Medication reconciliation
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1], Robert G. Badgett, M.D.[2]
Overview
Medication reconciliation is "the formal process of obtaining a complete and accurate list of each patient's current home medications including name, dosage, frequency, and route of administration, and comparing admission, transfer, and/or discharge medication orders to that list. The reconciliation is done to avoid medication errors."[1] Medication reconciliation may involve determining a "Best Possible Medication History" (BPMH).
Older adults have difficult in accurately recalling their medications[2].
Definitions
- IHI: "the process of creating the most accurate list possible of all medications a patient is taking"[3]
- CMS: "identifying the most accurate list of all medications that the patient is taking"[4]
- Joint Commission: "a clinician compares the medications a patient should be using (and is actually using) to the new medications that are ordered for the patient and resolves any discrepancies."[5]
Epidemiology
Frequency of reconciliation errors
In the inpatient setting, the following rates of medication errors have been found[6][7][8][9]:
Although not an error, a related problem is the increase in medication intensity at the time of discharge from the hospital[11].
In the outpatient setting, the following rates of medication errors have been found:[12][13][14][10][15]:
Regarding specific errors, a study of inpatients found[7]:
- Discrepancy with discharge summary: 34%
- Duplicate medications: 23%
- Extraneous medications: 14%
- Medications by indication or disease: 25%
- Medication omission 17%
Frequency of harm from reconciliation errors
Several studies report rates of complications from medication errors. It is unclear how many of the problems identified in these studies would be avoided by successful medication reconciliation.
In the first study, 851 patients diagnosed with ACS or CHF were assigned to either pharmacist-assisted medication reconciliation, low-literacy adherence aids, and individualized telephone follow-up 1-4 days after discharge or no intervention[16].
- 432 (50.8%) of subjects had clinically important medication errors. 22.9% of such errors were considered serious and 1.8% life-threatening.
- 258 patients (30.3%) had adverse drug events and 253 patients (29.7%) potential adverse events.
In the second study, 510 heme/oncology patients scheduled for infusion center appointments without a provider visit had medication reconciliation by a student pharmacist. The pharmacists found[14]:
- 88% of patients had at least one discrepancy identified in their medication history and corrected in the EMR.
- 11.4% of patients had a medication-related problem identified, including drug-drug interactions, untreated indications, adverse drug reactions, and untreated indications.
Among outpatients in 6 safety-net clinics in 3 states, discrepancies between patients' reports of medications and the medical record were associated with low hypertension control.[17].
Methods
Criteria for determining a medication problem
One proposed criteria is the "number of unintentional medication discrepancies per patient."[18] Because this measure requires a trained pharmacist to assess the gold standard, the authors of the measure suggest that "25 patients are sampled per month, or approximately 1 patient per weekday".[18] Problems with this proposal include unclear criteria used by the pharmacist and that measurement can not be automated or measured in the data routinely collected during patient care.
A medication reconciliation executed by a pharmacist may take over two hours.[19]; however, in the clinic a physician may have less than a minute to discuss medications[12].
Specific criteria
A study in the Washington DC VA proposed specific criteria for a medication reconciliation. It included internal medicine residents rotating through the hospital, using bi-monthly educational sessions directed by faculty/chief residents based on accuracy of discharge medication reconciliation. While some of the criteria showed significant change after an intervention, the reliability of these results were not tested.[7] The criteria used were:
- Medication duplicates
- Extraneous medications. In other studies, this is also called one-time medications, post-acute medications, or time-limited medications.
- Discrepancies from discharge summaries
- Omissions
- Grouping medication by indication or disease
Specific criteria for determining a successful medication reconciliation have also been developed by an interdisciplinary team at National Jewish Health (Denver) in an ambulatory practice serving patients with respiratory and related diseases[13]. This study assessed performance in medication reconciliation by the process of comparing patients’ medication lists at clinical transition points and demonstrated improvement in an outpatient setting, sustainable and valid measures are needed. Across 18 months
- Electronic attestation that med rec was completed at clinic visits increased from 9.8% to 91.3% (p < 0.0001)
- Medication duplication decreased from 4.0% to 2.6% (95% CI: 2.4%–2.8%) (p <0.0001)
- Significant improvement was noticed in missing doses, their frequencies
- Provision of medication safety handout with the patients’ medication lists
An additional finding in the study was that compliance remained a limiting factor in this study secondary to poor-buy in by participants due to redundancy of process.
Role of patient engagement and understanding
Elderly patients have much trouble understanding changes in medications[20].
Low health literacy is associated with discrepancies[21].
Role of regional health information exchanges
Use of data provided by a regional health information exchange has been advocated.[22][23] However, the clinical benefit of using a health information exchange is not established[24]. A randomized controlled trial found no reduction in adverse drug reactions.[24][25]
Quality measures
Medication reconciliation is a quality measure for Centers for Medicare & Medicaid Services (CMS)[26][27], it is also a quality measure for National Committee for Quality Assurance (NCQA).[28]
Public reporting
Medication reconciliation is part of the Centers for Medicare & Medicaid Services's (CMS) EHR Incentive Programs for the Measingful Use Stage 1[26] and the 2017 Modified Stage 2 Meaningful Use Program Requirements[27].
Interventions to promote successful medication reconciliation
Medication reconciliation, as an isolated intervention, may not be effective[29].
Medication reconciliation at time of hospital discharge alone is insufficient for prevention of hospital readmission[30][31] although subsequent emergency department usage may be reduced[31].
When medication reconciliation is combined with follow up phone calls, there is conflicting evidence of benefit with regard to hospital re-utilization after discharge. Trials report both benefit[6][32] and no benefit[16][9][33]. Comparing the studies,benefit is more likely when multiple, scripted phone falls are made,with patients bringing their medication to the phone.
Multi-factorial interventions that include medication reconciliation may decrease hospital readmissions[34].
References
- ↑ "Medication Reconciliation- MeSH - NCBI". Retrieved 2017-06-05.
- ↑ Goldberg EM, Marks SJ, Merchant RC, Nagy JL, Aquilante JA, Beaudoin FL (2020). "How Accurately Do Older Adult Emergency Department Patients Recall Their Medications?". Acad Emerg Med. doi:10.1111/acem.14032. PMID 32438496 Check
|pmid=value (help). - ↑ http://www.ihi.org/Topics/ADEsMedicationReconciliation/
- ↑ https://www.cms.gov/regulations-and-guidance/legislation/ehrincentiveprograms/downloads/7_medication_reconciliation.pdf
- ↑ https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2020/npsg_chapter_ahc_jul2020.pdf
- ↑ 6.0 6.1 6.2 Phatak A, Prusi R, Ward B, Hansen LO, Williams MV, Vetter E; et al. (2016). "Impact of pharmacist involvement in the transitional care of high-risk patients through medication reconciliation, medication education, and postdischarge call-backs (IPITCH Study)". J Hosp Med. 11 (1): 39–44. doi:10.1002/jhm.2493. PMID 26434752.
- ↑ 7.0 7.1 7.2 7.3 Arundel C, Logan J, Ayana R, Gannuscio J, Kerns J, Swenson R (2015). "Safe Medication Reconciliation: An Intervention to Improve Residents' Medication Reconciliation Skills". J Grad Med Educ. 7 (3): 407–11. doi:10.4300/JGME-D-14-00565.1. PMC 4597952. PMID 26457147.
- ↑ 8.0 8.1 Gallagher PF, O'Connor MN, O'Mahony D (2011). "Prevention of potentially inappropriate prescribing for elderly patients: a randomized controlled trial using STOPP/START criteria". Clin Pharmacol Ther. 89 (6): 845–54. doi:10.1038/clpt.2011.44. PMID 21508941.
- ↑ 9.0 9.1 9.2 Walker PC, Bernstein SJ, Jones JN, Piersma J, Kim HW, Regal RE; et al. (2009). "Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study". Arch Intern Med. 169 (21): 2003–10. doi:10.1001/archinternmed.2009.398. PMID 19933963.
- ↑ 10.0 10.1 10.2 Grant RW, Devita NG, Singer DE, Meigs JB (2003). "Improving adherence and reducing medication discrepancies in patients with diabetes". Ann Pharmacother. 37 (7–8): 962–9. doi:10.1345/aph.1C452. PMID 12841801.
- ↑ Anderson TS, Wray CM, Jing B, Fung K, Ngo S, Xu E; et al. (2018). "Intensification of older adults' outpatient blood pressure treatment at hospital discharge: national retrospective cohort study". BMJ. 362: k3503. doi:10.1136/bmj.k3503. PMID 30209052.
- ↑ 12.0 12.1 12.2 van der Gaag S, Janssen MJA, Wessemius H, Siegert CEH, Karapinar-Çarkit F (2017). "An evaluation of medication reconciliation at an outpatient Internal Medicines clinic". Eur J Intern Med. doi:10.1016/j.ejim.2017.07.015. PMID 28693941.
- ↑ 13.0 13.1 Kern E, Dingae MB, Langmack EL, Juarez C, Cott G, Meadows SK (2017). "Measuring to Improve Medication Reconciliation in a Large Subspecialty Outpatient Practice". Jt Comm J Qual Patient Saf. 43 (5): 212–223. doi:10.1016/j.jcjq.2017.02.005. PMID 28434454.
- ↑ 14.0 14.1 14.2 Ashjian E, Salamin LB, Eschenburg K, Kraft S, Mackler E (2015). "Evaluation of outpatient medication reconciliation involving student pharmacists at a comprehensive cancer center". J Am Pharm Assoc (2003). 55 (5): 540–5. doi:10.1331/JAPhA.2015.14214. PMID 26359964.
- ↑ 15.0 15.1 Bedell SE, Jabbour S, Goldberg R, Glaser H, Gobble S, Young-Xu Y; et al. (2000). "Discrepancies in the use of medications: their extent and predictors in an outpatient practice". Arch Intern Med. 160 (14): 2129–34. PMID 10904455.
- ↑ 16.0 16.1 Kripalani S, Roumie CL, Dalal AK, Cawthon C, Businger A, Eden SK; et al. (2012). "Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: a randomized trial". Ann Intern Med. 157 (1): 1–10. doi:10.7326/0003-4819-157-1-201207030-00003. PMC 3575734. PMID 22751755.
- ↑ Persell SD, Bailey SC, Tang J, Davis TC, Wolf MS (2010). "Medication reconciliation and hypertension control". Am J Med. 123 (2): 182.e9–182.e15. doi:10.1016/j.amjmed.2009.06.027. PMID 20103029.
- ↑ 18.0 18.1 Brigham and Women´s Hospital. Medication Reconciliation: Number of Unintentional Medication Discrepancies per Patient. National Quality Forum. Last updated Sep 09, 2014. Accessed July 2, 2017
- ↑ Gillespie U, Alassaad A, Henrohn D, Garmo H, Hammarlund-Udenaes M, Toss H; et al. (2009). "A comprehensive pharmacist intervention to reduce morbidity in patients 80 years or older: a randomized controlled trial". Arch Intern Med. 169 (9): 894–900. doi:10.1001/archinternmed.2009.71. PMID 19433702. Review in: Ann Intern Med. 2009 Sep 15;151(6):JC3-14
- ↑ Ziaeian B, Araujo KL, Van Ness PH, Horwitz LI (2012). "Medication reconciliation accuracy and patient understanding of intended medication changes on hospital discharge". J Gen Intern Med. 27 (11): 1513–20. doi:10.1007/s11606-012-2168-4. PMC 3475816. PMID 22798200.
- ↑ Persell SD, Osborn CY, Richard R, Skripkauskas S, Wolf MS (2007). "Limited health literacy is a barrier to medication reconciliation in ambulatory care". J Gen Intern Med. 22 (11): 1523–6. doi:10.1007/s11606-007-0334-x. PMC 2219798. PMID 17786521.
- ↑ Askin E, Margolius D (2016). "A call for a statewide medication reconciliation program". Am J Manag Care. 22 (10): e336–e337. PMID 28557524.
- ↑ Dhavle AA, Joseph S, Yang Y, DiBlasi C, Whittemore K (2017). "A better way: leveraging a proven and utilized system for improving current medication reconciliation processes". Am J Manag Care. 23 (3): e98–e99. PMID 28385027.
- ↑ 24.0 24.1 Boockvar KS, Ho W, Pruskowski J, DiPalo KE, Wong JJ, Patel J; et al. (2017). "Effect of health information exchange on recognition of medication discrepancies is interrupted when data charges are introduced: results of a cluster-randomized controlled trial". J Am Med Inform Assoc. doi:10.1093/jamia/ocx044. PMID 28505367.
- ↑ Boockvar K. "Regional Data Exchange to Improve Medication Safety - Study Results". ClinicalTrials.gov. Retrieved 2017-06-05.
- ↑ 26.0 26.1 "Step 5: Achieve Meaningful Use Stage 1: When should I perform medication reconciliation?". HealthIT.gov. Retrieved June 5, 2017.
- ↑ 27.0 27.1 "Step 5: Achieve Meaningful Use Stage 2: Medication Reconciliation". HealthIT.gov. Retrieved June 5, 2017.
- ↑ "Medication reconciliation post-discharge: percentage of discharges from January 1 to December 1 of the measurement year for members 18 years of age and older for whom medications were reconciled the date of discharge through 30 days after discharge (31 total days)". National Quality Measures Clearinghouse. Retrieved 2017-06-05.
- ↑ Redmond P, Grimes TC, McDonnell R, Boland F, Hughes C, Fahey T (2018). "Impact of medication reconciliation for improving transitions of care". Cochrane Database Syst Rev. 8: CD010791. doi:10.1002/14651858.CD010791.pub2. PMID 30136718.
- ↑ Christensen M, Lundh A (2016). "Medication review in hospitalised patients to reduce morbidity and mortality". Cochrane Database Syst Rev. 2: CD008986. doi:10.1002/14651858.CD008986.pub3. PMID 26895968.
- ↑ 31.0 31.1 Huiskes VJ, Burger DM, van den Ende CH, van den Bemt BJ (2017). "Effectiveness of medication review: a systematic review and meta-analysis of randomized controlled trials". BMC Fam Pract. 18 (1): 5. doi:10.1186/s12875-016-0577-x. PMC 5240219. PMID 28095780.
- ↑ Jack BW, Chetty VK, Anthony D, Greenwald JL, Sanchez GM, Johnson AE; et al. (2009). "A reengineered hospital discharge program to decrease rehospitalization: a randomized trial". Ann Intern Med. 150 (3): 178–87. PMC 2738592. PMID 19189907.
- ↑ Schnipper JL, Kirwin JL, Cotugno MC, Wahlstrom SA, Brown BA, Tarvin E; et al. (2006). "Role of pharmacist counseling in preventing adverse drug events after hospitalization". Arch Intern Med. 166 (5): 565–71. doi:10.1001/archinte.166.5.565. PMID 16534045.
- ↑ Ravn-Nielsen LV, Duckert ML, Lund ML, Henriksen JP, Nielsen ML, Eriksen CS; et al. (2018). "Effect of an In-Hospital Multifaceted Clinical Pharmacist Intervention on the Risk of Readmission: A Randomized Clinical Trial". JAMA Intern Med. doi:10.1001/jamainternmed.2017.8274. PMID 29379953.
External links
- AHRQ: Medication Reconciliation
- HealthIT.gov: Medication Reconciliation
- HIMSS: HIMSS Electronic Medication Reconciliation (Med Rec) Resource Center
- IHI: Medication Reconciliation to Prevent Adverse Drug Events
- Joint Commission Resources and the American Society of Health-System Pharmacists; 2006. ISBN: 0866889566 (First edition) Google Books, AHRQ
- Leapfrog Group: Medication Reconciliation
- WHO:Action on Patient Safety - High 5s