If you are unfortunate enough to be brought unexpectedly to the hospital ED, you may find yourself being asked questions about the medications you take without much chance of giving a decent answer.  In such cases other methods must be used to find the relevant information.  The process is often referred to as medication reconciliation, and it is such a difficult problem that the Joint Commission has placed it at number six (NPSG.03.06.01) on their list of National Patient Safety goals.

What is medication reconciliation?  It’s the process whereby a hospital is expected to:

  1. Obtain information on medications the patient is currently taking when he or she is admitted to the hospital or is seen in an outpatient setting.
  2. Provide patients (or family as needed) with written information on medication the patient should be taking when he or she is discharged from the hospital or at the end of an outpatient encounter. [1]

Resolving med lists sounds sounds pretty straightforward until you consider the fact that patients are not the best historians and obtaining a medication list from them can be hard.  Worse still, emergency patients rarely have time to grab for their bag of medications before they leave for hospital, may be confused, or unconscious, and consequently not be in a good position to describe the dose, route, or name of each medication they are taking to their intake nurse or in-hospital pharmacist.  In such cases medication reconciliation relies on a range of other techniques, and may be only partially successful, resulting in potential patient harm from missing medications, incorrect dosage, or a range of other effects.

One widely used approach is to try to obtain a best possible medication history (BPMH), a two step process that focuses on “obtaining a thorough history of all prescribed and non prescribed medications by using a structured patient interview, and verification of this information with at least 1 other reliable source of information (for example, a government medication database, medication vials, patient medication lists, a community pharmacy or your PCP” [2]  This YouTube video prepared by the Australian Commission on Safety and Quality in Healthcare may be helpful in describing the process (Note that ACSQH extends the two step model to a four step process including EMR entry).

There are well defined processes for BPMH such as the Medications at Transitions and Clinical Handoffs (MATCH) developed by the Agency for Healthcare Research and Quality (AHRQ) NorthWestern, and the Joint Commission.  MATCH describes a series of steps that institutions can use to develop effective medication reconciliation process that meet their institutions needs, as well as providing guidance on how to implement best practices.

BPMH is inherently manual, although systems such as EMRs can simplify the book keeping through the use of workflow and quality control mechanisms such as ensuring that impossible combinations of compound and dose are avoided.  Further labor savings can be obtained using products such as SureScripts Medication History for Acute and ED Settings, that aggregates data from pharmacies and prescription benefits systems (PBMs), allows queries to be started from inside the EMR, and integrates with the patient’s record.

In the ideal world much of the information needed would be available through local health information exchanges (HIE) aggregating the pharmacy data into a regional record of medication use. HIEs have data from documents such as discharge summaries that often contain a reconciled list of meds from a prior visit, and can be used to speed up the process for readmits.

BPMH is not always effective in emergency situations, and during a recent admission I had a chance to test the effectiveness at a large academic medical center.  The results were less than stellar as I was confused and could not recall many of my medicines or doses.  Worse still, my personal health record and medication bottles were at home locked in our safe, and my wife, who was with me at the hospital emergency room, had even less idea about the meds than I did.

To verify the medications, the hospital rang my pharmacy and ran a check on the state controlled substances website.  Thirty percent of the results were medications I was no longer taking, but they were ordered during my stay and arrived at my bedside where I refused them.  Ninety percent of my medicines were at the wrong dose, or given at the wrong time of day, and in many cases I did not detect the discrepancy until the following day.

Over the next two days the situation normalized.  More information trickled in, and eventually the set of meds prescribed became the meds I had at home.  Interestingly, nobody asked about non-prescription medicines, which could certainly interact with my normal regimen; a major omission that surprised me.

While this wasn’t a great experience I was lucky and suffered no long term harm. Not everybody has been so lucky, and it’s common for people in the field to refer to Medication Reconciliation as “MedWreck”, because it is such a rat’s nest of problems.  Given the amount of information required to perform BPMR, and the likelihood of conflicting information, it’s not hard to see why.

 

[1]  Joint Commission, Meaningful Use Have Hospitals Focused on Medication History and Reconciliation.

[2] Medication Reconciliation During Transitions of Care as a Patient Safety Strategy: A Systematic Review

Janice L. Kwan*, MD; Lisha Lo*, MPH; Margaret Sampson, MLIS, PhD; and Kaveh G. Shojania, MD

Ann Intern Med. 2013;158(5_Part_2):397-403. doi:10.7326/0003-4819-158-5-201303051-00006

 

 

 

 

 

 

2 thoughts

  1. great post. I do carry my med list on my phone & keep it updated, but yet it still doesn’t seem enough especially in the hospital. The kicker is also that medicines are often substituted if one is not carried by the hospital pharmacy. However, how often does a patient or someone outside healthcare really know it’s an equivalent medicine? I feel your pain. This is also an issue in rehabilitation wings of skilled nursing facilities too. It’s a real concern. The problem is also compounded if those of us with chronic or rare diseases have to utilize more than one health system. The lack of coordination between those entities is staggering too. In certain systems no one even wants to bother calling to verify. I’ve had that issue to & more than once been made to be the go-between between systems from my hospital bed because the staff refuses to do so, even when they want the information.

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