Tuesday, June 22, 2010

Medication reconciliation: can we get it right?

Medication reconciliation was one of Joint Commission's most meaningful patient safety goals. Unfortunately, hospitals found it so difficult to comply that JC has eased up. While hospitals are still expected to comply with the original standard, they will not be surveyed on it. Moreover, JC has announced now that they will be field testing a revised (and presumably easier) med rec standard.

Medication reconciliation means that any medication changes at transitions of care should take place with therapeutic intent and explicitly take into account the patient's preceding regimen. According to a recent JGIM study that process fails at hospital admission an alarming portion of the time:

Over one-third of study patients (35.9%) experienced 309 order errors; 85% of patients had errors originate in medication histories, and almost half were omissions. Cardiovascular agents were commonly in error (29.1%). If undetected, 52.4% of order errors were rated as potentially requiring increased monitoring or intervention to preclude harm; 11.7% were rated as potentially harmful.

The authors have developed a med rec tool kit accessible on line here. It's loaded with links and resources and borrows from a variety of process improvement methodologies including Six Sigma. A recurring theme of the tool kit is the idea of the “one source of truth”: the patient's real med list. The problem with that is, for many patients who present to the hospital such a list has never been defined. For other patients the list is merely an ideal. Sometimes in practice what the patient thinks s/he's supposed to take, what s/he's actually taking, what the most recent provider thinks s/he's supposed to be taking and what the medical record says represent four different “realities”.

A special problem arises with insulin. For patients who self-adjust it's extremely difficult to cleanly list in the medical record. Some patients literally cannot, or will not, articulate their dosing schemes. Sometimes the easiest work around for that situation is to merely let the patients use their home supply and self-administer. The med rec standards make that approach difficult and nowadays doctors may be tempted to cop out with a sliding scale, start from scratch or just guess.

There's no clear solution to some of these problems, but the tool kit does address areas where hospitals can improve. One is to explicitly define areas of responsibility. Who, for example, is responsible for generating the “one source of truth” medication list? ER nurse, physician, pharmacist, inpatient unit nurse? Is it shared among all?

Medication reconciliation, elegantly simple in concept, proved inscrutably complicated in its implementation. The tool kit provides robust process improvement methods to help make it work.

Via Today's Hospitalist.

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