Hughes RG, editor. Patient Safety and Quality: An Evidenced- based Handbook for Nurses.
According to the Institute of Medicine’s Preventing Medication Errors report, the average hospitalized patient is subject to at least one medication error per day. This confirms previous research findings that medication errors represent the most common patient safety error. Thus, the topic plays an important role in my practice both as an RN and as a legal nurse consultant.
Reviewing medications is an important role of the RN in order to provide safe, competent care to our patients. It’s a necessary process in avoiding the pitfalls that occur when we fail to ensure we have an accurate list of all patient medications; however, recent studies have shown that these errors are more prevalent during patient transitions rather than the result of having an incomplete medication list.
In an effort to avoid the errors of omission, duplication, incorrect doses or timing, and adverse drug-drug interactions a more formal process called Medication reconciliation was introduced as a National Patient Safety Goal by The Joint Commission in 2005.
Medication reconciliation is a formal process that compares a patient’s medication orders to all of the medications that the patient has been taking. 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.
Safety Vulnerabilities Necessitate Medication Reconciliation. Factors such as patients’ lack of knowledge of their medications, clinician’s workflows and lack of integration of patient health records across the continuum care have all contributed to the potential for error. When specialty health care providers are focused on one aspect of care, it’s easy to overlook medications that may cause an adverse event when combined with a new medication or different dosage.
What medications should be included and why? A comprehensive list of medications includes all prescription medications, herbals, vitamins, supplements, over-the –counter drugs, even diagnostic and contrast agents and intravenous nutrition. Interestingly, most clinicians do not consider over-the –counter drugs or dietary supplements to be medications and often do not include them in the record. Interactions can occur between various types of medications so they need to be part of the history.
What are the roles and responsibilities in Medication reconciliation? To start, there are many ways to gather, organize and communicate medication information and several disciplines involved in this process-medicine, pharmacy, and nursing- with little agreement on each other’s roles and responsibilities with respect to this process. Problems with duplication of data, documenting data in different places in the medical record from different sources can create discrepancies that rarely get resolved by any of the disciplines. Lack of a standard for reconciliation and what constitutes a comprehensive medication history has contributed to the creation of an unsafe medication environment in the acute care setting, and is only exacerbated by the movement towards electronic health records. Anyone who routinely reviews medical records can attest to the confusion and frustration of finding a patient’s medication list documented in many areas such as nursing admission, the medication administration record, the physician history or pharmacy profile. Often there are gaps and omissions in information, thus the data is only as accurate as what has been entered. Health care professionals need to clearly identify team responsibilities for the medication reconciliation process including location in the record where the medication history is kept and who will enter the data and document any changes.
Can Standardized systems address the Challenges? Many settings have found the use of a standardized medication form facilitates a more accurate list that is accessible and visible. Numerous examples of standardized medication forms are available on The Institute for Healthcare Improvement (IHI) website. Having a process in place for timely medication review and education programs to involve patients and families can be of value. Recognizing that much of the information is being gathered from laypeople, patient education needs to be a major focus going forward if they are to serve as advocates in their own medication safety.