In 1975, the work of the Institute for Safe Medication Practices (ISMP) officially began. Six years later, we saw the first printing of "Medication Errors: Causes and Prevention" which detailed the causes and prevention of drug mistakes. In the years that followed, medication safety stayed in the spotlight thanks to the Institute of Medicine's "To Err is Human: Building a Safer Health System," The Joint Commission's third National Patient Safety Goal (NPSG) focusing on improving the safety of using medications, and other initiatives and developments.
And yet, despite this national attention paid to medication safety and the subsequent redesign of medication reconciliation workflow in many hospitals, medication errors persist today with alarming regularity and frequency. As a StatPearls article notes, "Each year, in the United States alone, 7,000 to 9,000 people die as a result of a medication error. Additionally, hundreds of thousands of other patients experience but often do not report an adverse reaction or other medication complications. The total cost of looking after patients with medication-associated errors exceeds $40 billion each year."
There are many causes of medication errors, but one of the most significant — and sometimes overlooked — is a poor medication reconciliation workflow. When med rec is not performed properly, consistently, and at its highest level of effectiveness, errors and oversights are more likely to occur. The good news is that hospitals which take a closer look at their medication reconciliation workflow may find several opportunities for improvement.
6 Commonly Overlooked Facets of Medication Reconciliation Workflow
Below you will find a distillation of the most common things that are missing from the medication reconciliation process based on our interviews with more than 20 chief medical officers and quality executives from hospitals and health systems nationwide. If any of these issues sound familiar, we recommended looking into what your organization should be doing to address them.
1. Consistent Owner
All the clinical and quality leaders we spoke with said their medication reconciliation process is completed by multiple people who fill in multiple roles. This varied by shift and place of service. For example, in the emergency department (ED) and admissions, med rec is typically performed by physicians, nurses, and pharmacists or pharmacy technicians. In the physician office, it may be the responsibility of the physician, a nurse, or a medical assistant.
Variety may be the spice of life. However, when a variety of professionals have their hands in the medication reconciliation process, the result is usually that no one is accountable for a complete and accurate medication list. It's like the adage: When everybody is doing it, nothing really gets done.
As we will discuss below, there are certain professionals who are likely to be best suited to oversee the medication reconciliation process and better ensure it is performed at the appropriate times and in the most appropriate and complete manner.
2. Easy Way to Identify the Most Current Medications List
Do you have confidence in the medication data captured and stored in your electronic health record (EHR)? Most clinical leaders we interviewed said they typically do not believe the data is complete or accurate.
There are two primary reasons why this tends to be the case. First, there are "too many cooks in the kitchen" (reference #1, above), many of whom lack the experience or knowledge to conduct a thorough med rec. Second, there are gaps in the data. Even if the EHR medication list is accurate, it likely represents only the medication information concerning those prescriptions that were given to patients during their visit to the hospital or health system or from prescribers who share the same EHR, which may not include specialists, urgent care providers, surgeons, and other clinicians from outside the system.
Which leads us to issue #3 of what's missing in the mec rec workflow...
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 facility's own system, you will likely struggle to get the name, dosage, and frequency of that "small white pill" the patient told you she takes in the morning that you or a colleague did not prescribe.
The patient's pharmacy or prescriber 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 allow you to get the information you need. And when it does not, this 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 because of the encounter.
Without complete information about what the patient is taking, the clinician is essentially prescribing with one hand tied behind their 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 then clicks a button to magically sort and reconcile the information into what they hope is 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 (see #2 and #3 above). That's because when the ED or physician's clinic get busy (which is the norm these days), clinicians can find themselves speeding through the checkbox screens just to complete the visit note and move on to the next patient.
5. Accurate Patient Recollection About the Pills They Take
Anyone who has delivered patient care and needed to inquire about a patient's medication regimen has firsthand experience with this challenge. Patients are typically bad historians concerning their medication history. While there are ways we can help patients remember their medications, and even some tools that can improve medication management and adherence, we'll never change the fact that many patients will struggle to recall all the medications they are taking and the key details about these drugs (e.g., dosage, frequency).
That's one of the reasons why the use of technologies that can fill this information gap by providing the accurate medication data patients cannot have become so important for healthcare organizations and valuable for performing better medication reconciliation.
6. Pharmacists and Pharmacy Technicians
What is missing from most hospital — and virtually all medical clinic — medication reconciliations are pharmacists. In fact, this may be a leading cause of a poorly performed medication reconciliation process.
Here's why: The primary knowledge base of pharmacists and pharmacy technicians is pharmacology. But the primary knowledge base of physicians, nurses, and other clinicians is diagnosing and treating patients. And this is not a small nuance. It's a big disconnect in our health system that often results in avoidable mistakes, many of which cause or contribute to patient harm.
There are multiple studies that indicate pharmacists and technicians should be leading the med rec process. One study found that when pharmacists provided admission drug histories, nearly 4,000 deaths were avoided. Another study found that potential errors were reduced by more than 80% when trained pharmacy technicians obtained medication histories. And a third study focusing on the ED showed that the intervention of pharmacists reduced overall medication reconciliation discrepancies by about one-third.
Yet, the minority of hospitals employ pharmacists and technicians for this purpose, and even then, they often do not employ these professionals enough to provide 24/7 coverage. Clinical leaders in organizations with pharmacists who are leading med rec told us that these professionals are primarily available only during day shifts.
Putting pharmacists and pharmacy technicians in charge of medication reconciliation may be a change worth considering. Letting pharmacy lead could be the missing link to decreasing the medication errors and adverse drug events your organization has been striving toward.