During my 22 years as a hospital CIO, I experienced plenty of challenges – along with many successes – while working to implement new technologies, change outdated processes and modify inefficient workflows. One particularly demanding period followed the 2006 Joint Commission Sentinel Alert Event, which called for medication reconciliation at every transition of care.
Truthfully, when the standards were announced, I thought the task would be relatively easy and involve just a few tweaks to workflows, plus the creation of a couple of new forms. I never expected the amount of pushback that I received from doctors and staff, who complained that they lacked the time to perform reconciliations, especially when so few patients could accurately list all of their medications.
However, I knew the project was in big trouble the day my director of pharmacy called to ask which street corner he should stand on to buy marijuana, which at that time was illegal in every state. Apparently, an intake nurse had diligently noted a patient’s reported use of marijuana twice a day. When the patient was transferred from the emergency department (ED) to inpatient care, the doctor signed the reconciliation, noting that the patient should “continue all as originally taken.” Yes, we were indeed in big trouble.
Despite early struggles, my hospital eventually adjusted workflows and updated various processes, and implemented technology that provided patient medication histories from multiple sources. Although we mastered the reconciliation process, many organizations still struggle in this area, which is one reason that medication errors account for at least one death each day and injuries to 1.3 million people annually, according to the Food and Drug Administration. Perfect data, which is the ultimate goal of medication reconciliation, still eludes many healthcare providers.
The medication reconciliation process is meant to create a highly accurate list with all of a patient’s medications, including any medications identified during patient intake, plus changes noted on the physician’s admission, transfer and/or discharge orders. Done correctly, medication reconciliation improves patient safety and reduces the potential for adverse drug events. As I learned from my experience implementing a comprehensive medication reconciliation program at my former hospital, to achieve perfect data, organizations must have the right quantity and quality of data, as well as streamlined processes, regular user training and the right technology.
Despite the obvious benefits, medication reconciliation is a struggle for many hospitals. Processes and policies typically vary across departments—as does compliance. Technology is routinely underutilized, users are inadequately trained, and workflows are ineffective or incomplete. In one proprietary study that assessed medication reconciliation performance in hospitals, 90 percent of the organizations were found to have policy or workflow gaps; 67 percent had external medication history gaps; and 65 percent had issues because of gaps in their electronic health records systems.
One contributing factor is the inconsistent availability and use of external medication histories across the entire healthcare facility or system. All too frequently, clinicians are making medication decisions without complete histories, and often there is no medication reconciliation whatsoever when certain patient types—such as pediatrics—are transferred to other facilities. Such scenarios are unfortunately all too common and set the stage for potentially adverse events that negatively impact patient outcomes and add to the cost of care.
Additional issues arise when the nursing staff uses previous discharge medication lists as the active home medication list. This practice leads clinicians to place orders based on outdated medication lists, or based on the potentially faulty memories of patients or their family members. Best practice indicates that the patient should not be the “historian” and sole source of medication history information.
EHRs can improve the medication reconciliation process, although the technology presents its own hurdles. Finding medications and medication order strings during the medication history interview can be time-consuming because medications may be difficult to find quickly or because discharge medication instructions are confusing. Such inefficiencies can frustrate clinicians, not to mention take away from the already limited time that providers have for direct patient interaction at the point of encounter.
Finally, to be meaningful and complete, medication histories must come from multiple sources. However, interoperability between systems is a well-known challenge in healthcare. System integration obstacles must be overcome if organizations want to improve medication reconciliation accuracy.
Regular user training is critical when working to improve medication reconciliation effectiveness and efficiency. Hospitals must incorporate training that reinforces current organizational processes, the use of supporting technology and instructions on how to incorporate external medication histories.
Medication reconciliation training should be ongoing, with all users participating in hands-on, interactive refresher courses at least once a year. Even individuals that don’t frequently perform medication reconciliations, such as departmental nurses, should be regularly and thoroughly trained on current processes and technologies.
The quality of medication records is further enhanced when pharmacy staff is leveraged for the history review process and at transitions of care. Pharmacist participation speeds up the medication history interview and saves providers time when later performing medication reconciliations.
Pharmacy staff involvement lends the most value during and after the medication history interviews, such as for emergency patients who are likely to be admitted to the hospital; when comparing admission orders with medication histories to identify any gaps or discrepancies; when reviewing discharge medications; or when educating patients on new medications.
Organizations also should seek opportunities to leverage the relative benefits of their EHR and their medication reconciliation processes. For example, hospitals can extend the benefits of medication reconciliation when vital medication gaps are pinpointed in patient EHR records. Facilities could seek ways to optimize overall workflows, such as adding visual cues on EHR tracker/status boards to indicate when medication interviews are complete.
Finally, the importance of interoperability between systems cannot be understated. Without a seamless, secure exchange of data, medication reconciliation efforts will be hampered.
The medication reconciliation process is not quite as troubling as I once thought, although a successful implementation does not come without its challenges. These challenges can be overcome, however, with ongoing user training, efficient workflows and the right technology. The end goal—a complete and comprehensive medication history with perfect data—is worth the effort and truly the cornerstone for patient safety.
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