Research is needed on all aspects of the medication reconciliation process to provide an evidence base for impacting the prevention of adverse drug events. The Institute of Medicine report Preventing Medication Errors 1 found that currently most of the studies reported in the literature have small sample sizes and are single-site quality improvement projects.
Multisite studies across the continuum of care are needed to assess the scope of the problem. The medication reconciliation process takes time, initially an additional 30 to 60 minutes per admission. If nurses are responsible for the process, nursing hours per patient day may need to increase. Study of how medication reconciliation processes change the workflow and time associated with it are needed.
Busy clinicians are resistant to changing their workflow. Designing and testing streamlined processes that will work across the continuum of care, from the ambulatory to the inpatient setting, and having all stakeholders involved in the design will facilitate the process. Studies of the sustainability of medication reconciliation processes need to be carried out. What does it look like at 6, 12, and 24 months? Are improvements being maintained? Patients need to be full partners and self-advocates in the medication reconciliation process.
Studies on systematic, multifaceted education programs regarding how to best maintain a current and complete listing of all medications need to be undertaken, as recommended in Preventing Medication Errors. There is some evidence to demonstrate how a medication reconciliation process is effective at preventing adverse drug events.
Few studies have been published demonstrating how to do the process effectively or outlining the costs associated with design and implementation of programs. Nonetheless, an effective medication reconciliation process across care settings—where medications a patient is taking are compared to what is being ordered—is believed to reduce errors. Comparing what is being taken in one setting with what is being prescribed in another will avoid errors of omission, drug-drug interactions, drug-disease interactions, and other discrepancies.
Medication reconciliation is a major component of safe patient care in any environment. English-language health care literature from through March was reviewed. Reference lists from articles on medication reconciliation were also used to identify additional publications.
Articles that describe various components of the reconciliation process were found. Studies tended to be about one of the steps in the handoff process, such as admission from home to an acute care facility. No studies were identified that described the reconciliation process along the entire continuum of care from admission to an acute care facility, transfer from one level of care to another such as critical care to general care , and discharge back to the community to the primary care practitioner or skilled care facility.
The majority of articles were descriptive, and published studies were primarily quality improvement projects with small sample sizes limited to single clinical sites. Turn recording back on. National Center for Biotechnology Information , U. Show details Hughes RG, editor. Search term. Chapter 38 Medication Reconciliation Jane H. Author Information Authors Jane H. Affiliations Jane H.
Barnsteiner, Ph. E-mail: ude. Medication Reconciliation A comprehensive list of medications should include all prescription medications, herbals, vitamins, nutritional supplements, over-the-counter drugs, vaccines, diagnostic and contrast agents, radioactive medications, parenteral nutrition, blood derivatives, and intravenous solutions hereafter referred to collectively as medications.
Research Evidence Medication reconciliation studies have focused on the accuracy of the medication history during various transitions: ambulatory to acute care inpatient setting, skilled nursing facility to acute care inpatient setting, inpatient acute care setting to skilled nursing facility, inpatient acute care setting to discharge, inpatient floor to the intensive care unit ICU , and ICU to discharge.
Reconciliation in the Ambulatory Setting Medication discrepancies in outpatient records were addressed in three studies. Reconciliation in Acute Inpatient Settings Nine studies examined medication reconciliation in acute inpatient settings.
Admissions Between Skilled Nursing Facilities and Hospitals A study of medication changes during transfer from nursing home to hospital and hospital to nursing home found inaccurate and incomplete reconciliation of medication regimens. Inpatient to Discharge Four studies looked at the process of discharge from the hospital to home.
Medication History Accuracy With Electronic Health Records The electronic health record is generally believed to contain more accurate information and facilitate easier retrieval of information than paper-based medical records. Evidence-Based Practice Implications There are numerous areas for nurse involvement in the area of medication reconciliation. Define the Steps in the Reconciliation Process A first step in having an accurate listing of medications is defining the steps in obtaining a complete medication history.
Clearly Identify Responsibilities for the Process Health care professionals need to clearly identify team roles and responsibilities for medication reconciliation. Consider Use of a Standardized Form Many settings have found the use of a standardized medication form facilitates an accurate list that is accessible and visible. Challenges There are many challenges associated with implementation of effective medication reconciliation programs across the continuum of care. Research Implications Research is needed on all aspects of the medication reconciliation process to provide an evidence base for impacting the prevention of adverse drug events.
Conclusion There is some evidence to demonstrate how a medication reconciliation process is effective at preventing adverse drug events. Evidence Table Medication Reconciliation. References 1. Institute of Medicine. Preventing medication errors. The costs of adverse drug events in hospitalized patients. Patient safety standardization as a mechanism to improve safety in health care.
Jt Comm J Qual Saf. Reconciliation of discrepancies in medication histories and admission orders of newly hospitalized patients. Am J Health Syst Pharm. The Joint Commission. Medication reconciliation. National Patient Safety Goals. Barriers associated with medication information handoffs. The completeness of medication histories in hospital medical records of patients admitted to general internal medicine wards.
Medication reconciliation refers to the process of avoiding such inadvertent inconsistencies across transitions in care by reviewing the patient's complete medication regimen at the time of admission, transfer, and discharge and comparing it with the regimen being considered for the new setting of care.
Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. The evidence supporting patient benefits from reconciling medications is relatively scant.
Most medication reconciliation interventions have focused on attempting to prevent medication errors at hospital admission or discharge, but the most effective and generalizable strategies remain unclear. A systematic review found evidence that pharmacist-led processes could prevent medication discrepancies and potential ADEs at hospital admission, in-hospital transitions of care such as transfer into or out of the intensive care unit , and at hospital discharge.
However, both the actual clinical effect of medication discrepancies after discharge appears to be small, and therefore, medication reconciliation alone does not reduce readmissions or other adverse events after discharge. Information technology solutions are being widely studied, but their effect on preventing medication discrepancies and improving clinical outcomes is similarly unclear. The same systematic review found that electronic tools often lacked the functionality to accurately reconcile medications, perhaps explaining why medication discrepancies persist even in organizations with fully integrated electronic medical records.
Several studies have also investigated the role of enhanced patient engagement in medication reconciliation in the outpatient setting and after hospital discharge. These efforts are promising but also lack evidence regarding the impact on medication error rates.
Medication reconciliation has therefore become an example of a safety intervention that has been effective in research settings but has been difficult to implement successfully in general practice.
A commentary identified the major reasons for difficulty achieving safety improvements via medication reconciliation.
They include the resource intensive nature of interventions such as clinical pharmacists, which disincentivizes organizations from investing in medication reconciliation; the alterations to clinical workflow that result from interventions, which creates inefficiencies and confusion regarding the best possible medication history; and conflict between medication reconciliation and other system quality improvement priorities, such as patient flow improvement.
The commentary provides recommendations for organizations, clinicians, and researchers on how to better implement and evaluate medication reconciliation interventions. The Joint Commission's announcement called on organizations to "accurately and completely reconcile medications across the continuum of care. The Joint Commission suspended scoring of medication reconciliation during on-site accreditation surveys between and This policy change was made in recognition of the lack of proven strategies for accomplishing medication reconciliation.
As of July , medication reconciliation has been incorporated into National Patient Safety Goal 3, "Improving the safety of using medications. To sign up for updates or to access your subscriber preferences, please enter your email address below.
We want to hear from our users about how we can improve the PSNet experience. Please select your preferred way to submit a case. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions in care include changes in setting, service, practitioner or level of care. When clinicians work to uncover the cause of medication non-adherence, they can then unlock barriers and provide solutions to help patients better adherence with their regimen, feel better, and stay well.
There is an intimate, interrelatedness between medication adherence and medication reconciliation. Consider that clinicians can ask about the patient's knowledge of the disease state, explain how medications impact the trajectory of their condition, learn whether the patient is experiencing adverse reactions or side effects to their medications, determine whether non-adherence involves affordability or access, and then offer meaningful, patient-specific solutions that can achieve meaningful improvements.
Medication reconciliation and adherence are not divorced discussions, and the additional few minutes spent covering them together can make a significant difference in a patient's outcome. Research has uncovered some inconvenient truths about medication reconciliation features in electronic health record systems.
Although these features may satisfy a regulatory requirement, they are often doing little to improve patient safety and may be causing more harm than good. It gives clinicians the opportunity to review the medications in a patient's chart and check a box if the patient is still taking them. When presented with this option, users can be tempted to check all the boxes so they can click "Next" and keep moving through the screens to finish documenting the visit.
One could argue that this shouldn't qualify as performing medication reconciliation when it's that easy to complete a process which can then lead to potentially harmful consequences. Even if an EHR contains a properly reconciled and accurate medication list when a patient presents in the facility, there's a high probability that it's missing data from providers and facilities not connected to the EHR.
These gaps create the ongoing potential for problems such as therapeutic duplications, interactions, and dosage discrepancies, unless a thorough medication reconciliation is performed consistently at every point in the care continuum. Learn more by clicking here. Here's a common scenario: A patient with a recent ischemic stroke visits their internist a week following discharge.
The medical assistant who rooms the patient discusses the new discharge medicines, which include warfarin, but doesn't ask what's already in the patient's medicine cabinet. It turns out that the patient is on citalopram, which was prescribed by a psychiatrist unbeknownst to the internist. The patient continues to take the citalopram together with warfarin, which elevates the international normalized ratio INR and impacts bleeding risk.
A few weeks later, the patient has a hemorrhagic stroke and is readmitted to the hospital.
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