Originally introduced as a National Patient Safety Goal by The Joint Commission in 2005, medication reconciliation remains a challenge for many hospitals.
HCPro recently surveyed 43 facilities to find out what methods, policies, and procedures most healthcare facilities use to implement the medication reconciliation process. Most are healthcare facilities in urban (44%) and rural (40%) settings, with the minority in suburban (16%) settings. Most are smaller facilities, with fewer than 150 beds (63%).
Most respondents use paper medical records to document the medication reconciliation process, although 47% use electronic methods or a combination of electronic and paper methods. Electronic methods fare better during survey time, says Kurt Patton, principal of Patton Healthcare Consulting, LLC, in Glendale, AZ. He says electronic records can help keep medication list redundancy to a minimum, which lessens the chance of error.
Document only in one location
“The tip I give to organizations is to document meds in only one location, on the med rec list. The physician should refer to that list in the history and physical, and the nurse should refer to that list in the initial nursing assessment,” says Patton. “But don’t start to create additional or redundant lists of medications. One, it’s unnecessary. Two, it creates opportunity for error.”
Redundant lists can certainly be curtailed without a fully electronic process, says Susan Netherland, RN, director of quality management at Morehead Memorial Hospital in Eden, NC. Using the order form as the medication reconciliation form, with admission and discharge sections listed, helps keep everyone literally on the same page. And because it’s an order form, the same list is also reviewed by pharmacy.
Redundant lists aren’t the only woes of those trying to comply with dreaded Goal #8. The survey reported that 52% of respondents documented medication history at admission in radiology, 60% in ambulatory clinics, and 48% in other areas, including emergency and inpatient care. However, 90% of respondents said they did so in ambulatory surgery.
“That’s very problematic for hospitals because The Joint Commission looks for the reconciliation list to be created for every location of the hospital where you’re going to get meds,” Patton says.
Although hospitals still struggle to get the process in place in all units, 44% of respondents reported going beyond documentation requirements of The Joint Commission (formerly JCAHO) at admission, and 36% said they did so at discharge.
Most of the extra documentation was noting that the medication list was created at admission and given to the patient at discharge.
Patton says this extra step can help, but whether it’s necessary depends on the facility. “I recommend it if people have difficulty verbalizing what the hospital’s process is,” he says.
Look at documentation
Another area of the survey highlights the struggle hospitals face trying to fully integrate the process into hospital culture.
Most respondents (57%) said their documentation requirements affect work flow, such as not releasing a patient until instructions and a medication list are signed by a physician. This is a troublesome finding to Patton, who says the patient needs both but shouldn’t have to wait for them.
“You don’t want the reconciliation process to be delaying the discharge process,” says Patton. “The reconciliation process is such an integral part of the discharge process … We need to figure out a way to weave that in before the physician shows up on the morning of discharge and says, ‘Send them home.’ ”
Patton says that similar to the discharge process, preparing the medication list for the patient should start a few days prior to the actual discharge. The most important cultural aspect of the goal, which Netherland champions, is getting staff members (physicians in particular) to analyze the list before they sign off on it.
The same goes for quality staff members performing audits on the process, says Patton. Simply ensuring that staff members create a list is not passing an audit, he says.
Quality staff members must “dig through the list a little bit more” to determine whether every medication on the list was addressed, ensure documentation of the decision-making process, and check for redundant and discrepant lists elsewhere in the patient’s documentation, he says.
Although 86% of respondents said they have an audit process in place to monitor compliance with the medication reconciliation process (see Figure 3), the majority of respondents (57%) also said they have not begun auditing the accuracy and quality of the content of the medication list either at admission or discharge.
“What I see is a failure to reconcile,” says Patton. “Everybody is gathering a list, but people aren’t analyzing that list adequately.”