Medication Reconciliation: Doing What's Right for Safe Patient Care

Improving patient safety and efficiency of medication reconciliation through the development and adoption of a computer-assisted tool with automated electronic integration of population-based community drug data: the RightRx project

Background and Objective

Many countries require hospitals to implement medication reconciliation for accreditation, but the process is resource-intensive, thus adherence is poor. We report on the impact of prepopulating and aligning community and hospital drug lists with data from population-based and hospital-based drug information systems to reduce workload and enhance adoption and use of an e-medication reconciliation application, RightRx.

Methods

The prototype e-medical reconciliation web-based software was developed for a cluster-randomized trial at the McGill University Health Centre. User-centered design and agile development processes were used to develop features intended to enhance adoption, safety, and efficiency. RightRx was implemented in medical and surgical wards, with support and training provided by unit champions and field staff. The time spent per professional using RightRx was measured, as well as the medication reconciliation completion rates in the intervention and control units during the first 20 months of the trial.

Results

Users identified required modifications to the application, including the need for dose-based prescribing, the role of the discharge physician in prescribing community-based medication, and access to the rationale for medication decisions made during hospitalization. In the intervention units, both physicians and pharmacists were involved in discharge reconciliation, for 96.1% and 71.9% of patients, respectively. Medication reconciliation was completed for 80.7% (surgery) to 96.0% (medicine) of patients in the intervention units, and 0.7% (surgery) to 82.7% of patients in the control units. The odds of completing medication reconciliation were 9 times greater in the intervention compared to control units (odds ratio: 9.0, 95% confidence interval, 7.4-10.9, P < .0001) after adjusting for differences in patient characteristics.

Conclusion

High rates of medication reconciliation completion were achieved with automated prepopulation and alignment of community and hospital medication lists.

Medication reconciliation at patient admission: a randomized controlled trial

Objective:

To measure length of hospital stay (LHS) in patients receiving medication reconciliation. Secondary characteristics included analysis of number of preadmission medications, medications prescribed at admission, number of discrepancies, and pharmacists interventions done and accepted by the attending physician.

Methods:

A 6 month, randomized, controlled trial conducted at a public teaching hospital in southern Brazil. Patients admitted to general wards were randomized to receive usual care or medication reconciliation, performed within the first 72 hours of hospital admission.

Results:

The randomization process assigned 68 patients to UC and 65 to MR. LHS was 10±15 days in usual care and 9±16 days in medication reconciliation (p=0.620). The total number of discrepancies was 327 in the medication reconciliation group, comprising 52.6% of unintentional discrepancies. Physicians accepted approximately 75.0% of the interventions.

Conclusion:

These results highlight weakness at patient transition care levels in a public teaching hospital. LHS, the primary outcome, should be further investigated in larger studies. Medication reconciliation was well accepted by physicians and it is a useful tool to find and correct discrepancies, minimizing the risk of adverse drug events and improving patient safety.

An evaluation of a collaborative, safety focused, nurse-pharmacist intervention for improving the accuracy of the medication history

OBJECTIVE

To evaluate the impact of a standardized approach to collecting a medication history on the accuracy of the admission medication list.

METHODS

Pharmacists and nurses developed and implemented a structured, systematic assessment tool for use by nurses in obtaining a medication history. The tool was first evaluated with nursing students in an educational setting using mock patients and simulated scenarios. The number and type of medication errors (omissions) were compared between controls and those using the tool. Based on the findings from this phase of the study, we refined the tool and then implemented it on four medical/surgical units in a large academic teaching hospital and a smaller, affiliated community hospital. We compared medication error rates using hospital safety report records and discrepancies (i.e., delays in ordering, omissions) before and after implementation of the tool.

RESULTS

Accuracy of the medication history improved significantly with student nurses who used the tool versus those who did not (87% versus 74%, P = 0.010). We were unable to evaluate the numbers of medication discrepancies in the academic medical center because of a lack of availability of electronic admission history and physical reports during the study period. At the community hospital, there was a significant increase in the percentage of patients without medication discrepancies (before = 20% versus after = 42%, P = 0.017), a significant reduction of minor medication omissions during the hospital stay (1.10 versus post 0.60, P = 0.003) and a trend toward the reduction of important drug omissions in the discharge summary (pre 0.43 [0.71] versus post 0.18 [0.44], P = 0.053). The most common agents involved in a delay or omission were multivitamins, laxatives, antidepressants, antidiabetic agents, platelet inhibitors, and acid-suppressing agents.

CONCLUSIONS

The use of a structured tool to systematically obtain a medication history produced a measurable improvement in the accuracy of the admission medication list by student nurses and a reduction of medication errors in a community hospital.

Medication reconciliation at admission and discharge: a time and motion study

Background

Medication reconciliation at admission, transfer and discharge has been designated as a required hospital practice to reduce adverse drug events. However, implementation challenges have resulted in poor hospital adherence. The aim of this study was to assess the processes required to carry out medication reconciliation: the health professionals involved, the tasks and time devoted to medication reconciliation in general hospital settings.

Methods

A time-and-motion study design was used. Using a systematic sample of patients admitted and discharged from geriatric, medical and surgical units in two academic centers, health professionals involved in medication reconciliation were observed and timed. Descriptive statistics were used to summarize the number of professionals involved, tasks performed, and mean time devoted.

Results

Up to 3 professionals from 2 disciplines (medicine and pharmacy) were involved in the medication reconciliation process. Geriatric reconciliations took the most time to complete at admission (mean: 92.2 minutes (SD = 44.3)) and discharge (mean: 29.0 minutes (SD = 23.8)), followed by internal medicine at admission (mean: 46.2 minutes (SD = 21.1)) and 19.4 (SD = 11.7) minutes at discharge) and general surgery minutes at discharge (mean: 9.9 minutes (SD = 18.2)). Considerable differences in order, type and number of tasks performed were noted between and within units. Tasks independent of direct patient interaction took more than twice the time required to complete than tasks requiring patient interaction.

Conclusion

Lack of coordination, specialized training and agreement on the roles and responsibilities of professionals are among the most probable reasons for work-flow inefficiencies, possibly variability in quality, and time required for the current medication reconciliation process. A better understanding of the admission processes in general surgery is required. Standardization and use of electronic tools could improve efficiency and hospital adherence.

Using novel Canadian resources to improve medication reconciliation at discharge: study protocol for a randomized controlled trial

Background

Adverse drug events are responsible for up to 7% of all admissions to acute care hospitals. At least 58% of these are preventable, resulting from incomplete drug information, prescribing or dispensing errors, and overuse or underuse of medications. Effective implementation of medication reconciliation is considered essential to reduce preventable adverse drug events occurring at transitions between community and hospital care. An electronically enabled discharge reconciliation process represents an innovative approach to this problem.

Methods/Design

Participants will be recruited in Quebec and are eligible for inclusion if they are using prescription medication at admission, covered by the Quebec drug insurance plan, admitted from the community, 18 years or older, admitted to a general or intensive care medical or surgical unit, and discharged alive. A sample size of 3,714 will be required to detect a 5% reduction in adverse drug events. The intervention will comprise electronic retrieval of the community drug list, combined with an electronic discharge reconciliation module and an electronic discharge communication module. The primary outcomes will be adverse drug events occurring 30 days post-discharge, identified by a combination of patient self-report and chart abstraction. All emergency room visits and hospital readmission during this period will be measured as secondary outcomes. A cluster randomization approach will be used to allocate 16 medical and 10 surgical units to electronic discharge reconciliation and communication versus usual care. An intention-to-treat approach will be used to analyse data. Logistic regression will be undertaken within a generalized estimating equation framework to account for clustering within units.

Discussion

The goal of this prospective trial is to determine if electronically enabled discharge reconciliation will reduce the risk of adverse drug events, emergency room visits and readmissions 30 days post-discharge compared with usual care. We expect that this intervention will improve adherence to medication reconciliation at discharge, the accuracy of the community-based drug history and effective communication of hospital-based treatment changes to community care providers. The results may support policy-directed investments in computerizing and training of hospital staff, generate key requirements for future hospital accreditation standards, and highlight functional requirements for software vendors.

Trial registration

NCT01179867

Perceptions among general medical practitioners toward implementation of medication reconciliation program for patients discharged from hospitals in Penang, Malaysia

OBJECTIVE

This study aims to explore the perceptions of general practitioners (GPs) from the state of Penang toward the feasibility of implementing the medication reconciliation program in Malaysia.

METHODS

A cross-sectional descriptive study using a validated, self-completed anonymous 18-item questionnaire was undertaken over a period of 2 months in 2010. The study was conducted in the state of Penang, Malaysia. A letter consisting of survey questionnaires and prepaid return envelope were mailed to 429 GPs identified from the Private Medical Practice Control Department Registry.

RESULTS

A total of 86 responses were received with response rate of 20.1%. Majority (90.1%) of the respondents agreed that medication reconciliation can be a feasible strategy to improve medication safety, and 97.7% confirmed that having an accurate up-to-date list of the patient's previous medication will be useful in the rational prescribing process. However, about half (56.9%) of them felt that standardization of the medication reconciliation process in all clinics will be difficult to achieve. Three quarters (73.2%) of the respondents believed that the involvement of GPs alone is insufficient, and 74.5% agreed that this program should be expanded to community pharmacy setting. More than 90% of the respondents agreed upon the medication reconciliation card proposed by the researchers.

CONCLUSIONS

General practitioners in Penang are generally in favor of the implementation of medication reconciliation program in their practice. Because medication reconciliation has been shown to reduce many medicine-related problems, it is thus worth considering the feasibility of nationwide implementation of such program.

Drug-related problems in older people after hospital discharge and interventions to reduce them

Drug-related problems in older people during care transitions have become a major public health problem since they threaten patient safety. The objective of our paper is to investigate the extent and frequency of drug-related problems (discontinuity, adherence, errors, interactions and adverse events) after hospital discharge and the efficacy of interventions intended to reduce them. We included 20 studies in the review. All of them underlined the high frequency and complexity of drug-related problems in older people after hospital discharge. Interventions proposed to improve care transitions led to diverse and sometimes contradictory results, but the findings suggested that combining hospital discharge measures with home follow-up strategies is of value. We conclude that it is not possible to estimate the frequency of drug-related problem through a review of selected articles or to evaluate the efficacy of the proposed interventions. More research is needed in this field to reduce uncertainty and generate evidence-based recommendations for physicians.

Use of information technology in medication reconciliation: a scoping review

OBJECTIVE

To identify studies involving information technology (IT) in medication reconciliation (MedRec) and determine how IT is used to facilitate the MedRec process.

DATA SOURCES

The search strategy included a database search of MEDLINE and Cumulative Index of Nursing and Allied Health Literature (CINAHL), hand-searching of collected material, and references from articles retrieved. The database search was limited to English-language papers. MEDLINE includes publications dating back to 1950 and CINAHL includes those dating back to 1982. The search included articles in both databases up to March 2009. Boolean queries were constructed using combinations of search terms for medication reconciliation, IT, and electronic records.

STUDY SELECTION AND DATA EXTRACTION

Three inclusion criteria were used. The study had to (1) involve the MedRec process, (2) be a primary study, and (3) involve the use of IT. Selection was performed by 2 reviewers through consensus. Data related to study characteristics, focus, and IT use were extracted.

DATA SYNTHESIS

The included studies described a range of IT used throughout the MedRec process, from basic email and databases to specialized MedRec tools. A generic MedRec workflow was created and types of IT found in the studies were mapped to the workflow activities as well as to a set of functionalities based on the Institute of Medicine's Key Capabilities of an Electronic Health Record System. In the studies reviewed, IT was mainly used to obtain medication information. Although there were only a few MedRec tools in the studies, those that did exist supported the central activities for MedRec: comparison of medications and clarification of discrepancies.

CONCLUSIONS

MedRec is an important process to ensure patient medication safety. Evidence was found that IT can and has been used to facilitate some MedRec activities and new applications are being developed to support the entire MedRec process.