Tuesday, November 15, 2011

Can we rectify medication reconciliation in the ER?

Med lists generated by the ER medication reconciliation process are inaccurate according to this study:

Results: There were 98 patients enrolled in the study; 56% (55/98, 95% confidence interval [CI] 46–66%) of the medication lists for these patients had an omission and 80% (78/98, 95% CI 70–87%) had a dosing or frequency error; 87% of ED medication lists had at least one error (85/98, 95% CI 78–93%).

These findings are not surprising. Medication reconciliation requires a great deal of attention to detail. Often multiple people must be questioned and phone calls made. Medication bottles must be examined when available. Information on medication bottles, medication lists and the available medical records must be compared and any discrepancies explained. Often the patient's physician changes the directions without issuing a new prescription. For each item on the medication list or for each bottle the patient and/or family must be asked whether that is the case. Patients sometimes unilaterally (without involvement of a physician) change the way they take certain medications. For each medication the patient must be asked whether that is the case. Discrepancies between intended and actual use must then be made clear in the medication reconciliation section.

This process usually takes more than just a few minutes. It could take an hour or more. No wonder accuracy is so low. It's easy to understand why under the time pressure of the ER environment, personnel do not feel it is their priority to attend to this much detail.

It's also no wonder that Joint Commission's medication reconciliation initiative, which I once thought was a wonderful idea, has flopped. Miserably. There are some lessons here. First, no “systems approach” is a substitute for sitting down and spending time with the patient. Second, as we've seen in example after example (remember rapid response teams?) many “systems approaches” which sound like great ideas are accepted uncritically. But by the time they are well entrenched research data tell another, often disappointing, story.