Professional Documents
Culture Documents
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precipitate one or more allergic reactions, food and drug interactions, and/or drugdrug interactions. Medication reconciliation is an extremely important process that
needs to take place every time a patient is involved with any health care system.
Therefore, medication reconciliation was clearly an excellent choice when, in
July 2004, Our Lady of Lourdes Memorial Hospital, Inc., Binghamton, New York
(Lourdes Hospital), was asked by Ascension Health Ministries to participate in one
of the eight Priority For Action Teams, whose goal was to have no preventable
deaths by July 1, 2008. Medication reconciliation was one way to achieve that goal.
The Adverse Drug Event (ADE) Priority for Action (PFA) Team selected by
Lourdes Hospital was to be mostly composed of direct patient care nurses from all
departments (from inpatient to outpatient) and management from various clinical
and nonclinical backgrounds, including a pharmacist, a clinical nursing director, a
physician, a management engineer, and the chief nursing officer. During the initial
team meetings, a crystal clear definition of medication reconciliation was agreed
upon so that the medication reconciliation task could be implemented across the
organization. (See the box below for the definition of medication reconciliation as
well as the language for National Patient Safety Goal 8, which pertains to medication reconciliation.)
Because this particular chapter pertains to the nurses role in medication reconciliation, it is presented in the nursing process format, wherein the nursing assessMedication Reconciliation: The process of comparing a patients
medication orders (those newly prescribed) with all the medications the
patient takes (previously prescribed as well as self-prescribed, including
over-the-counter products such as herbals and supplements).1
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ment leads to the diagnosis of the problem, the planning of the goals and outcomes
is followed by the implementation of the process, and subsequent evaluation and
measurement dictate the success or failure of the process.
Assessment
Assessment of the issues involved with implementing medication reconciliation by
using a pilot unit
In September 2004, the organization chose the cardiac telemetry unit as a pilot
unit in which to assess and introduce the idea and subsequent use of medication
reconciliation. The first test of change for the new process included the following
participants:
One nurse (who was a member of the ADE team)
One physician (who admitted a high number of patients to the pilot unit and
would be amenable to change)
One patient (who was typical of the patient population and had an accurate list
of current medications)
Prior to enacting the new process on the pilot unit, medication reconciliation
was designed with the nurse, physician, and patient in mind. In the beginning, the
hospital system considered several factors: change theory, adult-learner theory, additional paperwork, staffing crises, and the typically hectic, busy nature of a nursing
unit. The nurse on the pilot unit as well as the selected physician had to be convinced that the benefit of medication reconciliation outweighed the burden of yet
another change, more paperwork, and the potential for being overwhelmed. At
first, the medication reconciliation process seemed complicated. Staff members perceived the additional paperwork as tedious. The nurses were naturally resistant and
reluctant to embrace another change. They needed to know that the ADE team
empathized with them and the ADE team needed the support of the nurses for the
process to be successful.
The process was to compare the patients current medications with the medications that the physician ordered on admission to the hospital. That seemed simple
enough; however, it was a change to the process and procedure, which created a new,
time-consuming, detailed system that was absolutely necessary (and soon would be
supported by policy). Fortunately, when the organization presented the process
change to nurses from the perspective of patient safety, nurses recognized its importance. After the test of change on the pilot unit by the core individuals involved was
successful, the idea was to spread the change. Nurses were beginning to incorporate
and streamline medication reconciliation. The first test of change identified issues
that the health care team had not considered, including the following:
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Nurses had to ask patients for lists of their current medications, which often
were incomplete.
Physicians had to order new medications that were pertinent to the hospital
diagnosis as well as to the patients current medication unless there was a duplication or an interaction.
Pharmacists had to evaluate all the medications ordered for food and drug interactions and drug-drug interactions.
Nurses were going to ask local pharmacies for pertinent information regarding
patients medications over the telephone.
Family members would be involved to reconcile a patients current medication.
The goal was to first make medication reconciliation on admission successful
on the pilot unit and then to spread the process to the emergency department
(ED), then to the remainder of inpatient nursing units, followed by the outpatient
areas, the off-site areas, and eventually on discharge from a hospital.
Diagnosis
Discussion of the current and potential problems for the patient and the nurse
Planning
Statement of the specific goals, action plans, and outcomes for patient safety
National Patient Safety Goal 8 defines the purpose of medication reconciliation, which is to avoid errors of transcription, omission, duplication of therapy, and
drug-drug and drug-disease interactions. The Joint Commission answers the question as to who is supposed to complete the medication reconciliation process in its
Frequently Asked Questions, which are posted on its Web site.2 According to the
Joint Commission, there are the following two models:
1. The physician completes the medication reconciliation process when he or she
writes the orders.
2. The pharmacist or nurse completes the medication reconciliation process before
preparing or administering the medications, and then notifies physicians if any
concerns arise.
The team decided that throughout the Lourdes Hospital system every nurse
will ask each one of his or her patients, on admission to the patient care unit, for a
list of the medications they are currently taking and will fill out a medication reconciliation form accordingly, with a good faith effort to obtain as complete a list
as possible, within 24 hours or less.1 Besides the actual medication, the nurses will
include the following information: dose, route, frequency, reasons for taking the
medication, and the time of the last dose taken.
herbal/natural products) will not be made available to hospital patients. A multidisciplinary team made this decision to prevent adverse drug events, and the
director of the pharmacy and the Lourdes Hospital Patient Care Services Policy
Figure 1-1: Medication Reconciliation/Physician Initial Medication Form
NKA, no known allergies; US, unit secretary; RN, nurse; MD, physician; Pt, patient.
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If and when the patient ever needs to be hospitalized, the updated medication
list from the primary care chart can be used with ease as the medication reconciliation/physician initial medication order form in the hospital chart. The only
items required will be the physician signature, date, and time at the bottom of
the list, and they can be included in the admission paperwork as medications
reconciled and medications ordered, thus saving time and steps and ensuring
each patients medication safety.
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practice because pharmacies across the nation are compelled to provide medicationinformation teaching sheets for any drug that is dispensed.
Implementation
Including tasks in the process and documenting observations
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assessed and initially treated, the primary nurse in the ED asks for her current list
of medications. The patient produces a Lourdes Hospital medication card from her
wallet that contains an up-to-date list of her medications, the doses in milligrams,
the times she takes them, and why. Her primary care physicians name and telephone number and an emergency contact and telephone number are also on the
card, as well as a brief summary of her health history, her allergies, and a list of
questions to ask about herself. Because she is alert and oriented and has been initially treated for dyspnea, the patient is able to tell the ED nurse exactly what
medication she has already taken today and what medication she still needs. This
information is then put on the medication reconciliation form that stays with her
chart for the entire hospitalization. When her admitting physician arrives to evaluate the patient, he can use this form (by simply circling the appropriate words) to
continue the same medications and/or stop other medications and/or order new
medications. By signing the medication reconciliation form at the bottom, the
medication reconciliation form becomes a physician initial medication order form
and is faxed to the pharmacy. At this time, the pharmacy is authorized to prepare
the medications for the nurses to administer. The ED nurse gives a face-to-face
report to the receiving nurse on the telemetry unit together with all that he/she
knows about this patient, including the medication reconciliation information. By
the time the patient arrives on the telemetry unit, her current medications have
been ordered and reconciled, the MAR has been printed, and the medications that
the patient did not already take today are ready to be administered. If there are
any new medications ordered or current medications stopped, the nurse can incorporate this information into the initial plan of care.
Example 2: A woman in her forties is brought into the ED by paramedics because
she was found wandering a residential neighborhood at 3:00 A.M. She knows who
she is and knows that yesterday was her birthday. She says she was celebrating
and her blood alcohol content on arrival was 0.29%. After she is assessed and
treated, the ED nurse attempts to ask her about her health history. The patient
continues to alternate between dozing off and repeating incomprehensible words.
The ED physician decides to admit the patient. The ED nurse cannot possibly
complete the medication reconciliation form, there are no family members present,
and the hospital pharmacy is closed because a 24-hour pharmacy does not exist at
Lourdes Hospital yet. Any retail pharmacy would also be closed at this time of
night and the hospitalist assigned to this admission does not know the patient at
all. When giving the report to the receiving unit, the ED nurse apologizes for the
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incomplete medication reconciliation form and asks the receiving nurse to make a
good faith effort in the morning toward reconciling this patients medications.
The next morning, the patient is more coherent and is questioned about any and
all medications that she may have been taking prior to her admission to the hospital. At this time, the patient is able to state to her nurse what she takes but does
not know the doses and she cannot remember anything about the day before. She
uses a local pharmacy and has given the nurse permission to contact the pharmacy
to obtain the medications and doses she takes. The nurse on the medical unit to
which the patient is assigned places a call to the pharmacy, and identifies herself
and the reason for her call. The local pharmacist asks for the patients demographics and then gives the nurse the requested information as to her patients medications and dosages. The nurse now places a call to the patients physician to request
the current medications and appropriate dosages for the patient. (She is taking escitalopram oxalate, metoprolol, ciprofloxacin, a nicotine patch, and ibuprofen.) Her
medications are reconciled and she is started back on her same drug regimen except
for the over-the-counter ibuprofen. (To prevent any potential gastric reflux or
ulcers, the ibuprofen was discontinued and pantoprazole sodium was ordered, as
well as folic acid, thiamine, vitamins, and diazepam to move her safely through
alcohol withdrawal.)
These two examples are at opposite ends of the spectrum when considering
medication reconciliation, but, as stated previously, it is the primary goal of keeping
patients safe that compels nurses to continue toward completing the medication
reconciliation process, regardless of how difficult this is to accomplish, at every portal of the system. Most of the time, medication reconciliation is successful because
of the initial steps the nurses take. There has been remarkable success in reducing
adverse drug events with the incorporation of medication reconciliation at Lourdes
Hospital as evidenced by the evaluation and measurement described below.
By August 2005, the goal of medication reconciliation (to reduce nonreconciled medications to <50%) on admission for all inpatients and, on admission and
on discharge for all ED patients and, at each visit in the primary care setting had
been met for the past six months. By August 2006, the goal of medication reconciliation (to reduce nonreconciled medications to <6.25%) on admission for all inpatients and all sites (inpatient, ED, ambulatory surgery, primary care) and on transfer and discharge had been met for the past 16 months. As evidenced by the statis31
References
1. Miller L., Mannino C.A.: Taking the Lead in Medication Reconciliation. The Cerner
Quarterly 2(2):4047, 2006.
2. The Joint Commission: FAQs for the 2006 National Patient Safety Goals. http://www.joint
commission.org/NR/rdonlyres/7C116D6D-AE82-449E-BA45-1DE49D2A0A34/
0/06_npsg_faq.pdf (accessed Jan. 22, 2006; site now discontinued).
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