Proper medication reconciliation can help prevent adverse drug events by identifying exactly what medications a patient was taking before coming to the hospital and confirming appropriate medication orders during and after hospitalization. Last year, the Agency for Healthcare Research and Quality awarded the Society of Hospital Medicine $1.5 million for a three-year Multi-Center Medication Reconciliation Quality Improvement Study. Jeffrey Schnipper, MD, MPH, director of clinical research of the BWH Hospitalist Service at Brigham and Women's Hospital in Boston and principal investigator of the MARQUIS project, explains the four steps healthcare organizations should take when performing medication reconciliation.
The study
The MARQUIS study is evaluating six hospitals' current medication reconciliation practices and will track the outcomes of an intervention designed to improve the process. The intervention will last for 21 months, and all participating hospitals will have started implementation by March. The main outcome SHM is interested in is unintentional medication discrepancies — differences between the patient's pre-admission medication regimen and either admission or discharge medication orders that were not intended by the provider. The MARQUIS team will also look at the culture and safety of the hospital, patient safety leadership, financial health of the institution and other factors that may influence the success of the medication reconciliation program. SHM will then analyze the findings and create a toolkit of medication reconciliation best practices that were learned from the study.
The intervention
The intervention is a bundle of several actions healthcare providers should take to perform medication reconciliation.
1. Medication history. The first step is to take a comprehensive medication history of the patient. SHM recommends providers start by looking at outpatient medical records or a discharge medication list if a patient was recently discharged from a hospital. If the patient brings his or her own list and it matches with the medical record, or the patient can explain all discrepancies, the first step is completed. However, this scenario occurs in only a minority of patients, Dr. Schnipper says. More often, patients do not bring their own list or they do not match with other sources, and providers have to contact the patient's pharmacy to determine what prescriptions have been filled. If there is still uncertainty, a call to the patient's primary care physician or specialists may be necessary. A final resource is to ask the family to bring in all the patients' pill bottles from home to confirm the medications the patient is currently taking.
2. Risk stratification. The next step is to do a risk stratification of patients based on their medication history. Dr. Schnipper says some risk factors include the following:
• A lack of a medical record containing the patient's medications.
• The patient's inability to provide a list of medications or pill bottles from home.
• The patient's use of 10 or more medications.
• The patient's use of three or more high-risk medications, such as insulin or opiates.
• The provider's suspicion of a medication problem.
Each patient's risk level will depend on how many of these factors are present. High-risk patients will likely need a more in-depth medication history and reconciliation process, such as having the history and reconciliation completed by a trained clinical pharmacist.
3. Reconciliation at discharge. Reconciliation at discharge is one of the most critical components of a medication reconciliation program because it can affect the patient's post-hospital safety and health, and thus the chance of readmission. Discharge orders should clearly categorize the medications that are the same from pre-admission, new medications and medications that require a different dose or frequency, Dr. Schnipper says. "Show very clearly how the discharge regimen is different than what the patient was taking prior to admission."
4. Education. Patient and family education is the final step in medication reconciliation. Clinicians need to explain to patients and their families what is different about their medications, why those changes were made and possible side effects, Dr. Schnipper says. In addition, when discharging a patient, hospitals should give discharge instructions to the subsequent caregiver(s) in both written and verbal forms to ensure comprehension and avoid adverse events.
Culture
The MARQUIS project aims to improve medication reconciliation practices and patient safety. However, it may be only the beginning of the movement towards more intensive medication reconciliation. "Medication reconciliation has gotten a bad reputation: many physicians view it as a Joint Commission requirement and someone else's problem," Dr. Schnipper says. "We need to create a cultural change so physicians understand that medication reconciliation is something we do to make sure patients are always receiving the correct medications no matter where they are. This is not about a regulatory requirement, it is about keeping patients safe from harm. As ordering providers, we're ultimately responsible for the safety of our patients."
Learn more about SHM.
The study
The MARQUIS study is evaluating six hospitals' current medication reconciliation practices and will track the outcomes of an intervention designed to improve the process. The intervention will last for 21 months, and all participating hospitals will have started implementation by March. The main outcome SHM is interested in is unintentional medication discrepancies — differences between the patient's pre-admission medication regimen and either admission or discharge medication orders that were not intended by the provider. The MARQUIS team will also look at the culture and safety of the hospital, patient safety leadership, financial health of the institution and other factors that may influence the success of the medication reconciliation program. SHM will then analyze the findings and create a toolkit of medication reconciliation best practices that were learned from the study.
The intervention
The intervention is a bundle of several actions healthcare providers should take to perform medication reconciliation.
1. Medication history. The first step is to take a comprehensive medication history of the patient. SHM recommends providers start by looking at outpatient medical records or a discharge medication list if a patient was recently discharged from a hospital. If the patient brings his or her own list and it matches with the medical record, or the patient can explain all discrepancies, the first step is completed. However, this scenario occurs in only a minority of patients, Dr. Schnipper says. More often, patients do not bring their own list or they do not match with other sources, and providers have to contact the patient's pharmacy to determine what prescriptions have been filled. If there is still uncertainty, a call to the patient's primary care physician or specialists may be necessary. A final resource is to ask the family to bring in all the patients' pill bottles from home to confirm the medications the patient is currently taking.
2. Risk stratification. The next step is to do a risk stratification of patients based on their medication history. Dr. Schnipper says some risk factors include the following:
• A lack of a medical record containing the patient's medications.
• The patient's inability to provide a list of medications or pill bottles from home.
• The patient's use of 10 or more medications.
• The patient's use of three or more high-risk medications, such as insulin or opiates.
• The provider's suspicion of a medication problem.
Each patient's risk level will depend on how many of these factors are present. High-risk patients will likely need a more in-depth medication history and reconciliation process, such as having the history and reconciliation completed by a trained clinical pharmacist.
3. Reconciliation at discharge. Reconciliation at discharge is one of the most critical components of a medication reconciliation program because it can affect the patient's post-hospital safety and health, and thus the chance of readmission. Discharge orders should clearly categorize the medications that are the same from pre-admission, new medications and medications that require a different dose or frequency, Dr. Schnipper says. "Show very clearly how the discharge regimen is different than what the patient was taking prior to admission."
4. Education. Patient and family education is the final step in medication reconciliation. Clinicians need to explain to patients and their families what is different about their medications, why those changes were made and possible side effects, Dr. Schnipper says. In addition, when discharging a patient, hospitals should give discharge instructions to the subsequent caregiver(s) in both written and verbal forms to ensure comprehension and avoid adverse events.
Culture
The MARQUIS project aims to improve medication reconciliation practices and patient safety. However, it may be only the beginning of the movement towards more intensive medication reconciliation. "Medication reconciliation has gotten a bad reputation: many physicians view it as a Joint Commission requirement and someone else's problem," Dr. Schnipper says. "We need to create a cultural change so physicians understand that medication reconciliation is something we do to make sure patients are always receiving the correct medications no matter where they are. This is not about a regulatory requirement, it is about keeping patients safe from harm. As ordering providers, we're ultimately responsible for the safety of our patients."
Learn more about SHM.
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