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Patient Education and Staff Training Significantly Improves Medication Reconciliation in Outpatient Clinics


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Summary

Mayo Clinic researchers developed a medication reconciliation intervention program for outpatient primary care settings that improved the accuracy of medication lists in the practice's electronic medical records relative to patient reports of actual prescription and nonprescription drugs and supplements used. The intervention included communicating with patients so that they were better prepared to provide information about their medications at the time of the visit, as well as educating providers on the importance of medication reconciliation and methods to improve documentation through patient–provider collaboration. The intervention significantly reduced the frequency of instances when a medication list was completely absent from the medical record (from 26 to 6 percent) and the prevalence of medication discrepancies, which fell by more than 50 percent.

Evidence Rating (What is this?)

Moderate: The evidence rating is based on a nonrandomized before and after comparative study.
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Developing Organizations

Mayo Clinic
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Use By Other Organizations

  • Several other primary and specialty care practices affiliated with Mayo Clinic have adapted this intervention with modifications to accommodate their clinic flow processes. Their experience suggests that this outpatient medication reconciliation is relatively easily transferred to other primary and specialty care clinic settings. Since September 2005, all providers at Mayo Clinic are expected to demonstrate competence in an interactive, Web-based module detailing the medication reconciliation process. Most outpatient clinics now have clinical assistants or licensed practical nurses who assist with the medication history intake process in collaboration with patients. Mayo is also in the process of implementing the electronic tools that will enhance the process and standardize the medication reconciliation process in several outpatient clinics.

Date First Implemented

2005

Problem Addressed

With the increasing age of the patient population, increased use of multiple medications from multiple providers, the similarity of many pharmaceutical names, and growing evidence that some patients do not understand dosing and other medication changes made by their physicians, there are ample opportunities for medication errors in the outpatient setting. Medication reconciliation is a proven process in the inpatient setting for identifying the most accurate list of all medications a patient takes, including the drug name, dosage, frequency, and route (e.g., oral, injection) of each medication, but it is not as widely implemented in the outpatient setting.
  • Medication errors are common and costly: The hospital costs related to adverse drug events is estimated to be about $3.8 million per hospital per year, about $1 million of which is preventable.1,2
  • Poor communication and documentation causes many errors: 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
  • Medication reconciliation can help: The Institute for Health Care Improvement has called on organizations to perform medication reconciliation as part of its 100,000 Lives Campaign, and all institutions are required to have a medication reconciliation process to ensure accurate drug consumption is in place. At the time of the study, there had not been a published systematic study of outpatient medication reconciliation and effective interventions to improve reconciliation. Most of the reported research and improvements in medication reconciliation have been done on hospitalized patients.

What They Did

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Description of the Innovative Activity

In this pilot intervention study, preventive medicine clinicians at Mayo Clinic monitored and cross-checked medications, including over-the-counter (OTC) drugs and herbal supplements, taken by adult patients treated at an outpatient clinic. The research team reminded patients before their appointments to bring in a complete and accurate medication list. This list was checked against the patients' electronic medical record (EMR) for accuracy. The patients' clinicians received reports about medication discrepancies and received training on the importance of medication reconciliation. The intervention included these key steps:

Before the Patient Visit
  • Reminder letter: After a patient makes an appointment, a receptionist or other designated team member mails the patient a reminder letter 1 week before the appointment. A portion of that letter asks the patient to bring in all medication bottles or an updated medication list, including prescription medications, OTC drugs, and herbal supplements, including the dosage taken, route, and frequency.
In the pilot program, office staff members printed a list of all of the patient's documented medications from the EMR, including dose, route, and frequency. Each drug has a yes or no check box beside it, including the question, "Are you taking the medication as prescribed?" The form also prompts the patient to list OTC medications and supplements and new medications in the event a specialist or other health care provider has prescribed something that has not yet been documented in the patient's EMR.

During the Office Visit

In the pilot program:
  • Patient review of list: On arrival, the receptionist or nurse gives the patient the medication list printout from the EMR. The patient is asked to verify the information (e.g., dosage) by checking the boxes (alternatively, a nurse or physician can review the list with the patient during the visit) and is asked about additional medications or supplements.
  • Updating the EMR list: A nurse or a pharmacist performs the "medication audit," comparing the patient's updated medication list with the EMR list. The provider reviews the patient's medication list, addresses any discrepancies, and makes corrections in the EMR list as needed.
  • New medication list: A new medication list is created in the patient's EMR, incorporating the changes and any new drugs. A copy can be given to the patient.
In the new program:
  • Review of list: The physician assistant meets with the patient and verifies the information (e.g., dosage, names of medications). Changes are made as necessary into a medication repository.
  • Updating the EMR list: When the patient meets with the physician, they discuss the list and the doctor makes changes directly into the medication repository, which is part of the EMR. The new list can be printed and given to the patient.
Provider Training and Feedback

In the pilot program:
  • Education and initial training: A physician provided academic detailing for providers during the initial pilot, with a typical one-on-one visit lasting 15 minutes. Providers receive one-on-one education about the importance of medication reconciliation, along with periodic reports on their reconciliation performance during the initial pilot.
  • Ongoing performance feedback: After the initial training, audits of medication reconciliation performance are performed weekly by nurses or pharmacists. Providers receive information via e-mail about their performance compared with that of their peers, along with examples of their errors for instructional purposes.
In the new program:
  • Education and initial training: A clinic-wide training program was implemented of all concerned providers and stakeholders.

Context of the Innovation

At the time of this study, Mayo Clinic's Division of Preventive, Occupational, and Aerospace Medicine had researched and developed enhanced medication reconciliation processes for its hospitals and academic hospital centers. That research revealed the following:
  • A multidisciplinary approach, including the participation of nurses, pharmacists, and doctors, was needed to create an effective medication reconciliation process and reduce medication errors in the hospital.
  • The patient's ability to produce an accurate list, which included drug, dosage, and routes, was essential to effective medication reconciliation.
  • Initial rapid feedback and reporting of medication errors was critical to reduce medication reconciliation errors and elicit buy-in and ongoing commitment to medication reconciliation from all the pilot clinic's medical team members.
  • The intervention processes for inpatient medication reconciliation that Mayo developed virtually eliminated medication inaccuracies at patient admission (which previously averaged 0.5 inaccuracies per patient) and significantly reduced inaccuracies at patient discharge, from 3.3 to 1.8 per patient.
After developing medication reconciliation quality improvement processes for inpatient settings, Mayo researchers realized that a systematic study and intervention process for outpatient settings was needed. Once outpatients receive a prescription, there are few connections back to the health care system to verify the accuracy of the drug, dose, and route. Using what they had learned from their inpatient research, the Mayo team designed and tested this medication reconciliation intervention process at one of their outpatient clinics that served a general patient population.

Did It Work?

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Results

The medication reconciliation program significantly reduced the frequency of missing medication lists and medication documentation discrepancies. A 2-month pilot study comparing the intervention with a control group found that the frequency of absent medication lists (from the medical record) fell from 26 to 6 percent. In addition, medication documentation discrepancies fell by more than 50 percent. Based on this success, the Mayo Clinic has decided to continue using this approach. More specific results are documented below:
  • Improved patient reporting: Patient reporting on their medications was much better in the intervention group than in the control group, suggesting that the reminder letters and other patient-related activities were effective. For example:
    • Patient compliance with instructions: Five percent of the control group patients brought in their medication bottles or an updated medication list to their office visit, compared with 52 percent of patients in the intervention group who had received the preappointment reminders.
    • Unreported herbal and OTC medications: 76.2 percent of control group visits identified an unreported herbal and OTC medication, compared with just 33.7 percent of intervention group visits, suggesting that direct questioning of the patient about these medications was effective.
  • Fewer medication discrepancies: The intervention significantly reduced medication discrepancies that frequently lead to medication errors. For example:
    • Prescription medications: 88.9 percent of control group medication lists had discrepancies, compared with just 66 percent in the intervention group lists.
    • Herbal and OTC medications: 76.2 percent of the control group had discrepancies relating to herbal and OTC medications, compared with just 33.7 percent in the intervention group.
    • All medications: Discrepancies occurred in 88.5 percent of the control group, compared with just 49.1 percent in the intervention group. The majority of the errors were related to incorrect or missing medication routes.
    • Provider documentation: The health care provider's documented medication list contained only 47.3 percent of patients' reported medications in the control group, compared with 92.6 percent in the intervention group.

Evidence Rating (What is this?)

Moderate: The evidence rating is based on a nonrandomized before and after comparative study.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Mapping the patient process: Researchers mapped the patient experience through an outpatient clinic to see where there were opportunities to collect the most accurate list of patient medications and compare that list with the patient's EMR.
  • Modifying the process: Based on this map, researchers sought to modify the process by getting buy-in from stakeholders, training medical staff about the importance of medication reconciliation, and educating patients about the need for them to participate to achieve the goal of improved medication reconciliation.
  • Developing definitions of medication accuracy and errors: A medication list was deemed complete if every medication in the list was described by name, dose, route, and frequency (e.g., Coumadin, 4 mg by mouth once daily). It was also considered accurate if there was no discrepancy between the EMR medication list and the medications the patient reported taking. Medication errors due to inadequate reconciliation included any discrepancies in accuracy or completeness.

Resources Used and Skills Needed

  • Administrative staffing: Administrative staff would add the medication list to the reminder calls, e-mails, or letters sent to patients before visits, based on what format worked best with the patient population. This should add no additional time to the existing reminder process. An administrative staff person could copy and paste the patient's medication list from his or her EMR onto the review sheet for the patient to review. If using hardcopy files, the staff person would photocopy the medication list for the patient to review. This could take approximately 2 hours per 75 patients, according to Mayo estimates.
  • Nurse/pharmacist: A nurse or pharmacist could perform the actual medication audits and then provide them to the physician champion to review and provide academic detailing.
  • Physicians/quality improvement advocate: Innovators estimate the champion or lead person would spend an initial half-hour or hour with the entire practice to review the project and explain medication reconciliation goals. The physicians would gather once to review initial results of the audit and discuss ways to improve medication reconciliation.
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Funding Sources

Mayo Clinic
The bulk of the funding was internal.end fs

Tools and Other Resources

The innovator is willing to provide reminder medication letters used by the clinic with other organizations free of charge. Sample reminder letters and measures used can be found in Varkey P, Cunningham J, Bisping S. Improving medication reconciliation in the outpatient setting. Jt Comm J Qual Patient Saf. 2007;33(5):286-92. [PubMed] Available at: http://www.ingentaconnect.com/content/jcaho/jcjqs/2007/00000033/00000005/art00005

Adoption Considerations

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Getting Started with This Innovation

For the pilot:
  • Identify champions: One or more physicians, nurses, and/or patient safety advocates are needed to promote and manage the intervention.
  • Assign responsibilities to appropriate individuals: Identify who within the practice will monitor medication lists, identify discrepancies, and issue medication reconciliation reports. Identify how often reviews will take place and the content of the initial medication reconciliation awareness training. Identify who will do academic detailing with providers.
  • Map the patient flow within the practice: Examine how medical history is gathered and where processes can be tweaked to enhance the medication reconciliation process. For example, clinics that serve immigrants or non-English speakers can ask patients to bring in medication bottles, instead of relying on verbal descriptions or prompts from a written medication list. Previsit reminders to bring in medication bottles may be more effective by phone or e-mail, depending on the patient population being served.
  • Determine when and who should review medications with the patient: The most effective time and method for reviewing the medication list may vary by practice. In some cases, a nurse may be best suited to perform the task; whereas, in others, a physician may be more appropriate. A different process may be appropriate for at-risk patients who are older, have more than one chronic condition, see numerous specialists, or take multiple medications.
  • Educate patients: The patient is a valuable team member in the effort to achieve an accurate medication list. Educational initiatives are needed to stress that maintaining an accurate medication list and taking the medications as prescribed are critical to ensuring high-quality care in a safe environment. It is especially important to educate patients to inform their health care team if they are taking OTC medications or herbal supplements, so that these can be accurately recorded in the medical record. Patients need to understand that this process will be more efficient and accurate if they bring in their medication bottles or most current medication list.
  • Consider alternate inquiry formats: Use of medication cards and/or nurse- or software-aided collection of medication lists from patients before visits are options, based on the documentation systems available in the practice.
  • Review medication reconciliation with transcriptionists: About 8.2 percent of the errors in the medication list occur at the time of transcription.4 To eliminate these types of errors, transcription staff should be trained, especially on medications that sound alike, and communication about discrepancies needs to be enhanced and clarified.

Sustaining This Innovation

  • Continually refine the process: Once established, the patient reminder, medication review, and education process should continue with modifications and improvements as needed to improve effectiveness and promote patient awareness.
  • Continue to monitor and provide feedback: The audits and provider training and feedback should continue on some basis to sustain improvement. At Mayo, quarterly reports are provided to division leaders.

Use By Other Organizations

  • Several other primary and specialty care practices affiliated with Mayo Clinic have adapted this intervention with modifications to accommodate their clinic flow processes. Their experience suggests that this outpatient medication reconciliation is relatively easily transferred to other primary and specialty care clinic settings. Since September 2005, all providers at Mayo Clinic are expected to demonstrate competence in an interactive, Web-based module detailing the medication reconciliation process. Most outpatient clinics now have clinical assistants or licensed practical nurses who assist with the medication history intake process in collaboration with patients. Mayo is also in the process of implementing the electronic tools that will enhance the process and standardize the medication reconciliation process in several outpatient clinics.

Additional Considerations

  • Use EMR lists to jog memories for noncompliant patients: Despite reminder letters, some patients still forget to bring in medication bottles or lists. Researchers found that having patients respond to a list of their medications copied from their EMRs was a powerful trigger that elicited a fairly accurate medication list.
  • More refinements in outpatient medication reconciliation systems are still needed: Although there was a statistically significant decrease in discrepancies, researchers believe that additional outpatient system redesigns that can accommodate the unique nature of individual practices and their patients are urgently needed.
  • Additional research needed: Mayo researchers believe that additional research is needed to study the long-term sustainability of this intervention and to develop a validated measurement tool to monitor medication errors and adverse events arising from inadequate medication reconciliation in outpatient clinics. Researchers also note the need for a method to assess the cost-effectiveness of the interventions and of electronic tools to facilitate medication reconciliation.

More Information

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References/Related Articles

A medication reconciliation review tool is available from the Institute for Healthcare Improvement online at http://www.ihi.org/explore/ADEsMedicationReconciliation/Pages/default.aspx.

Varkey P, Cunningham J, Bisping S. Improving medication reconciliation in the outpatient setting. Jt Comm J Qual Patient Saf. 2007;33(5):286-92. [PubMed] Available at: http://www.ingentaconnect.com/content/jcaho/jcjqs/2007/00000033/00000005/art00005

Varkey P, Cunningham J, O'Meara J, et al. Multidisciplinary approach to inpatient medication reconciliation in an academic setting. Am J Health Syst Pharm. 2007;64(8):850-4. [PubMed]

Pronovost P, Weast B, Schwarz M, et al. Medication reconciliation: a practical tool to reduce the risk of medication errors. J Crit Care. 2003;18(4):201-5. [PubMed]

Overhage JM, Lukes A. Practical, reliable, comprehensive method for characterizing pharmacists’ clinical activities. Am J Health Sys Pharm. 1999;56(23):2444–50. [PubMed]

Varkey P, Resar R. Medication reconciliation implementation in an academic center. Am J Med Qual. 2006;21(5):293-5. [PubMed]

Footnotes

1 Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. Adverse Drug Events Prevention Study Group. JAMA. 1997;277:307-11. [PubMed]
2 Classen DC, Pestotnik SL, Evans RS, et al. Adverse drug events in hospitalized patients: excess length of stay, extra costs, and attributable mortality. JAMA. 1997;277:301-6. [PubMed]
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. [PubMed]
4 Wagner MM, Hogan WR. The accuracy of medication data in an outpatient electronic medical record. J Am Med Inform Assoc. 1996;3(3):234-44. [PubMed]
Comment on this Innovation

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: April 14, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: May 07, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: February 11, 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.

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