You don't want to take chances with medication reconciliation. A poorly executed or incomplete medication reconciliation process greatly raises the chances of jeopardizing patient safety.
A Journal of General Internal Medicine study on risk factors and potential harm associated with medication errors at hospital admission found that 36 percent of patients had errors in their admission medication orders.
The majority of these occurred during the medication history gathering phase. It's no wonder that an Agency for Healthcare Research and Quality report states, "The effectiveness of a sound medication reconciliation process within and among care settings is an important component of patient safety goals."
How can an organization help ensure such a sound medication reconciliation process? It should develop a sound medication reconciliation policy and procedure. As a Patient Safety & Quality Healthcare report notes, formalized policies and procedures address a number of critical purposes, including the following:
- Simplify adherence with recognized professional practices.
- Promote regulatory compliance.
- Reduce practice variation and reliance on memory.
- Standardize practices across multiple entities within a health system.
- Serve as a resource for staff, particularly new personnel.
10 Items to Include in a Medication Reconciliation Policy and Procedure
What should you include in your medication reconciliation policy and procedure? Here are 10 items to consider.
Don't overlook the most basic of information! Anyone picking up the policy and procedure should immediately know it addresses your medication reconciliation process.
2. Policy overview
This would provide a brief, broad overview of the "who, what, when, where, why, and how" for the policy and procedure. It should allow someone who reviews the document to gain a general understanding of the rule(s) put in place by the policy and procedure.
Here is where you would explain the rationale behind the development of the policy and procedure. Summarize the medication reconciliation process and its objectives (e.g., reduce errors and patient harm).
If your organization includes multiple sites and the policy and procedure is applicable to more than one site, here is where you will want to describe those sites to which the policy applies.
This is an element of policies and procedures sometimes overlooked. One of the objectives of a policy and procedure is to eliminate any confusion or misunderstanding about the process to be followed. If there are words used in a policy and procedure unfamiliar to a reader or that can be defined multiple ways, a list of definitions can help provide a better understanding of the materials in the document.
Some words to consider defining in a medication reconciliation policy and procedure (assuming they are in your policy and procedure):
- medication (including the types your organization will want to capture during the reconciliation process);
- medication reconciliation;
- medication clarification;
- medication administration record;
- medication adherence;
- medication discrepancy;
- home medication list; and
- continuum of care.
This is where you will describe the process staff members should follow when performing medication reconciliation. You will want to provide an adequate level of detail so staff understand what is expected of them during every step of the process, but also try to keep information concise. Numbering steps and using bullets can help with organization and readability.
In this section, consider explaining at least the following:
- what medication information should be documented (e.g., medication name, dose, route, frequency) and how documentation should occur for patients not taking medications;
- when medication lists are to be updated and provided to patients;
- when and whose signatures are required;
- when and how patient and family education should be provided;
- when and how discrepancies will be checked; and
specific processes at different stages of a patient's visit to your organization (e.g., admission, transfer, discharge)
Include the effective date (the date the policy and procedure initially went into effect), revised date (if changes were made, so readers can stay current), and reviewed date (to note the last time the policy and procedure was reviewed to see if any changes were required; even if no changes are made, this date should be noted).
8. Authorizing individual
Note who has authorized the release of the policy and procedure. This will likely be someone in a leadership/management position.
If your organization sends new or updated policies and procedures to staff via email, intranet, or another distribution means, you may want to note how and when this distribution occurred.
10. Page numbers
These can prove helpful if your policy and procedure is several pages long. If it's printed, page numbers can help readers ensure they are reviewing materials in their correct order. Inclusion of page headers, with the title and number for the policy and procedure, can also help with organization.