The Cases

Case 1. A patient receiving care at a Veterans Affairs (VA) outpatient clinic was admitted to a local teaching hospital. When discharged, he was instructed to "resume" taking torsemide, although he had never taken this powerful diuretic previously. In his first follow-up appointment with his usual physician at the VA outpatient clinic, he requested a refill of the torsemide. His medication record showed that he had been taking terazosin for benign prostatic hyperplasia prior to the hospitalization; there was no record of his being on torsemide. When questioned about it, the patient said he had told the emergency department (ED) staff that he was taking a medicine whose name started with the letter T to make him urinate. The ED staff had entered torsemide into the electronic medical record. When discharged, this came up as an at-home medication, and he was instructed to resume taking it. When he came to see his primary MD at the VA clinic requesting a medication he didn't need and hadn't taken before, the error was detected.

Case 2. At another local teaching hospital, a family had given incorrect data to the ED staff (including listing the patient as being on prednisolone rather than prednisone), and the physicians caring for the patient had simply checked off the option to continue the home medications. When the records were carefully reviewed by a physician consulting for an upcoming cardiac procedure, almost all of the medications were found to be incorrect. Had the cardiologist assumed that the other physicians and nurses had accurately entered the medications, the errors would have gone undetected, and the patient's chronic steroid dependence might have not been appropriately addressed perioperatively. Fortunately, no harm occurred.

The Commentary

Both cases illustrate medication errors related to inaccurate patient medication information. Look-alike, sound-alike medication errors (1) might be prevented by effective medication reconciliation, a process emphasized by the Joint Commission National Patient Safety Goals.(2) However, institutions continue to struggle with developing and implementing safe and reliable reconciliation processes.(3) Furthermore, documentation and perpetuation of incorrect information in electronic health records (EHRs) does not pertain only to medications. Features specific to electronic data such as auto-completion during data entry (4), copying and pasting, and use of templates that automatically import information can create significant safety issues when data is incorrect. In this commentary, we use medication reconciliation as an example to discuss several "defenses" that might mitigate errors in reconciliation of medical records.

Defense 1: EHR Interoperability

In both cases, had the inpatient and outpatient EHRs been able to "talk with" one another (system interoperability), errors might have been prevented. Technical and organizational challenges associated with achieving interoperability (both within and external to the institution) are currently being discussed in many national forums.(5)

Defense 2: Standardized Reconciliation Procedures and Practices

It is unclear whether the non-VA facilities were using any medication reconciliation procedures, which might have prevented errors by the ED and discharge team in Case 1 and the inpatient team in Case 2. To be effective, reconciliation procedures first need to be better defined and standardized.(6) For instance, based on The Joint Commission and the VA Medication Reconciliation Initiative, effective medication reconciliation involves the following tasks:

• Obtain current medication information (e.g., all medications the patient is taking, how medications are being taken, and any associated problems or adverse reactions) from patient, caregiver, and family or other relevant sources. This may be obtained by brown bag inventory, verbal history, or medication lists.
• Compare that with medication information available from the EHR or other sources such as pharmacy data, other providers, and health care institutions.
• Reconcile, amend, or update these medications along with any changes pertinent to the episode of care into one medication list that is then documented.
• Communicate this medication information to the appropriate members of the health care team (within or outside the health care institution) as well as the patient, caregiver, and family.
• Explain the importance of maintaining accurate and up-to-date medication information to the patient, caregiver, and family.

A similar approach may also be useful for reconciling other types of critical information in the EHR. Emerging evidence suggests that problem lists are often outdated and incorrect, and with extensive copying and pasting of electronic notes, information that might have been critical at one point in time may no longer be accurate or relevant.(7)

Defense 3: Appropriate Use of Both Simple and Advanced Technology

Information technology (IT)–based techniques might prevent, as well as identify, reconciliation errors. For example, several techniques are currently being used or tested to guide medication reconciliation in EHR systems.(8) These techniques mostly facilitate the process of obtaining medication information.(9) However, if medication information is erroneously documented in the first place, this misinformation can be easily perpetuated in the EHR in the absence of other defenses designed to detect such errors. One promising solution is a user-friendly kiosk that patients can use to reconcile medications before seeing their providers.(10) This kiosk interfaces with the EHR and is being evaluated at the Portland VA facility. A "Virtual Patient Coach" is another emerging technology that could potentially perform these tasks (http://www.bu.edu/fammed/projectred/meetlouise.html). Such technologies can minimize providers' cognitive burden and help measure the effectiveness of reconciliation processes (e.g., by calculating discrepancy rates).

Future EHR-based software functionalities might be able to compare two sources of information and automatically identify, track, and alert users to discrepancies.(11) Some current EHRs can highlight copied information, and some prevent injudicious use of copying and pasting.

Although advanced IT might be able to streamline reconciliation, judicious use of verbal communication remains essential. When in doubt, such as in Case 1, a verbal dialogue should be initiated with the "remote" provider.

Defense 4: A New Attitude and Culture

With EHRs, we can finally find the information that we are looking for. However, an unintended consequence includes the potential for outdated, unverified, or even inaccurate data to be transferred indefinitely. At transitions, providers must double-check medication information from patients, family members, caregivers, and other health care team members from their own or external institutions. Future medical homes (12) might be the place to obtain this information easily. Examining medication bottles ("brown bag review") and asking concrete questions, such as "tell me about all the medications you have taken in the last 24 hours," help elicit more accurate medication information from patients. Providers must also not hesitate to contact the dispensing pharmacies and use other tools such as online e-prescribing clearinghouses.(13)

A greater challenge is to inculcate a culture of "dynamic skepticism," an attitude of questioning the validity of previous assumptions by constantly evaluating incoming data.(14) This concept from aviation may be beneficial in certain health care situations and might have led the cardiologist in Case 2 to find the error. Providers must resist the automatic assumption that previously obtained information is (still) accurate, especially when it does not make sense. For instance, the ED provider in Case 1 could have asked, "Is there a reason for this patient to be taking torsemide?"

Defense 5: Patients, Our Final Defense

An engaged patient is one of our best strategies to prevent reconciliation errors. However, as illustrated by Case 2, both patients and their caregivers and family members must keep critical information up to date and remain engaged with providers across different systems. Web-based patient portals, such as "My HealtheVet" (http://www.myhealth.va.gov/), allow patients to compare their information with that of the organization to help address any discrepancies they identify. Patients themselves can also communicate significant updates or changes via web-based secure messaging (15) or other available means. And finally, patients and caregivers must also continuously monitor and develop a healthy amount of skepticism for risky situations (such as medications at transitions).

Take-Home Points

Errors in reconciling medication records can be prevented by using a multifaceted approach that includes:

• Better EHR linkages.
• Standardized practices and procedures for certain high-risk tasks such as medication reconciliation.
• Using technology to reduce (and not introduce) errors that might get perpetuated.
• Developing new attitudes such as dynamic skepticism.
• Engaging patients in actively contributing to their care and monitoring their clinical conditions.

Hardeep Singh, MD, MPH

Assistant Professor of Medicine

Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine

Dean F. Sittig, PhD

Professor of Health Information Sciences

University of Texas School of Biomedical Informatics

Maureen Layden, MD, MPH

Director, VA Medication Reconciliation Initiative

Veterans Health Administration, Pharmacy Benefits Management

References

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