Despite the national attention paid to medication safety over the last decade, and the subsequent redesign of medication reconciliation workflow in many hospitals, medication errors persist with alarming regularity.
Based on our interviews with more than twenty chief medical officers and quality executives from hospitals and health systems nationwide, here’s a distillation of the most common things that are missing from the medication reconciliation process. If any of them sound familiar, what is your organization doing to address them?
1. A Consistent Owner
All of the clinical and quality leaders we spoke with said their medication reconciliation process is completed by multiple people, in multiple roles. And, this varies by shift and place of service. In the emergency department (ED) and admissions, medication reconciliation is typically conducted by physicians, nurses, and pharmacists or pharmacy technicians. In the physician office it may be the physician, a nurse, or a medical assistant.
Variety may be the spice of life. But when a variety of roles have their hands in the medication reconciliation process, no one is accountable for a complete and accurate medication list. It’s like that old adage, when everybody is doing it, nothing really gets done.
2. An Easy Way to Identify the Most Current Medications List
Do you trust the medication data in your electronic health record (EHR)? The majority of clinical leaders we interviewed said they typically don’t believe it’s complete or accurate.
There are two primary reasons: Too many cooks in the kitchen (reference #1, above), many of whom don’t have the education or knowledge to conduct a thorough reconciliation. And, gaps that are outside of their control. Because even if the EHR list is accurate, it represents only the medication information within the hospital or health system or its EHR.
Which leads us to “what’s missing” issue #3...
3. Access to the Patient’s Medications Outside of the System or EHR
Interoperability among EHRs remains a big issue. If the only EHR you can access is your own, you can’t get the name and dosage of that “blue pill” the patient told you she takes in the morning.
Certainly the pharmacy can be called. But given the time of day, support staff available, and patient volume being handled by the clinician, this may or may not get done. And when it doesn’t, it creates a data gap that renders the medication list incomplete. It also increases the opportunity for drug-drug or allergic reactions from the medications added as a result of the encounter.
Without complete information about what the patient is taking, the clinician is prescribing with one hand tied behind his or her back.
4. Automation That Actually Works
Most of the big EHR systems have what is referred to as a “checkbox” system that theoretically reconciles the medications noted as discontinued, changed, or added during the reconciliation process. The clinician checks a box next to each medication on various screens while conducting the medication review, and clicks a button to magically sort and reconcile the information into an accurate list.
In a perfect world, this abracadabra step would work. But in the real world, the magic button is frequently reconciling incomplete or inaccurate information (reference #2 and #3 above). That’s because when the ED or physician’s clinic is busy, clinicians resort to speeding through the check box screens just to complete the visit note and get on to the next patient.
5. Accurate Patient Recollection About the Pills They Take
Anyone who has delivered patient care has first-hand experience with this.
Patients are the worst historians when it comes to their memory about medications. We’ll never change this. Which is why we need easy to access, interoperable EHRs and other systems that fill the gaps by providing the accurate data patients can’t.
6. Pharmacists and Pharmacy Technicians
What’s missing from the majority of hospital - and virtually all medical clinic - medication reconciliations is pharmacists. In fact, this may be a leading cause of a poorly conducted medication reconciliation process. Here’s why: The primary knowledge base of pharmacists and pharmacy technicians is, well, pharmacology. But the primary knowledge base of physicians, nurses, and other clinicians is diagnosing and treating patients.
This is not a small nuance. It’s a big disconnect in our system. And it results in mistakes. Many of which cause patient harm.
There are multiple studies that indicate pharmacists and technicians should be leading medication reconciliation. One study found that, when pharmacists provided admission drug histories, 3,988 deaths were avoided. Another found that potential errors were reduced by 82% when trained pharmacy technicians obtained medication histories. And another focused on the emergency department, where the intervention of pharmacists reduced overall medication reconciliation discrepancies by 33%.
Yet, it’s the minority of hospitals that employ pharmacists and technicians for this purpose, and even then, they don’t employ enough for 24/7 coverage. Clinical leaders in organizations with pharmacists leading medication reconciliation told us that they are primarily available only during day shifts.
Having pharmacists and pharmacy technicians own medication reconciliation may be a change worth considering. Letting pharmacy lead could be the missing link to decreasing medication errors and adverse drug events your organization has been striving toward.
 Value of the Pharmacist in the Medication Reconciliation Process, Jennifer Splawski, PharmD, BCPS and Heather Minger, PharmD, BCPS, Pharmacy & Therapeutics, P T. 2016 Mar; 41(3): 176–178. www.ncbi.nlm.nih.gov/pmc/articles/PMC4771087/