation post-discharge, there are a number of best practices that organizations can take to improve medication reconciliation. We highlighted five in this blog:
- 1. Start the process before the patient shows up
- 2. Put pharmacists or registered nurses in charge
- 3. Decouple medication reconciliation from rooming tasks
- 4. Educate and involve patients
- 5. Be militant about consistency
In addition, medication reconciliation software and clinical services, such as those provided by Cureatr, can make a significant difference in enhancing medication reconciliation processes and performance. To learn more about how Cureatr helps healthcare providers strengthen medication reconciliation and achieve significant improvements in quality and financial performance, contact us.