Why Medication Reconciliation Needs to be More Than “Checking the Box”

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In 2002 The Joint Commission established the National Patient Safety Goals (NPSGs) program. The objective: "… help accredited organizations address specific areas of concern in regard to patient safety."

Fast forward to 2018, and eight types of facilities now have their own NPSGs, including hospitals, ambulatory health care, critical access hospitals, and office-based surgery. These facilities, when accredited by The Joint Commission, are surveyed for compliance with the requirements of the goals. Hospitals, for example, are expected to comply with 16 NPSGs broken out into seven categories. Each NPSG includes Elements of Performance (EPs) detailing what is expected of the hospital.

One NPSG — NPSG.03.06.01 — addresses the matter of medication reconciliation. The NPSG's expectations are described as follows: "Record and pass along correct information about a patient's medicines. Find out what medicines the patient is taking. Compare those medicines to new medicines given to the patient. Make sure the patient knows which medicines to take when they are at home. Tell the patient it is important to bring their up-to-date list of medicines every time they visit a doctor."

This description summarizes the five EPs included in NPSG.03.06.01. The Joint Commission makes the case that if hospitals and other organizations required to meet these EPs can complete each of these steps as described, i.e. "check their box," then patients will receive safer care and organizations will deliver better outcomes. In fact, when The Joint Commission finds that an organization is in compliance with all applicable NPSGs, the organization receives a "check mark" on the summary page of its Quality Report.

But one can argue that simply striving to check the box and ultimately earn this check mark is fraught with risk. In the case of the medication reconciliation NPSG (and others), the EPs can serve as valuable guides. But with short descriptions and one or two accompanying notes, they lack the level of detail and guidance organizations need if they truly want to take medication reconciliation and patient safety to a new level.

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5 Tips to Improve Medication Reconciliation

To help you accomplish this worthwhile objective while supporting efforts to achieve compliance with NPSG.03.06.01, follow these five quick tips.

1. Approach patients without preconceptions

When it comes to medication reconciliation - and many other components of care delivery - it is critical to never assume anything about your patients. They will present with varying levels of health literacy. They will speak different languages and follow different religious beliefs. Some will have strong memories that allow them to recall what medications they take while others will struggle with recollection. Some patients will be comfortable in healthcare settings; others will be terrified. There will be patients who have had great healthcare experiences and patients with horror stories to tell.

These and other patient qualities can be a help or hindrance to the medication reconciliation process. Understanding how they can affect your medication reconciliation efforts will be vital to most effectively meeting unique patient needs.

2. Commit more resources to high-risk patients

Some patients are naturally more prone to medication errors. The Massachusetts Board of Registration in Medicine's Quality and Patient Safety Division identifies such high-risk patients as follows:

  • Patients with low health literacy.
  • Patients with multiple co-morbidities.
  • Patients with a cognitive impairment due to delirium, medication, and acute illness.
  • The elderly.
  • Patients transferred from facility outside of the hospital system.
  • Patients taking multiple medications and high-risk medications.
  • Instances when providers lack access to preadmission medication sources.
  • Instances when providers are concerned about medication safety.

Your organization should implement processes to flag such patients and detail how members of your organization tasked with medication reconciliation responsibilities should work to address these and other barriers to safety.

3. Standardize documentation

You can help reduce the potential for unreconciled medications by using a standardized form. And there's no need to create one from scratch. Examples are available from the Institute for Healthcare Improvement (free registration required), the Agency for Healthcare Research and Quality (AHRQ), and other organizations.

Before changing your documentation, make sure staff is educated on the reason(s) for the change and trained on how to appropriately and consistently use the new documentation.

4. Avoid overreliance on electronic records

In an interview with Patient Safety & Quality Healthcare, Megan Maddox, medication and safety officer at Sanford Medical Center, noted that Sanford research indicated its medication reconciliation team found an average of four discrepancies per patient on their electronic medication list.

Maddox's advice: "While it's true that electronic recordkeeping can make a provider's job easier, keeping a medication reconciliation list still requires human contact and communication to succeed. The interview process is the most important factor, and that requires a provider with the skills, training, and knowledge to ask the right questions and avoid errors."

5. Monitor performance

Thinking you have an effective medication reconciliation process is very different from confidently knowing you have such as process. It's critical for organizations to develop and implement a method to monitor adherence to the process and measure whether the process is effective. This includes identifying any patient harm associated with unreconciled medications. Organizations should also ensure they have an effective method to share the results of the monitoring process with those individuals tasked with medication reconciliation responsibilities.

Note: AHRQ, in its "Medications at Transitions and Clinical Handoffs Toolkit for Medication Reconciliation," provides a sample medication reconciliation audit form in the appendix (A-21) that you can consider modifying for use in your organization.

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