Standardized Medication Reconciliation Research Articles

Effectiveness of Standardized Medication Reconciliation Education on Provider's Compliance and Medication Discrepancies in an Ambulatory Clinic Caring for Post-Allo HSCT Patients. a Quality Improvement Project.

Effectiveness of Standardized Medication Reconciliation Education on Provider's Compliance and Medication Discrepancies in an Ambulatory Clinic Caring for Post-Allo HSCT Patients. a Quality Improvement Project.

Evaluation of Pharmacy Resident-Driven Medication Reconciliation on Patients at High Risk of Hospital Readmission.

Purpose: Pharmacists play a key role in preventing medication errors during transitions of care and preventing hospital readmissions through medication reconciliation (MR) programs. This study retrospectively evaluated the implementation of a standardized pharmacy residentdriven MR program for patients at high risk for readmission as defined by the Hospital Readmissions Reduction Program (HRRP). Methods: This was a single-center, retrospective cross sectional study of a pharmacy resident-driven MR program including patients at high risk of readmission defined by HRRP. The primary objective was to determine the number of inpatient regimen interventions identified during the MR. Secondary objectives include severity of interventions, number of medication discrepancies identified, types of interventions and discrepancies identified, and all-cause hospital readmission rates within 30 days of discharge.. Results: Fifty-three high-risk patients were included in the study. Pharmacy intervention recommendations were accepted by prescribers for nine patients (9/53; 17.0%) with a total of 13 accepted inpatient regimen interventions. The two most commonly identified medication classes for interventions were anticonvulsants (3/13; 23.1%) and antidepressants (6/13; 46.2%). Discrepancies on the admission MR were identified for 46 (46/53; 86.8%) patients with a median of three discrepancies per patient (interquartile range 2-4). The most common type of discrepancy was an incorrect or unnecessary drug. The 30-day all-cause readmission rate was 35.8% (19/53) for the total patient Conclusion: A pharmacy-resident driven MR program provided value in clarifying prior to admission medications and may help prevent drugrelated adverse events.

A prospective assessment of the Medicaid Web portal for admission medication reconciliation at a community hospital in Montana.

Medication reconciliation (MR) is a complicated and tedious process but is crucial to prevent errors when ordering patients' discharge medications during a hospital admission. Our institution currently uses a variety of methods to gather a patient's medication history, including review of the medical records and electronic pharmaceutical claims data (EPCD) from a commercial health information exchange organization, as well as a patient or caregiver interview. Occasionally, more information is needed to obtain the most accurate history. To augment current methods, EPCD can also be accessed for patients with Medicaid insurance using a state Medicaid Web portal. We aimed to evaluate the utility of the Medicaid Web portal for reducing medication errors during the MR process at hospital admission. A single-center, prospective, quality improvement initiative was conducted to evaluate 100 patient medication lists for all nonobstetric Medicaid patients admitted to our institution to identify discrepancies in medication lists when the state Medicaid Web portal was used in addition to standard MR methods. We found that, when EPCD from commercial organizations were available, they matched the patient's current medication list 64% of the time. One in 4 patients had at least 1 discrepancy on their verified medication list that was identified using the Medicaid Web portal. The discrepancies identified were addressed and corrected in real time to improve patient care. EPCD from the state Medicaid Web portal could supplement the use of current methods to obtain a more accurate medication history and reduce the number of erroneously ordered discharge medications during hospital admission.

Impact of Pharmacy-Driven Medication Reconciliation upon Admission to Improve Patient Safety in a Family Medicine Unit

Introduction: Medication reconciliation is the process of comparing a patient’s ordered medications to what the patient is actually taking. For several years, it has been included as part of The Joint Commission National Patient Safety Goals for improving medication safety. Our study investigated the impact of pharmacy personnel involvement in the medication reconciliation process on a family medicine unit in a large, urban, academic medical center. Materials and Methods: A prospective, non-randomized, cross-sectional study was conducted from November 2017 through March 2018. The number of medication discrepancies identified as well as the characteristics of the patients, types and medication classes most commonly associated with discrepancies were assessed. Results: Approximately 104 out of 134 or 78% of patients had at least one discrepancy at the time of admission. The most common discrepancy type was related to the electronic medical record followed by omissions, patient non-compliance and the drug being held. The medication classes mostly commonly associated with discrepancies were over the counter medications, cardiac medications and analgesics. Of the 104 patients that had at least one discrepancy, 31 (30%) required an intervention by a member of the pharmacy team. Conclusion: Pharmacy interns identified additional prescription and non-prescription medication discrepancies after the medication reconciliation process had already been completed. Involving pharmacy interns in a formal, standardized medication reconciliation process can help maintain and communicate accurate patient information.

Identification of undocumented over-the-counter medications in an academic nephrology clinic

ObjectivesTo explore how accurately over-the-counter (OTC) medications were documented in an academic nephrology clinic and the benefits of using a novel short questionnaire as part of medication reconciliation (MR). MethodsWe developed a 3-item tailored questionnaire with questions about use of aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and proton pump inhibitors (PPIs), which clinical leadership identified as medications of interest. Over the course of 20 days, medical assistants administered the questionnaire to clinic patients immediately after the standard MR. We summarized the rate of inaccurate medication documentation by individual drug and drug class, comparing the standard MR process with the questionnaire. We also calculated diagnostic performance characteristics of the questionnaire. We evaluated the severity of drug-drug interactions between OTC medications discovered using the OTC medication questionnaire and patients’ other prescription medications. ResultsNearly 30% (n = 133 of 450) of the participants had at least 1 inaccurately documented OTC medication after the standard MR. The sensitivity and specificity of the standard MR were 79.2% and 93.5%, respectively, for aspirin; 14.5% and 99.5% for NSAIDs; and 80.4% and 97.3% for PPIs. Medication omissions were resolved in the electronic health record approximately two-thirds of the time using the questionnaire. At least 1 drug-drug interaction (DDI) involving active use of an OTC medication was identified in 9.6% of the patients. Of the DDIs, the most common portended effects were increased nephrotoxicity (52.9%), increased bleeding risk (22.9%), and enhanced antiplatelet activity (7.1%). ConclusionDespite the standard MR process, inaccurate documentation of commonly used OTC medications occurred in nearly one-third of outpatients in a nephrology clinic. A brief OTC medication questionnaire may be a scalable and effective strategy to address this problem.

Detecting direct oral anticoagulants in trauma patients using liquid chromatography-mass spectrometry: A novel approach to medication reconciliation.

Accurate medication reconciliation in trauma patients is essential but difficult. Currently, there is no established clinical method of detecting direct oral anticoagulants (DOACs) in trauma patients. We hypothesized that a liquid chromatography-mass spectrometry (LCMS)-based assay can be used to accurately detect DOACs in trauma patients upon hospital arrival. Plasma samples were collected from 356 patients who provided informed consent including 10 healthy controls, 19 known positive or negative controls, and 327 trauma patients older than 65 years who were evaluated at our large, urban level 1 trauma center. The assay methodology was developed in healthy and known controls to detect apixaban, rivaroxaban, and dabigatran using LCMS and then applied to 327 samples from trauma patients. Standard medication reconciliation processes in the electronic medical record documenting DOAC usage were compared with LCMS results to determine overall accuracy, sensitivity, specificity, and positive and negative predictive values (PPV, NPV) of the assay. Of 356 patients, 39 (10.96%) were on DOACs: 21 were on apixaban, 14 on rivaroxaban, and 4 on dabigatran. The overall accuracy of the assay for detecting any DOAC was 98.60%, with a sensitivity of 94.87% and specificity of 99.05% (PPV, 92.50%; NPV, 99.37%). The assay detected apixaban with a sensitivity of 90.48% and specificity of 99.10% (PPV, 86.36%; NPV 99.40%). There were three false-positive results and two false-negative LCMS results for apixaban. Dabigatran and rivaroxaban were detected with 100% sensitivity and specificity. This LCMS-based assay was highly accurate in detecting DOACs in trauma patients. Further studies need to confirm the clinical efficacy of this LCMS assay and its value for medication reconciliation in trauma patients. Diagnostic Test, level III.

Medication reconciliation: ineffective or hard to implement?

In this issue of BMJ Quality & Safety , Schnipper et al evaluate the implementation of a multifaceted medication reconciliation intervention at six hospitals using the MARQUIS medication reconciliation implementation...

Clinical pharmacist-led program on medication reconciliation implementation at hospital admission: experience of a single university hospital in Croatia.

AimTo evaluate the clinical pharmacist-led medication reconciliation process in clinical practice by quantifying and analyzing unintentional medication discrepancies at hospital admission.MethodsAn observational prospective study was conducted at the Clinical Department of Internal Medicine, University Hospital Dubrava, during a 1-year period (October 2014 – September 2015) as a part of the implementation of Safe Clinical Practice, Medication Reconciliation of the European Network for Patient Safety and Quality of Care Joint Action (PASQ JA) project. Patients older than 18 years taking at least one regular prescription medication were eligible for inclusion. Discrepancies between pharmacists' Best Possible Medication History (BPMH) and physicians' admission orders were detected and communicated directly to the physicians to clarify whether the observed changes in therapy were intentional or unintentional. All discrepancies were discussed by an expert panel and classified according to their potential to cause harm.ResultsIn 411 patients included in the study, 1200 medication discrepancies were identified, with 202 (16.8%) being unintentional. One or more unintentional medication discrepancy was found in 148 (35%) patients. The most frequent type of unintentional medication discrepancy was drug omission (63.9%) followed by an incorrect dose (24.2%). More than half (59.9%) of the identified unintentional medication discrepancies had the potential to cause moderate to severe discomfort or clinical deterioration in the patient.ConclusionAround 60% of medication errors were assessed as having the potential to threaten the patient safety. Clinical pharmacist-led medication reconciliation was shown to be an important tool in detecting medication discrepancies and preventing adverse patient outcomes. This standardized medication reconciliation process may be widely applicable to other health care organizations and clinical settings.

Nursing's Role in Successful Transitions Across Settings.

Care transitions across settings (hospital, other institutional settings, and home) are vulnerable exchange points for patients and family caregivers that contribute to higher risk of poor health outcomes.1 The Institute of Medicine and National Quality Forum identified improving transitions across the continuum from acute care to home as a national priority.2,3 Despite this, care transitions for individuals with disabling conditions, such as stroke, remain inefficient, resulting in unmet patient and caregiver needs, increased safety risks, high rates of preventable readmissions, and increased healthcare costs.4 Nurses have an integral role in care coordination activities at various practice levels and settings, thus nurses can help transform healthcare delivery for stroke survivors through improving transitions. Stroke is the leading cause of major disability. Annually, ≈800 000 people are hospitalized for stroke in the United States. In 2010, there were ≈6.6 million stroke survivors with a predicted increase in prevalence of >20% over the next 20 years.5 Despite medical advances resulting in reduced stroke mortality, disability after stroke remains a major concern and adds complexity to care transitions for this population. Given stroke prevalence, improving nurses’ engagement in optimizing care transitions for this population is essential. Readmissions after discharge from institutional settings to the community are a closely monitored measurement of care transition effectiveness. Readmissions may indicate unresolved problems, discharge to an inappropriate level of care, quality of immediate posthospital care, or a combination of these factors.6 Thirty-day readmission rates after hospital discharge are reported at 14.4%, with 11.9% of these determined as preventable.7 Readmissions after discharge from inpatient rehabilitation facilities range from 9.0% to 16.7%, varying with the severity of stroke impairment.8 Patients discharged to skilled nursing facilities have the highest 30-day readmission rates.9 Readmissions are associated with substantial economic burden on the healthcare …

Roadmap to Quality: Effective Medication Reconciliation Minimizes Errors in a Long-Term Care Setting

Medication reconciliation commonly known as “med rec,” is identified by the Joint Commission as a process of “accurately and completely reconciling medications across the continuum of care.” The Joint Commission established National Patient Safety Goal (NPSG) 03.06.01, which is the need to maintain and communicate accurate patient medication information. The need for medication reconciliation is evident during the time of a patient transition, because medication error occurs most often when a patient transitions from one setting to another. Medication reconciliation NPSG has expanded to long-term care (LTC) organizations, as well as to other healthcare systems. In July 2013, the Institute for Safe Medication Practices reported that approximately one-third of 1.4 million LTC residents “will take an average of nine medications daily, which significantly increases the risk of medication errors, particularly during transition from hospital to LTC facility.” Therefore, it is imperative to establish a standardize medication reconciliation process to insure accurate and comprehensive medication review at transitional points in care. The purpose of this performance improvement project is to determine if implementing a standardized medication reconciliation process minimizes medication errors.

Predicting risk of adverse drug reactions in older adults.

Adverse drug reactions (ADRs) are common in older adults, with falls, orthostatic hypotension, delirium, renal failure, gastrointestinal and intracranial bleeding being amongst the most common clinical manifestations. ADR risk increases with age-related changes in pharmacokinetics and pharmacodynamics, increasing burden of comorbidity, polypharmacy, inappropriate prescribing and suboptimal monitoring of drugs. ADRs are a preventable cause of harm to patients and an unnecessary waste of healthcare resources. Several ADR risk tools exist but none has sufficient predictive value for clinical practice. Good clinical practice for detecting and predicting ADRs in vulnerable patients includes detailed documentation and regular review of prescribed and over-the-counter medications through standardized medication reconciliation. New medications should be prescribed cautiously with clear therapeutic goals and recognition of the impact a drug can have on multiple organ systems. Prescribers should regularly review medication efficacy and be vigilant for ADRs and their contributory risk factors. Deprescribing should occur at an individual level when drugs are no longer efficacious or beneficial or when safer alternatives exist. Inappropriate prescribing and unnecessary polypharmacy should be minimized. Comprehensive geriatric assessment and the use of explicit prescribing criteria can be useful in this regard.

Whose responsibility is medication reconciliation: Physicians, pharmacists or nurses? A survey in an academic tertiary care hospital

Background: Medication errors occur frequently at transitions in care and can result in morbidity and mortality. Medication reconciliation is a recognized hospital accreditation requirement and designed to limit errors in transitions in care. Objectives: To identify beliefs, perceived roles and responsibilities of physicians, pharmacists and nurses prior to the implementation of a standardized medication reconciliation process. Methods: A survey was distributed to the three professions: pharmacists in the pharmacy and physicians and nurses in hospital in-patient units. It contained questions about the current level of medication reconciliation practices, as well as perceived roles and responsibilities of each profession when a standardized process is implemented. Value, barriers to implementing medication reconciliation and the role of information technology were also assessed. Analyses were performed using univariate statistics. Results: There was a lack of clarity of current medication reconciliation practices as well as lack of agreement between the three professions. Physicians and pharmacists considered their professions as the main providers while nurses considered physicians followed by themselves as the main providers with limited roles for pharmacists. The three professions recognize the values and benefits of medication reconciliation yet pharmacists, more than others, stated limited time to implement reconciliation is a major barrier. Obstacles such as unreliable sources of medication history, patient knowledge and lack of coordination and communication between the three professions were expressed. Conclusions: The three health care professions recognize the value of medication reconciliation and want to see it implemented in the hospital, yet there is a lack of agreement with regard to roles and responsibilities of each profession within the process. This needs to be addressed by the hospital administration to design clear procedures and defined roles for each profession within a standardized medication reconciliation process.

Rapid Reduction in Use of Antidiabetic Medication after Laparoscopic Sleeve Gastrectomy: The Newfoundland and Labrador Bariatric Surgery Cohort (BaSCo) Study.

Patients who have undergone bariatric surgery generally need fewer medications as they experience improvement in, or even resolution of, various medical conditions, including type 2 diabetes mellitus, hypertension, and dyslipidemia. Published data on changes in medication use after laparoscopic sleeve gastrectomy, a type of bariatric surgery that is growing in popularity, are limited. To determine whether patients took fewer medications for management of type 2 diabetes, hypertension, and dyslipidemia after laparoscopic sleeve gastrectomy, relative to preprocedure medications. In this prospective, single-centre cohort study, a nurse practitioner used standard medication reconciliation and study data-extraction forms to interview adult patients who had undergone laparoscopic sleeve gastrectomy and determine their medication use and pertinent demographic data. The data were analyzed using generalized estimating equations and standard statistical software. Outcome measures included changes in the use of antidiabetic, antihypertensive, and antilipemic medications at 1, 3, and 6 months after the surgery. A total of 65 patients who underwent laparoscopic sleeve gastrectomy between May 2011 and January 2014 met the study inclusion criteria. Before surgery, the 30 patients with type 2 diabetes were taking an average of 1.9 antidiabetic medications. One month after the procedure, 15 (50%) had discontinued all antidiabetic medications, with a further decline at 3 and 6 months (p < 0.001 at each time point). Among the patients who were taking antihypertensives (n = 48) and antilipemics (n = 33) before surgery, the decline in use occurred at a more modest rate, with 6 (12%) and 2 (6%), respectively, discontinuing these medication classes within 1 month, and 12 (25%) (p = 0.001) and 8 (24%) (p = 0.015) having discontinued by 6 months. These findings suggest that patients with a history of type 2 diabetes mellitus, hypertension, and/or dyslipidemia who undergo laparoscopic sleeve gastrectomy are less likely to require disease-specific medications shortly after surgery.

Student pharmacist initiated medication reconciliation in the outpatient setting

The Joint Commission continues to emphasize the importance of medication reconciliation in all practice settings. Pharmacists and student pharmacists are uniquely trained in this aspect of patient care, and can assist with keeping accurate and complete medication records through patient interview in the outpatient setting. The objective of this study was to quantify and describe medication reconciliation efforts by student pharmacists in an outpatient family medicine center. A retrospective review was conducted of all standard medication reconciliation forms completed by student pharmacists during patient interviews from April 2010 to July 2010. The number of reviews conducted was recorded, along with the frequency of each type of discrepancy. A discrepancy was defined as any lack of agreement between the medication list in the electronic health record (EHR) and the patient-reported regimen and included any differences in dose or frequency of a medication, duplication of the same medication, medication no longer taken or omission of any medication. A total of 213 standard medication forms from the 4 month period were reviewed. A total of 555 discrepancies were found, including medications no longer taken, prescription medications that needed to be added to the EHR, over-the-counter(OTC) and herbal medications that needed to be added to the EHR, medications taken differently than recorded in the EHR, and medication allergies which needed to be updated. An average of 2.6 discrepancies was found per patient interviewed. Student pharmacist-initiated medication reconciliation in an outpatient family medicine center resulted in the resolution of numerous discrepancies in the medication lists of individual patients. Pharmacists and student pharmacists are uniquely trained in medication history taking and play a vital role in medication reconciliation in the outpatient setting.

Medication review software to improve the accuracy of outpatient medication histories: protocol for a randomized controlled trial

AbstractMedication‐prescribing errors generated at interfaces‐in‐care are the most common cause of preventable health care errors and contribute substantially to adverse patient outcomes. For this reason, standardized medication reconciliation (MR) processes need to be inserted at these interfaces. However, MR is an inherently complex task, and little data exist to inform system‐based operationalization. The Portland Informatics Center addressed this challenge by creating an electronic patient‐directed multimedia survey to automate the medication history collection. This article describes a research protocol designed to compare the software's medication discrepancy detection rate with traditional history collection strategies. For this randomized, controlled, single‐blind trial, participants are randomly allocated into one of two groups: the control group reviews a paper list printed from the electronic record, whereas the intervention group uses a computer‐assisted reconciliation survey that includes display of visual data (i.e., medication pictures). © 2011 Wiley Periodicals, Inc.

Best Possible Medication History in the Emergency Department: Comparing Pharmacy Technicians and Pharmacists

Obtaining an accurate and complete medication list (i.e., the best possible medication history [BPMH]) is the first step in completing medication reconciliation. The ability of pharmacy technicians to obtain medication histories, relative to that of pharmacists, has not been formally assessed. To determine whether pharmacy technicians at the authors' institution could obtain a BPMH as accurately and completely as pharmacists and if both groups met national norms for unintentional discrepancies and the success index for medication reconciliation. Pharmacy technicians were trained in obtaining a BPMH at the beginning of the study, before any patients were enrolled. Patients presenting to the emergency department were prospectively enrolled to be interviewed separately by both a pharmacist and a technician, with information recorded on standard medication reconciliation forms. The completed forms for each patient were compared following each set of interviews, and discrepancies were clarified with the patient. Fifty-nine patients were included in the study, and 3 pharmacists and 2 technicians obtained the histories. There was no significant difference between pharmacists and technicians in terms of discrepancies involving prescription drugs (χ(2) = 0.52, df = 1, n = 118, p = 0.47, Cramer's V for effect size = 0.07) or over-the-counter medications (χ(2) = 0.09, df = 1, n = 118, p = 0.77, Cramer's V = 0.03). The mean number of discrepancies per patient did not differ significantly between the pharmacists and technicians (t = 0.15, df = 58, p = 0.88 for prescription drugs; t = -0.22, df = 58, p = 0.83 for over-the-counter products). For both groups, the number of unintentional discrepancies per patient was significantly lower and the success index for medication reconciliation significantly higher than the national average. Trained pharmacy technicians at the authors' institution were able to obtain a BPMH with as much accuracy and completeness as pharmacists. Both groups were significantly superior to the national average in terms of unintentional discrepancies and success index for medication reconciliation.

Using Consumer-Based Kiosk Technology to Improve and Standardize Medication Reconciliation in a Specialty Care Setting

Discrepancies in medication documentation most often occur at handoffs or transition points in care. A process improvement team at the Portland Department of Veterans Affairs developed a standardized medication reconciliation process for the Portland chemotherapy administration unit, a physically self-contained clinic with a standard intake process and a uniform patient traffic pattern. The team developed the automated patient history intake device (APHID), a reconciliation software program accessed by the patient using a computer terminal kiosk in the clinic lobby. The program simultaneously checks in patients for an appointment and gathers a medication-adherence history by retrieving medication lists from all Veterans Affairs facilities and pairing each medication with a pill picture. Installation of the APHID kiosk included an initial two-week roll-in period beginning in February 2008. During the roll-in period, 91 (82.0%) of 111 patients completed check-in and performed medication reconciliation using the kiosk. Medication lists gathered at the kiosk were compared with existing health record documentation and clinician interviews. For each patient encounter, the process demonstrated an average of 4.59 discrepancies and an average of 1.61 clinically significant or potentially lethal discrepancies. The new process saved approximately 0.24 full-time equivalents of nursing time in the chemotherapy clinic-a nearly 50% reduction in nursing time dedicated to reconciliation activities without an apparent loss in data accuracy. A patient-centered reconciliation model using consumer-based kiosk technology helped providers efficiently retrieve a comprehensive list of medications across a geographically diverse area and improve patient medication recall using visual cues including medication pictures.

Implementing Online Medication Reconciliation at a Large Academic Medical Center

Most examples of successful medication reconciliation (MR) programs have reported on paper-based systems, the most common of which is a standardized MR form that often serves as a medication order form. An interdisciplinary process was undertaken by Bellevue Hospital, New York City, to develop a full, online MR program. PHASE 1. MOVING BEYOND PAPER: In 2005 Bellevue piloted a paper-based MR process. However, this effort was unsuccessful, so an online MR application that would be more accessible and easier to audit was initiated. The longitudinal outpatient medication list--the definitive, electronic medication list for patients in our system--formed the basis of the MR project. The list included every prescription written in the electronic health record (EHR). Historical medication could also be entered into the list, representing a useful function in the outpatient setting for patients who transfer their care to Bellevue and are already on chronic medications. In a two-month pilot in Summer 2006, compliance was achieved for only 20% of patients. PHASE 2. In April 2007, MR was made a mandatory part of the admission process; a blocking function in the EHR prevented medication orders if the admission MR had not been completed. Compliance rates subsequently increased to 90% throughout the hospital. To "close the loop" in the reconciliation process, in November 2007, a discharge reconciliation was made a mandatory part of the discharge process, resulting in 95% compliance. Successful implementation of admission and discharge MR suggested several lessons, including (1) mandatory functionality leads to adaptation and integration of MR into housestaff work flows and (2) an electronic MR is preferable to a paper-based process in organizations with an EHR and computerized physician order entry.