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Medication Reconciliation Process Results in Anecdotal Reports of Improved Safety in Inpatient Setting


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Snapshot

Summary

Onslow Memorial Hospital implemented a medication reconciliation process, the cornerstone of which is a one-page structured form that nurses, physicians, and pharmacists use to list all medications taken by the patient at home. Clinicians use the form to confirm the continuation of existing medications, order newly prescribed medications, and facilitate medication reconciliation during patient transfers and at discharge. The new process and form are being widely utilized by clinicians at the hospital, and anecdotal feedback from them suggests that they have enhanced confidence in the accuracy of drug-related information and helped to improve patient safety. In addition, the number of adverse drug events has fallen, but there is no way to know the extent to which this decline is due to the medication reconciliation process.

Evidence Rating (What is this?)

Suggestive: The evidence consists of before-and-after comparisons of adherence to the medication reconciliation process and of the number of adverse drug events at the hospital, along with post-implementation anecdotes from clinicians on the reconciliation process/form. As noted, other factors besides the medication reconciliation form are likely to influence adverse drug events; Onslow will continue to track adverse drug events on an ongoing basis.
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Developing Organizations

Onslow Memorial Hospital
Jacksonville, NCend do

Use By Other Organizations

The North Carolina Center for Hospital Quality and Patient Safety led three medication reconciliation collaboratives for North Carolina hospitals between 2005 and 2008. The first collaborative included 10 hospitals, the second had 11 participants, and the third had 13 (with some overlap in participation across collaboratives). Each participating hospital developed a unique medication reconciliation process specific to its own organizational circumstances.

Date First Implemented

2006

Problem Addressed

Medication errors are a common, costly, and often preventable problem. Major national organizations, including the Institute for Healthcare Improvement (IHI) and The Joint Commission, have urged hospitals to adopt medication reconciliation processes as a strategy for reducing such errors.
  • A common, costly problem that, if unaddressed, may get worse: Medication errors injure at least 1.5 million Americans annually, costing the nation more than $3.5 billion a year.1 As the patient population ages, the problem may get worse if not addressed, due to the increased use of multiple medications from multiple providers, the similarity of many pharmaceutical names (which creates confusion among patients), and the concern that some (especially elderly) patients do not understand dosing and other medication changes made by their physicians.
  • Poor communication and documentation as a root cause: Nearly two-thirds (63 percent) of the more than 350 medication errors resulting in death or major injury that are in The Joint Commission's sentinel event database were caused primarily by breakdowns in communication.2 Experience from hundreds of organizations shows that poor communication and documentation of medical information accounts for 46 percent of all medication errors and up to 20 percent of adverse drug events in hospitals.3 Estimates suggest that up to 60 percent of patients have at least one discrepancy in their admission medication history.4
  • Medication reconciliation as a partial solution: Approximately one-half of the errors in The Joint Commission database would have been avoided through effective medication reconciliation.2 Based on this estimate and others like it, IHI, as part of its 100,000 Lives Campaign, has called on organizations to perform medication reconciliation, while The Joint Commission made adoption of medication reconciliation processes one of its 2006 National Patient Safety Goals.5

What They Did

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Description of the Innovative Activity

Onslow Memorial Hospital implemented a medication reconciliation process, the cornerstone of which began as a one-page structured form and is now a template in the EMR, that nurses, physicians, and pharmacists use to list all medications taken by the patient at home, confirm the continuation of existing medications, order newly prescribed medications, and facilitate medication reconciliation during patient transfers and at discharge. Key elements of the process include the following:
  • Initial medication assessment: As part of the initial assessment of all newly admitted patients, the nurse interviews the patient to gather information on the medications that he or she takes at home. When patients are unsure of their medications or medication names, the nurse talks to family members, pharmacists, and the patient's physicians to create a complete and accurate list.
  • Completion of medication reconciliation form: Based on the information gathered during the assessment, the nurse lists all the patient's current medications on a structured medication reconciliation template that includes the following information:
    • Medication name, dose, route, frequency, indications, and last dose taken (including the opportunity to address vitamins/supplements or herbal products)
    • Drug allergies
    • Patient height and weight
    • Disposition of any patient medications brought to the hospital (i.e., sent home or kept and stored in a listed location)
  • Decision to continue/discontinue medications: Within 24 hours of patient admission, the physician reviews the medication reconciliation list in conjunction with the nurse. The physician uses the template, which also serves as an order form, to indicate whether each home medication should be continued during the patient's hospital stay. The physician also adds orders for new medications required as part of inpatient care. The physician then transmits this to the pharmacy for further medication reconciliation.
  • Pharmacy review and dispensing: The pharmacist receives the transmission, checks for drug interactions and contraindications (contacting the physician for clarification if any are identified), and dispenses the medications.
  • Creation of active drug profile: The pharmacist creates the patient's active drug profile, which is maintained in the pharmacy's electronic system during the inpatient stay. A printed copy can be made available by the unit nurse for inclusion in the patient chart or addressed electronically by the provider.
  • Additional dispensing and updating: If the physician sends an order for additional medications during the patient stay, the pharmacist again checks for interactions, contraindications, and duplications; dispenses the medications as appropriate; and adds the new medications to the active drug profile.
  • Ongoing reconciliation, including at transfers: Clinicians can review the medication reconciliation list and the active drug profile at any time during the patient's hospitalization. At a minimum, medication reconciliation occurs at every patient transfer (e.g., from the postoperative care unit to the floor unit), with a receiving unit nurse can generate the active patient drug profile for review with the physician, who indicates whether or not to continue each medication. This can be addressed electronically by the provider.
  • Reconciliation at discharge: The nurse includes the active patient drug profile in the patient's discharge plan. The physician reviews the profile and confirms medications to be taken by the patient after discharge.
  • Electronic medical record (EMR) adoption: With the implementation of the EMR in October 2011, the EMR has allowed for a more efficient review of medications (for example, providers can view the home medications entered on previous visits, and do not need to reenter medications). The final phase of EMR implementation involves 100% computerized physician order entry.

Context of the Innovation

Onslow Memorial Hospital is a 162-bed, not-for-profit community hospital in Jacksonville, NC, that handles more than 47,000 emergency department (ED) visits and approximately 8,000 inpatient admissions annually. The development of the hospital's medication reconciliation process was spurred by the release of The Joint Commission's 2006 National Patient Safety Goals, which mandated that hospitals adhere to its standards for medication reconciliation at admission, transfer, and discharge by January 2006. After developing the initial medication reconciliation process and form and implementing them by this deadline, Onslow joined one of three collaboratives sponsored by the North Carolina Center for Hospital Quality and Patient Safety in partnership with other organizations. Known as the North Carolina 2007 Medication Reconciliation Collaborative, this year-long initiative included 13 hospitals from eastern North Carolina. The collaborative helped Onslow to further refine and improve the program. (See the next section for more details.)

Did It Work?

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Results

The medication reconciliation process and form have been widely utilized by clinicians at the hospital, and anecdotal feedback suggests that the process and form have enhanced confidence in the accuracy of drug-related information and helped to improve patient safety. In addition, the number of adverse drug events has decreased over time, but there is no way to know the extent to which this decline is due to the medication reconciliation process (because the hospital has launched multiple initiatives to address adverse drug events).
  • Widespread adherence: Overall adherence to the medication reconciliation process increased from approximately 70 to 80 percent when the program was first implemented in January 2007 to 90 percent in June 2008. ("Nonadherence" can be defined in several ways, including instances when the form was completed but not within 24 hours of admission and occasions when the form was sent to the pharmacy before physician review.) Information provided in December 2013 indicates that adherence rates through third quarter third quarter 2013 were 94.5 percent for admissions, 93.3 percent for transfers; and 93 percent at point of discharge.
  • Positive anecdotal feedback, suggesting improved safety: Anecdotal feedback from physicians and nurses indicate that the reconciliation process and form have enabled them to identify and prevent potential problems with medication orders (including duplicative orders and drug–drug interactions), thereby saving patients from harm. Clinicians also note that the form helps them visualize and understand the patient's total medication regimen.
  • Fewer adverse drug events: The medication reconciliation process and form contributed to a decline in adverse drug events (no data available), particularly due to reconciliation during the admission process.

Evidence Rating (What is this?)

Suggestive: The evidence consists of before-and-after comparisons of adherence to the medication reconciliation process and of the number of adverse drug events at the hospital, along with post-implementation anecdotes from clinicians on the reconciliation process/form. As noted, other factors besides the medication reconciliation form are likely to influence adverse drug events; Onslow will continue to track adverse drug events on an ongoing basis.

How They Did It

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Planning and Development Process

Key elements of the planning and development process included the following:
  • Initial development of process and form: In 2005, a multidisciplinary team that consisted of a physician champion, the director of education (now the chief nursing officer), an ED representative, medical–surgical unit frontline staff, the director of pharmacy, and staff from the performance improvement department met monthly to design the medication reconciliation form and process. The team identified sample forms through research and adapted them to fit the care process at Onslow.
  • Clinician education: Team representatives, led by the physician champion, made presentations at unit and department meetings to highlight the new process, including the purpose and use of the form. In addition, because some physicians who admit patients do not attend these meetings, team representatives visited physician offices to provide education about the new process and form. Similar educational initiatives were also incorporated into the hospital's nursing internship.
  • Program launch: The hospital began using the new process and form in January 2006, first for patients admitted from the ED and then for all newly admitted patients.
  • Participation in collaborative: The hospital joined the aforementioned collaborative in April 2007 (the collaborative began in October 2006) to track and improve its medication reconciliation process. Using the collaborative's Medication Reconciliation Toolkit, Onslow developed an aim statement, collected medication reconciliation data via a monthly audit of 10 charts, and analyzed trends to inform the ongoing refinement of the medication reconciliation form. Onslow also worked with colleagues in the collaborative to obtain ideas for how to refine the form and process. (Note: As of November 2012, the ongoing monthly chart audit increased to 20 charts.)
  • Ongoing revisions: Based on IHI's Plan-Do-Study-Act (PDSA) cycles, the form has continually been updated and revised based on suggestions from users. For example, staff input led to the addition of a section summarizing immunizations. A PDSA cycle is currently being used to improve the form's user friendliness with respect to the patient discharge process.

Resources Used and Skills Needed

  • Staffing: The initial development and ongoing use of the process and form require no new staff, as existing staff incorporate it into their daily routines.
  • Costs: The only cost associated with this initiative was a nominal fee of $500 for joining the collaborative.
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Funding Sources

Onslow Memorial Hospital
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Tools and Other Resources

The one-page form used by Onslow Memorial Hospital is available from the program developers along with a screen shot of the EMR.

The North Carolina Center for Hospital Quality and Patient Safety offers a comprehensive medication reconciliation toolkit designed to help hospitals improve quality and safety through better medication reconciliation. The toolkit includes resources to support assessment of current practices and the development, pilot testing, and rollout of specific ideas for improvement. A number of hospitals that have used the toolkit have improved their medication reconciliation processes. The toolkit is available in the Resources section of the center's Web site at http://www.ncqualitycenter.org.

The Joint Commission's 2006 National Patient Safety Goals, which were a driver of this innovation, are no longer available online. However, updated goals for 2011 are available at http://www.jointcommission.org/patientsafety/nationalpatientsafetygoals.

The Institute for Healthcare Improvement's Medication Safety Reconciliation Toolkit is available at
http://www.ihi.org/knowledge/Pages/Tools/MedicationSafetyReconciliationToolKit.aspx.

Adoption Considerations

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Getting Started with This Innovation

  • Identify a physician champion: Enlist a physician champion to encourage other physicians to pay attention to medication history and remind them of their responsibility to prescribe appropriate medicines.
  • Encourage cross-discipline collaboration: To ensure the accuracy of information and records, encourage collaboration among all team members and hospital staff, particularly at transition points.
  • Participate in a collaborative to gather best practices: Collaboratives can be useful in the initial development and/or the ongoing refinement of the program. For example, collaborative participation enabled Onslow representatives to refine its medication reconciliation process and form based on the experiences and suggestions of colleagues.

Sustaining This Innovation

  • Emphasize ongoing importance of medication reconciliation: To maintain medication reconciliation as a "top-of-mind" issue, remind clinicians about its importance and share data about adherence with the process.
  • Continually improve the process and form: PDSA cycles can be very valuable because they encourage teams to make improvements quickly, which makes quality improvement seem less overwhelming.

Use By Other Organizations

The North Carolina Center for Hospital Quality and Patient Safety led three medication reconciliation collaboratives for North Carolina hospitals between 2005 and 2008. The first collaborative included 10 hospitals, the second had 11 participants, and the third had 13 (with some overlap in participation across collaboratives). Each participating hospital developed a unique medication reconciliation process specific to its own organizational circumstances.

Additional Considerations

Note: Onslow Memorial was surveyed by the Joint Commission in March 2012 and was found to be in full compliance with the standards.

More Information

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Contact the Innovator

Jo Malfitano DNP, MBA, RN, CPHQ, NE-BC
Performance Improvement and Accreditation Manager
Onslow Memorial Hospital
317 Western Blvd.
Jacksonville, NC 28546
Office: (910) 577-2549
Fax: (910) 577-2556
E-mail: jo.malfitano@onslow.org

Innovator Disclosures

Ms. Malfitano has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

The Joint Commission. Using medication reconciliation to prevent errors. Sentinel Event Alerts, Issue 35, Jan 25, 2006. Available at: http://www.jointcommission.org/assets/1/18/SEA_35.PDF

Footnotes

1 Institute of Medicine. Preventing Medication Errors. Washington, DC: The National Academies Press, 2007.
2 The Joint Commission. Using medication reconciliation to prevent errors. Sentinel Event Alerts, Issue 35, Jan 25, 2006. Available at: http://www.jointcommission.org/assets/1/18/SEA_35.PDF
3 Barnsteiner JH. Medication reconciliation: transfer of medication information across settings-keeping it free from error. Am J Nurs. 2005;105(3 Suppl):31-6, quiz 48-51. [PubMed]
4 Cornish PL, Knowles SR, Marchesano R, et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005;165(4):424-9. [PubMed]
5 The North Carolina Center for Hospital Quality and Patient Safety. Medication Reconciliation Toolkit. Available at: http://www.ihi.org/knowledge/Pages/Tools/MedicationSafetyReconciliationToolKit.aspx
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: June 22, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: January 15, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: December 10, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.