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Getting patients right drugs at right time no easy task

With reconciliation a top source of medical errors, hospitals are under pressure to improve their programs

From the October ACP Observer, copyright 2006 by the American College of Physicians.

By Janice C. Simmons

In one case, a patient inadvertently ended up taking two beta blockers after he left the hospital, because he was sent home with one that had a generic name and one that had a trade name. In another, a physician mistakenly wrote admitting orders for a psychotropic agent that was 10 times the strength of what the patient was taking at home.

Faulty medication reconciliation programs—or lack of ones at all—that lead to these types of errors are under intense scrutiny in the wake of a new study that identifies reconciliation as a source of mistakes and adverse drug events and a new sentinel event alert from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) prompting hospitals to address this problem.

As hospitals begin developing and testing new ways to make sure patients get the right drugs at the right time, they've discovered that the problem is a lot more complicated than anyone thought.

"What we think is a very, very simple process has uncovered many problems in the medication delivery system," said Roger Resar, MD, assistant professor of medicine at the Mayo School of Medicine and a senior fellow with the Cambridge, Mass.-based Institute for Healthcare Improvement (IHI). Dr. Resar was part of the team at Luther Midelfort Hospital-Mayo Health System in Eau Claire, Wis., that pioneered the use of medication reconciliation tools in 1999 as part of an IHI initiative on medication safety.

Attempts to solve these problems may put hospitalists in the middle of what can be time-consuming efforts to build teamwork and find the right processes—including a transition to electronic health records (EHRs)—for each institution.

“There’s no magic device or form out there that does the job. Everybody has had to kind of create and adopt for themselves something that would fit the bill [to achieve medication reconciliation],” said James W. Lederer, ACP Member, medical director for clinical improvement of Corporate Novant Health, a nine-hospital system based in North Carolina. This meant getting the views of “key users”—particularly hospitalists—to develop a system that worked. “Hospitalists today manage about a third to 40% of the med-surgical patients. They are a huge presence…and we had to get their input.”

Why now?

While experts say it's critical to find the right answers, right now to ensure patient safety, the pressure for hospitals to improve medication reconciliation has, in fact, been steadily building:

  • Institute of Medicine report. In July, the Institute of Medicine's new report, Preventing Medication Errors, noted that numerous studies have found medication reconciliation to be an effective way to decrease errors and adverse drug events. In the past, hospitals have known about the problem, but have often overlooked it, the report said.

  • JCAHO alert. In January, the JCAHO issued Sentinel Event Alert #35 calling for hospitals to prevent errors by focusing on the accuracy of medications given to patients as they transition from one care setting to another, and from one practitioner to another.

  • IHI campaign. The IHI, noting that poor communication of medical information at transition points is responsible for up to half of all medication errors and 20% of adverse drug events in hospitals, made reconciling medication at all transition points one of the six best-practice interventions in its 100,000 Lives patient safety campaign that will soon be entering its second year.

Three types of errors make up 70% of those mistakes related to reconciliation failure, according to recent U.S. Pharmacopeia data: improper dose or quantity, omission errors, and prescribing errors. Others include wrong drug, wrong time, extra dose, wrong patient, mislabeling, wrong administration technique, wrong dosage form, deteriorated product, and incorrect preparation.

“We know there are hundreds of organizations that are making progress in this area [of medication reconciliation],” Dr. Resar said. “But we know that there are hundreds—if not thousands—of hospitals out there that think this is a simple process in terms of making a switch [and then start] doing it tomorrow. It’s not going to work that way.”

All for one

Many agree that the first, and perhaps most important, step is to get hospital staff to work as a team to reconcile a patient's medications. That's the only way, they explain, to gather all the right information.

Whether it is an admission or a transfer between floors in a hospital, finding ways to improve medication reconciliation does not “seem to make any difference without the teamwork," Dr. Resar said.

He said a successful team should focus on:

  • verifying the medications that the patient is taking at home;

  • clarifying medication questions and reviewing any discrepancies;

  • reconciling each patient's medications; and

  • transmitting the information to the next stage of the health care process.

Teamwork has paid off for Centra Health, a two-hospital system based in Lynchburg, Va., where unreconciled medications among patients dropped from 54.8% to 6% since the system started an initiative focusing on medication reconciliation nearly a year and a half ago.

Centra struggled to gather all of the initial information given that patients had been seeing multiple physicians and pharmacists, said Kirk Sydnor, MD, medical director of Centra's hospitalist service.

In the past, health care workers didn't coordinate efforts to find the information, which may have come from many sources such as old records, since many of the patients did not have their medications with them. "We had physicians doing one thing on their own, and nurses doing another thing on their own," Dr. Sydnor said.

A team at Centra—consisting of physicians and hospitalists, nurses, and pharmacists—decided to instead consolidate nurse and physician efforts by starting the reconciliation process at the point of entry, which for most patients was the emergency department. The nurses there now play a large role in initially gathering the data because they usually are the first ones "connecting with the families and patients upon their arrival," Dr. Sydnor said.

The information is then transmitted to the physicians who can quickly find out what medicines the patients are taking and then proceed with their ordering sheets. “By combining all of these efforts [of the physicians and nurses], we get better information. We’re able to create reproducible processes that assure that the information is more accurate. We’re able to pick up on things [about the patient] that weren’t initially known,” Dr. Sydnor said.

Looking for solutions

Some hospitals may think that they will be able to start or fix their medication reconciliation programs with just one plan. It's not that easy, according to Dr. Resar. "There's no single process that's going to work across an entire hospital or system of hospitals," he said.

For example, hospitals may run into problems establishing a protocol because they don't understand the particular requirements for a surgical floor versus a medical floor, he said. These hospitals may have reconciliation processes for medical floors where there are internists who understand these medications, Dr. Resar said. "These same processes don't work for the surgical floors," he said. For instance, some hospitals may require surgeons on the orthopedic floor to make reconciliation decisions about cardiac medications.

Some hospitals recognize that their reconciliation process may not always work. At Luther Midelfort, for example, physicians are encouraged to get "consultations if they don't understand the medicine," said Leslie Spitz, MD, who is the hospital's physician champion of the medication reconciliation team.

Physicians on staff at Luther Midelfort—including those in the surgical specialties who are uncomfortable reconciling medications or ordering medications for discharges—can request a "medication management visit" with hospitalists or internists at the hospital. The medication management visits, lasting about 10 minutes, are considered just hospital visits—not consults, Dr. Spitz said. “[This] is the kind of contingency that needs to be built in for floors such as orthopedic floors or other surgical floors. Hospitalists can play a tremendous role in that contingency.”

The EMR 'nirvana'

Proper record keeping is turning out to be a key aspect of medication reconciliation processes and hospitals are responding with detailed protocols and an eye toward transitioning to EMR technology.

At Forsyth Medical Center in Winston-Salem, NC, distinctions are made between "simple admissions," such as surgical admission, and "medical admissions" when it comes to medication reconciliation, said Gerald B. Hogsette, FACP, medical director of inpatient physicians.

Patients admitted for surgery generally come into the hospital and leave with the same medications. "The only addition might be a pain medication," he said. Therefore, these patients need only a simple form—one that later can be used for an order set.

But for complex medical admission cases—such as a 60-year-old patient on 16 medications—the reconciliation information is incorporated into the medical record. It includes what they took at home before being admitted and what they will continue on at home after discharge. "But we would write our own orders to confirm that as a matter of safety," Dr. Hogsette said.

Forsysth, like many other hospitals, is still using pen and paper to record patient reconciliation information. But it is inching toward the use of EMRs as other areas of its parent company, Novant Health, move in that direction.

"I think the [reconciliation] nirvana will be an electronic medical record," said Novant’s Dr. Lederer.

However, the new JCAHO reconciliation requirements have taken many of the EMR vendors by surprise. As a result, the technology may not yet be ready to handle the complex hospital protocols that may try to reconcile all the medicines from admission with those used throughout the different care areas of the hospital and then with the medications patients take home.

"Medication reconciliation data may not be in this year's updates [of EHRs]; it may not be for several years because you have such complex medical records," Dr. Lederer said. "That's not simple coding. That's a brand-new module."

Reducing the risk

But even when the modules are ready, EHRs will only be as good as the information that's entered.

A key step to ensuring that accuracy is for health care providers to have clear conversations about medications with their patients, Dr. Spitz of Luther Midelfort emphasized. "You still have to sit down with the patient and ask, 'is this the medication that you take?'" he said. "The risk in automating this is to assume that everything [in the EHR] will be correct."

It's no surprise then that these new reconciliation processes take more time for hospitalists, Dr. Hogsette noted. "I hate to admit it, but Forsyth's new record-keeping protocol has added 20 minutes to every discharge," he said.

That's discouraged some of his fellow physicians from buying into the new processes, especially those who are reluctant to give up their old ways, he said. "They don't recognize that they've had errors," said Dr. Hogsette, who readily acknowledged that the new process shed light on his own mistakes.

"There is no question that it caught errors that I was making routinely," he said.

Personal experience, he said, may be the only way other physicians will accept the new protocols. "If they just go through the step-by-step process, they will see that this is a safer way," he said.

"They just have to do it. It cannot be a leap of faith."

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For more information

Institute of Medicine
Preventing Medication Errors: Quality Chasm Series

Joint Commission of Accreditation of Healthcare Organizations
Sentinel Event Alert #35

Joint Commission International Center for Patient Safety
"Reconciliation Failures Lead to Medication Errors"

Institute for Healthcare Improvement
"Medication Reconciliation and Discharge Medications Policy"

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