An ongoing concern for patient saftey

As the healthcare system in the US becomes ever more collaborative, one risk that increases is that of inaccurately reconciled patient medications during transitions of care. Ann Gaffey of Sedgwick Claims Management Services assesses the problem and how to tackle it.

The failure to reconcile patient medications adequately and accurately during transitions of care places patients at risk of harm related to adverse drug events (ADE) and adds to the risk of inappropriate or ineffective care management. Medication reconciliation (MR), as defined by the American Medical Association (AMA), is:

“… making sense of a patient’s medications and resolving conflicts between different sources of information to minimize harm and maximize therapeutic effects. It is an ongoing, dynamic, episodic and team-based process that should be led by, and is the responsibility of, the patient’s attending/personal physician in collaboration with other healthcare professionals”.

When seeking best practices to ensure safe patient care related to MR, physicians in office practice settings should ensure specific tasks are completed that will help to recognize gaps or inconsistencies in the systems in their offices and in individual practitioner practice that impede MR.

A significant amount of literature has been published that confirms and addresses the safety issues involved with poor or absent MR in the outpatient setting. The scope of medication-related errors is as, or more, extensive in the outpatient setting than during hospitalization, with one study estimating the rate of ADEs in the ambulatory setting to be 27 per 100 patients. When analysing the events further, the more vulnerable population for ADEs is individuals aged 65 or older, in part due to their higher use of multiple medications.

Overall, 26 percent of the population take herbal products and supplements, and 30 percent of prescription drug users take a herbal product or supplement—all which can contribute to a drug interaction or adverse event, if the information is not known to the prescribing provider. In addition, it has also been noted by the AMA that 49 percent of previously hospitalized patients who were receiving continuing care from their primary care physician experienced at least one medication error within two months of discharge from the hospital.
Medical information and medical treatment are often complex, and it is not unusual for patients to lack understanding of their health problems, and lack the ability to clearly and accurately communicate health information to their physicians.

Some primary steps in MR in physician offices are expected:
• Verification (the collection of the patient’s medication history);

• Clarification (ensuring that medications and doses are appropriate); and

• Reconciliation (documentation of changes in medication orders to determine an accurate list at the end of the visit).

Physicians and nurses should keep in mind that, even with longstanding patients, they should never assume that the medication information provided is accurate or that the patient is taking everything on the list as prescribed. Thus, it is important to complete a thorough question and answer reconciliation process at each physician/provider encounter.

The following steps in the MR process are identified as vital to ensuring patient safety:

ASSEMBLING A LIST Develop a clear documented understanding when the patient presents to the office of what current medications they are taking by assembling a list that includes the name of the drug, the dose, the frequency, the route and the reason/indication for taking it, eg, hypertension. This list should include any over-the-counter drugs, herbal preparations or supplements, vitamins and minerals. The list would also optimally include who prescribed the medication and the sources of medication (eg, local or mail-in pharmacy, Internet, foreign countries, etc).

DETERMINING THE ACCURACY OF THE LIST Review and compare prior lists and new lists provided by the patient, if available. A key process to the success of reconciliation is going through each drug individually, and not asking broad questions such as “Have any of your medications changed?”

RECONCILING THE LIST Reconcile and resolve any discrepancies, and document the source of information (eg, the patient, family member, list from patient, hospital discharge summary, a combination of these, etc). Ask the primary pharmacy about the patient’s refill history.

DOCUMENTING DRUG ALLERGIES Document any drug allergies, to include what the reaction and/or response is (to inform physicians about potential for interaction with prescription drugs or interference with clinical diagnosis and treatment efforts).

VALIDATING THE CURRENT REGIMEN Ask the patient when the last dose of each medication was taken, and if not taken as scheduled, why not (eg, ran out, cutting in half because too expensive, makes them feel ‘bad’, etc).

DOCUMENTING UNDERSTANDING Document any changes made to any medication during the visit (eg, stopped a medication, started a medication, changed a dose of a current medication, changed the frequency of a current medication).

DOCUMENTING PROVIDER EDUCATION TO PATIENT/FAMILY MEMBER Educate patients/authorized family members regarding any new medication prescribed, and validate understanding by using teach-back methodology. For example, a question such as “In your own words, can you explain to me what we have discussed?” provides an open-ended opportunity for the patient to verbalize her or his understanding. An evaluation of literacy and numeracy should be included when educating patients to ensure their ability to read labels and dosage instructions.

PROVIDING A COMPLETE AND LEGIBLE LIST OF MEDICATIONS AT THE END OF THE VISIT Provide a complete, legible list of medications to patients at the end of the visit for them to have at home as a reference, and to share with other providers who may not have access (if electronic) to this information. Ensure the list includes the name, dose, route, frequency, indication, and name of prescribing physician (or at least specialty of prescriber), and that it is expressed in a manner the patient can understand. (Patient misuse of medications is often caused by misunderstanding label instructions and misinterpreting text or icons.)

Ensuring a thorough MR process is completed during each transition of a patient’s care is essential to ensure patients receive the correct medication, in the correct dosage, for the correct frequency and duration of treatment. Risk reduction strategies such as those mentioned above will assist healthcare providers in achieving safe medication practices for their patients. 

HELPFUL RESOURCES
Numerous resources are available to support MR in the ambulatory setting, including:
The Institute for Safe Medication Practices, www.ismp.org
Massachusetts Coalition for the Prevention of Medical Errors: Reducing Medication Errors in Ambulatory Settings—Medication List,  www.macoalition.org/reducing_medication_errors.shtml
National Transitions of Care Coalition—Consumer Resources,  www.ntocc.org/WhoWeServe/Consumers.aspx
Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation, http://www.ahrq.gov/qual/match/