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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 2021. 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  11 NPSGs across seven categories. Each NPSG includes  elements of performance  (EPs) detailing what is expected of the hospital.

One NPSG — NPSG.03.06.01 — addresses  medication reconciliation. The NPSG's expectations for the med rec NPSG 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 complies with a NPSG, the organization receives a "checkmark" on the summary page of its Quality Report.

But one can argue that working toward earning this checkmark as the foundation for assessing the effectiveness of an organization's med rec program is fraught with risk. In the case of the medication reconciliation NPSG (and others), their accompanying EPs can serve as valuable guides to improve performance with NSPG compliance. But with short descriptions and just one or two accompanying notes, the EPs typically lack the level of detail and guidance organizations need if they truly want to take medication reconciliation and patient safety to a new level.

8 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 eight 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 clearly recall their medication regimen and all its essential details (e.g., frequency, route, dosage) while others will struggle with recollection of even basic details. 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 multiple horror stories to tell.

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

2. 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 use the new documentation appropriately and consistently.

3. Involve pharmacists in medication reconciliation

Is your organization performing medication reconciliation without involvement and insight from pharmacists? If so, not only should you involve pharmacists, but you may want to strongly consider having pharmacy oversee your med rec program.

Why? Consider that at Beaufort Memorial Hospital in South Carolina, medication reconciliation was primarily the nurses' responsibility. The hospital placed a trained pharmacist or pharmacy tech in charge of the medication list at patient admission, during patient transfers, and at discharge. The results of the initiative: Errors in active medication lists dropped from 34% to 2%. Read this case study on the S.C. Hospital Association website.

In fact, expanding pharmacist involvement in a patient care during hospital stays has also been proven to increase patient satisfaction.

4. Strengthen patient medication interviews

The more effectively you can interview patients about their medication regimen, the more likely it is that you will gather the essential details about the regimen that will support efforts to perform better med rec.

AHRQ provides tips for conducting a patient medication interview. This includes capturing details about all a patient's medications — which goes beyond prescriptions to also encompass over-the-counter medications, vitamins, health supplements, and respiratory therapy-related medications like inhalers) — and the full dosing information for each medication as well as asking "probing questions" that can help trigger a patient's memory on the medications they are currently taking.

5. 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 ensure there are processes and procedures in place to help guide those members of your organization tasked with medication reconciliation responsibilities to work to address these and other barriers to safety.

6. 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."

7. Monitor medication reconciliation 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 med rec 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.

8. Make medication reconciliation post-discharge a priority

Medication-related problems after hospitalization are far too common of an occurrence. Why do they occur? As a PLoS One article notes, contributing factors include "when changes in patients' medication regimens are accompanied by insufficient patient education, poor information transfer between healthcare providers, and inadequate follow-up post-discharge."

We'll add another cause to this list: poor  medication reconciliation post-discharge (MRP). All should patients receive an MRP within 72 hours of discharge. However, research indicates that MRP only happens approximately half of the time. This contributes to the increased risk of patients requiring what would be an avoidable readmission. The cost of unplanned readmissions has been estimated at $15 billion to $20 billion dollars annually. Strengthening MRP is one of the easiest ways for an organization to improve outcomes and reduce costs. To learn more about MRP and ways to improve it, including through the addition of a tech-enabled clinical pharmacy service, read this blog post.

Resolve Issues with Medication Reconciliation - Ebook


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