Medication Reconciliation in the Health System
By Curt Passafume, Jr., MBA, RPh |
Hospital-related medication errors and adverse drug effects due to poor communication are among the most common breakdowns in transitions of care. And with medication errors accounting for more than 7,000 deaths in the U.S. every year,1it's clear the impact an effective medication reconciliation program can have on patient outcomes.2 What is less transparent are the longer-term benefits related to the efficiencies that can be created when medication histories and medication reconciliation are done through ambulatory care pharmacies - from reaching more patients and gaining physician trust to enabling practitioners to deliver better quality of care across the hospital enterprise.
While the road to implementing medication reconciliation through the ambulatory pharmacy may have its challenges, experienced health system pharmacists agree on these irrevocable building blocks.
Making the Case for Bringing Medication Reconciliation Into the Pharmacy
Normal medication reconciliation in the Emergency Department (ED) by a pharmacist has been shown to reduce prescribing errors compared to histories obtained by doctors and nurses in the ED or on the admitting service.3 In fact, the percent error in medication histories between pharmacy and non-pharmacy staff can vary by more than 30 percent.4 An evaluation of the accuracy of medication history by discipline will most likely demonstrate vulnerabilities in the health system's current medication reconciliation program as well as provide the data needed to identify improvements, should the pharmacy be given the opportunity to lead the program. Health systems that want to pursue such a program within their own pharmacies to improve quality and transitions of care should consider starting with a pilot program to assess:
- Overall patient capture rate
- Frequency and type of medication discrepancies
- Time spent on medication history activities
- Accuracy of medication history
Begging, Borrowing and (Later) Securing the Right Resources
During the initial pilot phase of the program, health systems should leverage existing human resources. Consider assembling a blended pharmacy team that might include students, interns and technicians. The idea is to demonstrate success and then ask for the additional resources needed to expand the program. Full-time, dedicated resources are difficult to justify until the pharmacy can demonstrate sustained results - in the form of quality rather than mere ROI.
As the ambulatory care pharmacy practice has evolved, so too have the technologies that enable more efficient medication reconciliation, especially as it relates to obtaining medication histories. A tool that can electronically aggregate data and provide an almost seamless integration with the hospital's electronic healthcare records (EHR) solution is critical to gaining physician satisfaction - a metric that will be needed to implement a more permanent program down the road. And while such a solution might have to come at a later phase of the pilot, hospitals and health systems cannot underestimate the role information technology plays in sustaining a successful program.
Measuring Success - and How to Demonstrate It
In addition to measuring progress against the primary objectives, pharmacy leadership should arm the health system's C-suite with a view into how the program impacted operations and quality across the enterprise. The accuracy of the discharge medication lists, for example, is a quality measure that can be objectively measured and have a quality impact that can be tied back to readmissions. Using readmissions alone as a metric can be near impossible unless there is a mechanism to track specific patients both within the health system and outside of it.
While the total patient capture rate and average time spent reflects an element of efficiency, data gleaned during patient interviews serves to frame effectiveness. Accumulated patient interview results should deliver:
- Number of medication histories completed
- Average age of patient
- A single count of all medications from all sources (home, hospital, etc.)
- Number of medication changes made to admission medication history
- Number of interventions, categorized by level of impact5 and/or prescribing error
Physician satisfaction surveys are another critical component to demonstrating not only the success of the program but also the value of the medication reconciliation technicians as it relates to internal efficiencies and patient safety. Consider asking practitioners to complete a brief, Likert scale survey both to establish a pre-pilot baseline and to measure post-pilot results. Survey responses can be as simple as agreeing/disagreeing with the following statements:
- The medication reconciliation technicians helped to increase the level of patient safety.
- The medication reconciliation technicians were helpful in enabling me to perform my job efficiently.
- The medication reconciliation technicians helped to improve the quality of care that my patients received.
While there have been many studies that prove the effectiveness of a pharmacy-led medication reconciliation process, showing a reduction in error rates, risk of adverse drug reactions and prescription costs, health systems now have more to consider. Serving as a critical partner to practitioners and helping to support better care for more people is an important step toward ensuring pharmacy has a place at the table with the health system C-level.
1. Becker's Hospital Review. Closing the gap on transitions of care. 10 October 2014. Available online athttp://www.beckershospitalreview.com/quality/closing-the-gap-on-transitions-of-care.html. Accessed 2 February 2016.
2. Institute of Medicine. To err is human: building a safer health system. Washington, DC: National Academy Press; 1999.
3. Mills PR, McGuffie AC. Formal medicine reconciliation within the emergency department reduces the medication error rates for emergency admissions. Emerg Med J 2010;27:911-5 and Vasileff HM, Whitten LE, Pink JA, Goldsworthy SJ, Angley MT. The effect on medication errors of pharmacists charting medication in an emergency department. Pharm World Sci 2009;31:373-9.
4. Hart, Coleen, Christine Price, Glenn Graziose, and Jonathan Grey. "A Program Using Pharmacy Technicians to Collect Medication Histories in the Emergency Department." Pharmacy and Therapeutics. MediMedia USA, Inc., n.d. Web. 02 Feb. 2016.
5. National Coordinating Council for Medication Error Reporting and Prevention. Types of Medication Errors. ND. Available online at http://www.nccmerp.org/types-medication-errors. Accessed 7 March 2016.