Case Objectives

• Appreciate the prevalence and impact of medication discrepancies at times of transition in the health care system.
• List barriers to successful medication reconciliation.
• Understand best practices for reconciling medications.

Case & Commentary: Part 1

A woman with a history of seizures was scheduled for repair of a prolapsed rectum. A consultation prior to surgery listed her home medication as "Neurontin 250 mg." When admitted for surgery, the patient reported to the anesthesiologist that she took Zarontin (ethosuximide) 250 mg twice daily. This was recorded on her preanesthesia care record where another entry for Neurontin had been entered and crossed out. The admitting history and physical note listed her current medications as "See her list." Postoperatively, the patient was prescribed Neurontin (gabapentin) 250 mg twice daily.

Hospital admissions and discharges are complex events, characterized by multiple handoffs among health care providers and numerous changes to the patient's therapeutic plan. The intended medication regimen before, during, and after the hospital stay often becomes a point of confusion for patients and clinicians during care transition points across the hospital and outpatient settings. Much of this confusion is fueled by multiple changes to medication regimens (1), discontinuity of care (2), short hospitalizations, and inadequate patient education.(3,4) Recent research strongly suggests that such confusion is a major cause of medication errors and adverse drug events (ADEs).(5-9) A recent systematic review on errors in medication history at admission estimated that 54%–67% of all admitted patients have at least one discrepancy between the medication history obtained by the admitting clinicians and the actual preadmission regimen and that, in 27%–59% of those cases, such discrepancies have the potential to cause harm.(10-12) A study of hospitalization-related ADEs also found that medication discrepancy was the most common drug-related problem at the time of discharge and the cause of half of all preventable ADEs 30 days after discharge.(13)

Discrepancies such as the one illustrated by this case can be prevented through a process commonly known as medication reconciliation. As defined by the Institute for Healthcare Improvement (IHI), medication reconciliation is a process of identifying the most accurate list of all medications a patient is taking—including name, dosage, frequency, and route—and using this list to provide correct medications for patients anywhere within the health care system. For patients admitted to a hospital, this process involves comparing the patient's current list of medications against the physician's admission, transfer, and/or discharge orders.(14)

Given the patient safety risk posed by medication discrepancies during transitions of care, leading patient safety organizations, such as IHI and the Massachusetts Coalition for the Prevention of Medical Errors, have developed recommendations and tools to help health care organizations build robust medication reconciliation processes.(14,15) The Joint Commission's recent mandate for all health care organizations to "accurately and completely reconcile medications across the continuum of care" has heightened interest in this important patient safety issue and has spurred many hospitals to design and implement reliable and efficient medication reconciliation systems.(16)

Case & Commentary: Part 2

When the order for gabapentin 250 mg twice daily was received in the pharmacy, it was entered as "gabapentin liquid" (gabapentin is not available in tablet/capsule strengths that would allow a 250-mg dose). The pharmacist dispensed gabapentin liquid 250 mg/5 mL with a note in the pharmacy computer record to indicate "dispense size = 120 mL." This comment was necessary so that the pharmacy would know how much was dispensed. This comment also appeared on the prescription label and in the electronic medication administration record (EMAR). The hospital had recently implemented a new EMAR system, and there was no way to suppress this information from appearing on the EMAR. The nurse caring for the patient misinterpreted the EMAR and gave an excessive amount of the gabapentin liquid on two consecutive evenings (the exact amount was not documented). The patient told the nurse that the amount of medicine given seemed to be more than she was accustomed to taking. Shortly thereafter, the patient became lethargic and could not walk. The pharmacist determined that the gabapentin liquid had been refilled earlier than expected and that an overdose had occurred. Although the overdosage was noted at the time, the administration of the incorrect drug (Neurontin, instead of Zarontin) was not recognized until several weeks later when the event was investigated in more detail.

While the goals of medication reconciliation are simple, efforts by hospitals nationwide to address this issue have uncovered daunting challenges.(17) Health care providers are often asked to piece together an accurate medication history using information from multiple and often imperfect sources, including the patient, his/her caregiver, the primary care physician, medical specialists, outpatient medical records, hospital discharge summaries, and community pharmacies. In addition, each of the major disciplines involved, including physicians, nurses, and pharmacists, often have divergent expectations about who is responsible for reconciling medications at various phases of the patient's care and how that should be done. This uncoordinated set of reconciliation activities often leads to either unnecessary redundancy or failure to share key clinical information.

These challenges are well illustrated in this case. First, the preoperative consultant sowed the seeds of this adverse event by obtaining the wrong preadmission medication list (PAML) from the patient. The consultant also failed to verify the medication history; he did not contact the patient's PCP, neurologist, or pharmacist, nor did he attempt to access the patient's outpatient medical record or pharmacy dispensing record. Second, although the medication history was later corrected by the anesthesiologist, the clinician responsible for writing the patient's inpatient medication orders was not alerted about the correction, thus allowing the preoperative consultant's error to propagate from the outpatient to the inpatient setting. Third, the admitting physician and nurse failed to review the anesthesiology records or reconfirm the patient's PAML with the patient, allowing them to miss additional opportunities to correct the error. Fourth, it is likely that the amended medication list generated by the anesthesiologist was not available to the pharmacist, making it impossible for the pharmacist to compare the admission orders against the patient's PAML. Fifth, both the ordering physician and the dispensing pharmacist blindly trusted the information passed on to them from another clinical colleague, failed to question the unusual dose of Neurontin, and, as a result, missed at least two other opportunities to avert the adverse event.

How might adverse events like the one seen in this case be prevented? While other strategies, such as the use of unit dosing, barcode scanning during medication administration, and better naming conventions to prevent mix-ups between "sound-alike" pharmaceuticals, hold significant promise, the multitude of errors involved in the medication reconciliation process points to the need to re-engineer the process itself. As the best practices for reconciling medications are being defined on the front lines, several common themes have emerged from learning collaboratives (14,15,17) and published literature (7,18,19):

• Given the number of disciplines involved in the medication-use process, a robust medication reconciliation process should include participation by physicians, nurses, and pharmacists.
• The process for medication reconciliation must be clearly defined by a multidisciplinary team, and responsibilities for each component of the process must be assigned to the parties involved. For example, the Figure illustrates a sample medication reconciliation process for surgical patients who are seen by nurse practitioners in the preoperative evaluation center before the surgery and are subsequently admitted into the hospital.(20) Once defined, the process needs to be validated with other front-line clinicians.
• Implementers of the medication reconciliation process need to recognize that no single universal process will meet the needs of all patients entering a hospital, and that a limited number of different processes will need to be developed, depending on the patient population and patients' point of entry into the hospital.
• Implementers should understand that successful implementation of the process will require significant training, education, and support from clinical leaders. Willingness to engage in continuous improvement and monitoring for compliance are likely success factors for a multidisciplinary team.
• Implementers should expect to encounter resistance to the process by staff, because in many cases, staff will be asked to take on tasks that should have been done but were previously done incompletely (or not at all) due to the lack of time (e.g., asking the admitting physician to obtain an accurate medication history). Implementers should stand ready to articulate the safety benefits of the new process and to emphasize that understanding the patient's medication history is part of good care.
• Patients should be leveraged as a resource in the medication reconciliation process, especially since they stand to gain the most from a safe medication-use process. Patients and families should be encouraged to keep an up-to-date list of medications. They should also understand why they take each of the medications as well as why medication changes occur. In turn, the medical staff should ensure that during the discharge process patients are appropriately educated about any changes in medication regimen.

Using the aforementioned principles, many organizations have begun to experience success.(7,18,19) In addition, as hospitals nationwide tackle this problem, novel approaches have emerged. One such approach involves the use of information technology to facilitate the process of medication reconciliation. Specifically, for health care systems that have access to reliable sources of patients' medication history in electronic format, an electronic tool could facilitate the verification of the patient's medication history and construction of the PAML. Moreover, once verified, the electronic PAML could be shared across multiple disciplines and inform the decision making of physicians, nurses, and pharmacists during the admission and discharge processes. For hospitals that have computerized physician order entry (CPOE) systems, the electronic PAML can also be used to facilitate the ordering of inpatient medications during admission and construction of the posthospitalization medication list during discharge.(20) Hospitals are exploring this approach to increase the reliability and decrease the time burden of the medication reconciliation process. However, this approach, while promising, has not been fully evaluated to determine its effectiveness and cost-effectiveness. Furthermore, as we have learned about the limitations of information technology in other health care contexts, we need to understand that no amount of technology can obviate the need to design a reliable process or secure buy-in from front-line clinicians.

Take-Home Points

• Failure to reconcile medications during transitions of care accounts for many preventable adverse events.
• To design a robust medication reconciliation process, first define steps involved and decide who should be responsible for each step.
• A reliable medication reconciliation system requires a multidisciplinary approach, often with the participation of physicians, nurses, and pharmacists across the continuum of care.
• A one-size-fits-all approach is unlikely to work, even within one hospital.
• Information technology can facilitate medication reconciliation if it is devised to support a well-designed process.

Eric G. Poon, MD, MPH Assistant Professor of Medicine, Harvard Medical School Division of General Medicine and Primary Care, Brigham and Women's Hospital

Faculty Disclosure: Dr. Poon has received research funding from the Agency for Healthcare Research and Quality. The commentary does not include information regarding investigational or off-label use of products or devices. All conflicts of interest have been resolved in accordance with the ACCME Updated Standards for commercial support.

References

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2. Kripalani S. Best practices in communication after hospital discharge. Operational track lecture presented at: Annual Meeting of the Society of Hospital Medicine; April 19–21, 2004; New Orleans, Louisiana. http://www.hospitalmedicine.org/AM/Template.cfm?Section=SHM_Presentations&Template=/CM/ ContentDisplay.cfm&ContentFileID=1779

3. Alibhai SM, Han RK, Naglie G. Medication education of acutely hospitalized older patients. J Gen Intern Med. 1999;14:610-616. [go to PubMed]

4. Calkins DR, Davis RB, Reiley P, et al. Patient-physician communication at hospital discharge and patients' understanding of the postdischarge treatment plan. Arch Intern Med. 1997;157:1026-1030. [go to PubMed]

5. Forster AJ, Murff HJ, Peterson JF, et al. The incidence and severity of adverse events affecting patients after discharge from hospitals. Ann Intern Med. 2003;138:161-167. [go to PubMed]

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8. Tam VC, Knowles SR, Cornish PL, et al. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. CMAJ. 2005;173:510-515. [go to PubMed]

9. Coleman EA, Smith JD, Raha D, et al. Posthospital medication discrepancies: prevalence and contributing factors. Arch Intern Med. 2005;165:1842-1847. [go to PubMed]

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11. Gleason KM, Groszek JM, Sullivan C, et al. Reconciliation of discrepancies in medication histories and admission orders of newly hospitalized patients. Am J Health Syst Pharm. 2004;61:1689-1695. [go to PubMed]

12. Akwagyriam I, Goodyer LI, Harding L, et al. Drug history taking and the identification of drug related problems in an accident and emergency department. J Accid Emerg Med. 1996;13:166-168. [go to PubMed]

13. Schnipper JL, Kirwin JL, Cotugno MC, et al. Role of pharmacist counseling in preventing adverse drug events after hospitalization. Arch Intern Med. 2006;166:565-571. [go to PubMed]

14. Institute for Healthcare Improvement. Getting started kit: prevent adverse drug events (medication reconciliation) how-to guide. Available at: http://www.ihi.org/IHI/Programs/Campaign/Campaign.htm?TabId=2 - PreventAdverseDrugEvents. Accessed August 7, 2007.

15. Massachusetts Coalition for Prevention of Medical Errors. Reconciling medications: recommended practices. Available at: http://www.macoalition.org/documents/RecMedPractices.pdf. Accessed August 7, 2007.

16. Joint Commission. 2006 Critical access hospital and hospital national patient safety goals. Available at: http://www.jointcommission.org/PatientSafety/ NationalPatientSafetyGoals/06_npsg_cah.htm. Accessed August 7, 2007.

17. Practitioners agree on medication reconciliation value, but frustration and difficulties abound. ISMP Medication Safety Alert! Acute Care Edition. July 13, 2006. Available at: http://www.ismp.org/Newsletters/acutecare/ articles/20060713.asp. Accessed August 7, 2007.

18. Michels RD, Meisel SB. Program using pharmacy technicians to obtain medication histories. Am J Health Syst Pharm. 2003;60:1982-1986. [go to PubMed]

19. Whittington J, Cohen H. OSF healthcare's journey in patient safety. Qual Manag Health Care. 2004;13:53-59. [go to PubMed]

20. Poon EG, Blumefeld B, Hamann C, et al. Design and implementation of an application and associated services to support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network. J Am Med Inform Assoc. 2006;13:581-592. [go to PubMed]

Figure

Figure. Sample cross-functional flow chart, defining the responsibilities for medication reconciliation for elective surgical patients. Reprinted with permission from Elsevier. In: Poon EG, Blumefeld B, Hamann C, et al. Design and implementation of an application and associated services to support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network. J Am Med Inform Assoc. 2006;13:581-592.

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