ISMP Survey on Medication Reconciliation

Total: 1610
About you
1. What is your profession?
Nurse 69%
Other 5%
Pharmacist 22%
Physician/prescriber 4%
2. What is your staffing level?
Administrator 13%
Manager 34%
Other 18%
Staff 35%
3. Are you familiar with the JC NPSG related to medication reconciliation? 91% - Yes 9% - No
4. Have you attended inservice education regarding your role in medication reconciliation? 74% - Yes 26% - No
About your facility
5. In what type of facility are you employed?
Assisted living 2%
Home care 4%
Hospital 81%
Long term care 3%
Other 3%
Outpatient/office-based facility 5%
Surgery center 2%
6. For admissions, how long has a medication reconciliation process been in place on your unit/in your department/facility? 
0 months 8%
1-3 months 18%
3-6 months 28%
6-12 months 19%
Don’t know 10%
More than a year 17%
7. For transfers to a different level of care, how long has a medication reconciliation process been in place on your unit/in your department/facility? 
0 months 13%
1-3 months 17%
3-6 months 23%
6-12 months 17%
Don’t know 13%
More than a year 18%
8. For discharges from your care, how long has a medication reconciliation process been in place on your unit/in your department/facility?   
0 months 13%
1-3 months 19%
3-6 months 22%
6-12 months 16%
Don’t know 15%
More than a year 16%
About your process

9. Who is primarily responsible for the following (you may choose more than one category)…

 Nurse Pharmacist Physician/ Prescriber Medical Records Other Don’t Know
a. Collecting an initial medication history 82% 5% 27% 1% 2% 0%
b. Assuring the medication history is accurate 68% 19% 40% 1% 2% 3%
c. Reconciling medications between the history and the admission orders 56% 23% 44% 1% 2% 4%
d. Reconciling medications upon transfer of a patient to another level of care 59% 19% 46% 0% 2% 4%
e. Reconciling medications at the time of discharge 60% 10% 50% 0% 2% 6%
f. Sending the patient’s discharge medication list to the patient’s physician/next provider 45% 3% 16% 8% 9% 22%
10. After an admission medication history is obtained, your policy states all medications must be reconciled within how many hours?
12 11%
24 41%
36 2%
48 4%
Not Sure 30%
Other 13%
11. Does your policy specify a different timeframe for reconciliation depending upon the critical nature of the drugs on the medication history list?
No 52%
Not Sure 35%
Yes 13%
12. Your medication reconciliation process is documented on which type of form?
Combination of both 24%
Computer charting system 15%
Not documented 4%
Not sure 6%
Paper chart 50%
13. Does the prescriber order medications directly on the same form or screen used to document the initial medication history?
Always 31%
Never 44%
Not Sure 10%
Sometimes 16%
14. Please rank the relative importance of success factors and barriers encountered during the implementation of the medication reconciliation program at your facility. Scale: 1=most important, 8=least important (use each number once in the ranking process).
a. SUCCESS FACTORS
Rank
b. BARRIERS
Rank
i. Teamwork among disciplines
1 52%
2 15%
3 10%
4 7%
5 5%
6 3%
7 3%
8 4%
i. Unreliable patient
1 39%
2 16%
3 13%
4 9%
5 7%
6 6%
7 6%
8 4%
ii. Clearly defined protocols
1 36%
2 23%
3 12%
4 10%
5 7%
6 4%
7 4%
8 4%
ii. Documentation from other sources
1 19%
2 19%
3 16%
4 14%
5 12%
6 9%
7 8%
8 4%
iii. Centralized history form/screen
1 30%
2 20%
3 15%
4 12%
5 8%
6 6%
7 6%
8 4%
iii. Lack of teamwork among disciplines
1 28%
2 16%
3 16%
4 12%
5 10%
6 7%
7 7%
8 5%
iv. History collection by pharmacist
1 10%
2 7%
3 9%
4 11%
5 11%
6 11%
7 21%
8 18%
iv. Extra burden
1 20%
2 16%
3 14%
4 15%
5 11%
6 8%
7 10%
8 6%
v. Easy communication with outpatient providers
1 15%
2 13%
3 12%
4 13%
5 13%
6 17%
7 12%
8 5%
v. Lack of frontline staff input into process
1 17%
2 13%
3 14%
4 14%
5 13%
6 13%
7 9%
8 7%
vi. Reasonable expectations for “complete” history
1 22%
2 18%
3 15%
4 14%
5 12%
6 11%
7 6%
8 3%
vi. Lack of administrative leadership 
1 15%
2 12%
3 11%
4 10%
5 12%
6 13%
7 17%
8 9%
vii. Awareness of the role of each contributor
1 22%
2 17%
3 15%
4 13%
5 10%
6 9%
7 10%
8 4%
vii. Lack of physician leadership
1 29%
2 17%
3 11%
4 11%
5 8%
6 9%
7 9%
8 6%
15. On a scale of 1 to 5, with 1=not valuable and 5=very valuable, please select a number below indicating your perception of the value of the medication reconciliation process to patient safety overall:

1 3%

2 5%

3 10%

4 20%
5 62%

16. Other comments:

The presentaion of this NPSG is just one more in a lne of JCAHO requirements for which there is no template. It is untested or at least not completely tested. This is a problem for which there must be a global solution not a piecemeal, patchwork of systems. The reality is that our healthcare system is not amenable to a global solution at this point and time in history. This is another demand on all healthcare providers in place of something that they were already doing. Advice on this NPSG has gone from, "it is the providers responsibility to reconcile, to the pharmacist, nurse or provider. Who do you think will end up with this one? This has gone from inpatient only to outpatient clinics. There are a few systems that are remarkable within themselves, (the VA for example)however, in most cases, an accurate transfer to another system or provider is not there. It is likely that there will be many RFI(s) written on this one before JCAHO backs up on this one. In some cases this NPSG will cause a more dangerous patient safety scenario, rather that one that is safer. And since it has gone so far, it will be extremely difficult for them to retract this one. Perhaps they will at least give our healthcare system a little more time...

JCAHO has instituted several safety issues in the last few years that are wonderful in theory but an absolute nightmare in accomplishment. Physicians should assume more responsibility in this process.

The more comprehensive the reconiciliation process appears, the more likely that staff will depend on it as accurate. This is dangerous because the information is often incomplete because of fragmented care. The process is very valuable in a setting where the sources of providing medications is limited.

Very valuable, but difficult process especially when trying to reconcile physician History and physical with the medications that the patient states they are currently taking.

Many of your "Success factors" are barriers at our facility. History collection is the Physicians ultimate responsibility, often done by nursing staff. Pharmacist involvement is minimal due to staffing/ & lack of Physicians asking for help from Pharmacy. Communication between facilities and retail pharmacies is poor at best, and would benefit if a formalized universal method of communicating med profiles can be instituted preferably via electronic processing.

When JCAHO wanted this, they should have given guidelines for staffing, forms, and how we should do it. We have spent more time on the forms and the process than any other project. We have also had to increase staffing in pharmacy without reimbursement from from any insurance or other payer.

On the medical unit that I work on, the most frequent problem is patients who come in without a clear medication list. They give additional info for at least two more days after they are admitted. The greatest help to us is what only one physicians' group does is to send over a clear and current med list from the office on addmission.

I am a CNS in a Regional Perinatal Center. I clearly see the value of medication reconciliation, but I have not been successful in helping to see the value in the process for our patients. They clearly see the value for Med-Surg units, but not for Ob. As women are aging and still having babies, the number of meds they take also increases. My nurses think it's all about prenatal vitamins and iron.

Medication Reconciliation has brought to the forefront, the numerous problems in obtaining and continuing accurate patient medication information. If the problem is not corrected at the admission, the problem continues until the first office visit at the patient's primary care provider where it is identified. Until there is a national database for patient medication histories, medication reconciliation will be continue to be problematic for all- doctors, nurses, and pharmacies! Staffing issues continue to threaten this very necessary process as it takes time to complete an accurate history. As hospitals stuggle to change to all encompassing computer systems, hospitals that have both paper and computer systems will continue to be burned by this process. I could elaborate more on our challenges and opportunities for improvement but due to lack of time I can't at this time. Mary Cubick, Pharm.D.

A resource intensive process to start, will take a culture shift to get everyone on board; if done right at the first time will have much success. Important to undertand how patients enter the system. This is a journey that will take at least 12- 24 months to get significant measurable results. If presented up front as a safety initiative not to meet some regualtory or accreditation needs, there is better acceptance.

JCAHO NPSG 8 A&B requirement of 100% compliane is quite a challenge. We are part of a seven hospital system with multiple other outpatient and long term care facilities. As a system we are in the process of standardizing our forms, communication stratagies and process across the continuum of care. To date our complince from data submitted is 81-85%. Medications missed at discharge are multivitamines, glucosamine, birth control pills- mostly OTC meds.

education of the patients is upmost in my mind. So many men say "ask my wife" when asked what meds they take. When taking medicine hx I ask what each med is used for, this helps to eleminate wrong med names. About 10 years ago our hospital printed a med list card that we fill out in pencil with the Drug name, Dosage, How often it is taken and for what purpose. The card folds to the size of a credit card and seems to be well received by our patients. The patients and their families are then responsible to keep it current and keep it in their wallet or purse. The hospital gets these out to the patients at health fairs and through admissions to the hospital. It does at times take up my time by completing this card, but I really express to the patient and their famlies how very important this card is to their care. I have many times seen patients out in the community and they ask me if I could please get them another card, so they do use them.

Our process is coming along well, though the staff is still on a learning curve!

The physicians need to understand that working out the process for medication reconciliation is an ongoing project, just as any new process. Due to the many facets of this process, it is going to take a considerable amount of time to tweak to make this work for everyone. Even then, change is always possible.

MDs especially outpatient surgeons are highly resistant to the process. They feel that they are not the prescribers and they don't know the meds so they don't want to be responsible.

In our institution. I think the pharmacists and pharm techs would DIE before they ever became involved in anything like gathering data or speaking with a patient. There is not a process to "Hand over" the resposibility when this collection is very difficult to gather. Administration is so out of touch with what happens at the bedside that it is sad and dangerous because they are adding more and more to the caregivers' responsibilities that there is less time to do our jobs and more chances for errors and safety issues.

The med rec form is printed from the computer by a nurse on to a paper form where it is reviewed against the medications that are on the patient information form (filled out by the patient/family) and the patient. Forms are then faxed to the pharmacy.

I believe people do not know what their medications are for. They take a lot of supplements and over the counter drugs because of the TV push for such "wonder" drugs. They go see MD's for various specialities and no MD coordinates the care between the internist and the cardiologist and the urologist, etc. Hopefully, they use the same pharmacy so there is a check and balance.We have an elderly population and they may be on 35 different drugs and supplements. How can any one afford this and keep up with when and what to take?

While I believe that pt safety is of primary importance, I think the reconciliation process our facility has is too cumbersome, lacks clarity about how it is used, and has not been communicated well to all users. I don't see much difference in this process from prior admission process. It seems that errors often still get thru several people people before they are caught. Just yesterday I had one where an MD wrote for mg instead of the correct dose in grams. It went thru 5 people (MD, discharge planning RN, home care RN, hospital pharmacist and floor staff RN, before it was caught by the home IV pharmacist). The order was written correctly in on one form (by the discharge planning nurse) and incorrectly on another form (by the MD). This caused a several hour delay in the pt being discharged from the hospital due to need to contact MD and obtain clarification. No harm to the pt, but definitely inconvenience. It also caused an hour of overtime for the IV home nurse, and possibly for the home care IV pharmacist.

We're having difficulty with compliance with the process and ensuring reliability of the patient provided information.

the public should be educated to the importance of knowing their oun medical issues and choices.

hard to understand your ranking questions as to barriers, success factors

Getting started has been very challenging. Since we are a computerized facility, it tands to be somewhat cumbersome trying to unite the 2 processes. We enter meds on the Medication Reconciliation Form, but then have to enter onto the computer for hand out when patient is discharged. Our Biggest obstacle is getting the physicians to comply. Changing that behavior will take alot of time, even my best docs are lax in this area.

Before reading this I had no idea what medication reconcilitaion was. Thanks for making me more knowledgeable.

Hard to reconcill when patient's doctor offices closed and patient obtains medication through a mail order.

Given the computerized record we use, reconciliation is a matter of clicking on a tab - the outpatient, inpatient and other medications are there - plus a web clink to click on to get to other facilities - this should be an easy process for nurses and providers

My role as rn admitting,transfer and discharging a pt I am the last stop for pt safety in relation to their meds. I have a huge advantage of being in the home and actually looking at the bottles, the med cabinet, the kitchen counter,etc. I have to be sure they are taking the meds as ordered and communicate the list to all their doctors, this is an overwhelming job at times. I could not sleepat night if I did not give 100% every time evry visit. I may never know but I am sure I have prented med errors in the home by completing med rec. Thankyou Lora RN CPC

Providers and staff seem not to understand that all this does is formalize a process that has been poorly done for years. All they see is the increased liability, not the improvements for the pt. We had an interdisciplinary team implement, but it seems like every unit is different and has it's own cultural reaction to change.

oops, delete previous submission, wrong response #16

Many medications are not reconciled/ordered by the physician even though the patient has been on them at home for years and there are no contraindications for them. It is also difficult and time consuming to reconcile medications from patients that are unreliable and you have to call a pharmacy, family member, or physician office (this is particularly difficult when a patient is admitted at night). I wonder if both physicians and patients need to be more educated on the importance of medication reconciliation?

NOT ALL THE PHYSICIANS HAVE BOUGHT INTO THE IMPORTANCE OF MED RECONCILLATION.

As a homecare nurse, very often we get multiple different lists from hospital, rehab and what the patient has. Many times there is no explanation as to why a medicine change was made particularly when a patient was on one med at D/C from hospital and those meds changed at D/C from rehab. Also, the patient's medicines in the home can be very different from any of the lists we receive, and PCPs are often not put in the loop of med changes that occur during inpatient stays. It can be very challenging to try and figure out what the patient is really taking.

Medication reconciliation is a difficult process for many different reasons. A medication may be forgotten or also too many medications can be administered if the reconciliation is not done properly.Ideally a pharmacist should do the reconciliation with patient's meds, pharmacy list and patient interview , practically it needs too much resources.

The form is valuable only if it is completed/the pt. knows their medications and doses/the physician reviews.

The concept is valuable...the process and barriers with an accurate and timely process is what is lacking and causes most confusion.

becasue of the shortage of pharmacist the med reconciliation has more errors than before. Nurses do not know what they are doing, physicians do not wnat to spend the time listening to a nurse read off the list. The nurses do not know dosages, drugs, or even frequencies. This whole process is failing because of inconsistant nurses who just are not the drug experts. If there were more pharmacists or pharmacy students availalbe this would be a great process. It should be the pharmacist doing drug histories and reconciling withthe physicians. That is the only way to reduce errors!!!!

Medictation Reconciliation (MR) is a valuable NPSG to help reduce medication errors. Demonstrating the importance of the goal to physicians and nursing staff has been a major obstacle though training was implemented prior to its initiation. Teamwork among the disciplines is crucial for an effective MR process.

We are still having difficulties and problems with the whole process and have another team looking at it. At present, it could cause errors. For example, the medication list may not be complete because the pharmacy needs to be called. But the MD writes admitting orders and they are scanned to pharmacy. Then the next day the list is complete and the physician indicates which meds to continue in hospital. It is scanned to pharmacy. However, the doses are different than the admitting orders. Now which one is right?

Screens do not stay open long enough during my procedures for this valuable information to be readily available in the procedure room, without my ungloving and pulling it up again.

Very important issue, but complicated by many factors outside the control of the acute care hospital. These problems (accurate med history etc) cleary demonstrate the need for a central organized database of patients medical histories.

The toughest part of this process is getting everybody to agree that correct execution is worth the time it takes to implement. We are still in the formative stage, and it's been six months, because our main motivation was JCAHO last November.

I really feel that the initial reconciliation on admission is an accident waiting to happen. We have had some severe near misses. The MD takes these sheets as gospel... Needs to be fixed ????

This process is very lengthy and time consuming for nurses. This takes away valuable time that could be spent at the bedside. For our particular hospital, long-term ACUTE care, patients often have no idea of the meds because they have been in another facility for weeks or even months. On discharge, some patients have been here for 2-4 months and the med rec form can be multiple pages, once again, very time consuming.

Implementation was easier than we thought; our Nursing dept made the med recon form part of the initial admission assessment form; as an incentive to complete, Pharmacy had to have allergies on the assessment form in order to enter any meds into the computer system. The MDs absolutely love and have asked if we could set up computers in their lounges so they can access transfer or post-op MARs on their own. Still a WIP after 3-6mos. Started in December.

We struggle profoundly with physician willingness to assume responsibility for ordering of home meds in the hospital, or addressing home meds to continue/change when returning home. Surgeons have a completely "hands off" approach. "I don't know about most of the home meds, and it doesn't matter while they are in the hospital." Their position is that what they do in the hospital (i.e. orthopedic surgery) doesn't alter the meds the patient will take at home postop. Interestingly, they feel fine writing orders to "continue home meds" (in the hospital) and "resume home meds" (after discharge), but when provided a list of these meds, they do not want to address them individually. Much of the concern surrounds the accuracy of the home med list. The surgeons don't want to be held responsible if they indicate a home med is to be continued, then later find out that the dose was wrong (i.e. patient reported dose incorrectly). Our Medicine physicians (i.e. "Admit and Manage" MDs), are very thorough in their collection of detailed admit medication histories. However, they do not manage the surgeons patients. Difficult issues to resolve!

It takes a lot of time to do this accurately. On a busy med/surg unit you are constantly getting admissions and discharges and transfers. I know this is needed but it is very stressful trying to get it done along with all the other safety issues going on and also care for all the other patients on the unit. Many medical patients are on huge lists of medications. Patient acuity is higher than ever. To make this happen i think the government should be looking at ways to reimberse hospitals so more staff could be hired to help make this happen. We need more pharmacy and nurses to get this done timely and accurately. It would be nice to see some funding to help get adequate staff. It is all well and good to give directives but if the government wants it to happen they need to put their money where their mouth is.

The discharge process has been the most difficult to institute. The inpatient process has been the initial focus. Outpatient will follow after the inpatient process is completed.

Parents, for the most part, have been unreliable in providing information. For example, one parent said her child was on zantac. The physician ordered zantac. The child was on zyrtec, not zantac, at home. One parent told us the child was on Ritalin XR 100mg. Wrong dose, however, the physician ordered as Ritalin XR 100mg. More education needed.

I work in an outpt radiation clinic within a hospital. I find that the medication list is often not updated by the medical oncologist or NP at the chemo facility across the street

not too sure how to answer question # 14 in the barrier column.

Physician handwriting (poor) and use of non-approved abbreviations is often a challenge.

But I think that we are unduly burdening the other members of the healthcare team - this should remain a physician responsibility - with added emphasis on providing the patient with a written list. Also - we should work harder on educating patients as to keeping a list.

But I think that we are unduly burdening the other members of the healthcare team - this should remain a physician responsibility - with added emphasis on providing the patient with a written list. Also - we should work harder on educating patients as to keeping a list.

Facilities sending to us didn't realize that LTC is part of the continuim of care & it's taken quite a while for them to start sending med rec forms to us.

Difficult in obtaining Discharge Medication orders for Same Day Surgical Patients...usually attending physician is not on staff and Surgeon does not want to rewrite discharge meds since not the primary physician..big problem Any suggestions..since Attending not on staff, RN can not take phone order for discharge meds..HELP!!!!

The challenge is the physicians do not want to take the time nor the responsiblity in the medication reconiliation process. The other challenge is electronic medical records in producing the med rec form from what is entered often produces duplicates.

we don't have med. reconcilation

We still struggle with this whole process. Unfortunately, the Med Rec often is not completed until after medical staff has written orders, and then it is not always double checked. It is placed in the physician order section for medical staff to review, but this just doesn't happen. Need to come up with a way to get medical staff fired up over this.

It could be valuable but information is only as accurate as the patient gives it to you, so often you are doomed from the start with inaccurate information. Too often physicians will never look at the info just order whatever the patient says they are on.

It is important to note that pharmacy plays a vital role in this process. Nurses are not trained pharmacist and we are asking them to perform duties that a pharmacist should be doing (knowing all classifications of drugs, noting 2 or more drugs in the same class, food food food drug. Everyone plays a role, but pharmacy the most vital role

It is important to note that pharmacy plays a vital role in this process. Nurses are not trained pharmacist and we are asking them to perform duties that a pharmacist should be doing (knowing all classifications of drugs, noting 2 or more drugs in the same class, food food food drug. Everyone plays a role, but pharmacy the most vital role

We found that just starting the discussion of medication reconciliation increased awareness at all levels and we saw a decrese in errors. The most successful team has been the pharmacy and the nursing staff. The MD's are not very engaged in the process at this point but we are working on it.

Because of the lack of an interface with PBM's or outpatient pharmacies it is difficult to obtain reliable complete information. Many times caregivers are not aware of drug or dose of patients they bring in. Within hospital's without computerized records this perceived by many as another form to fill out as opposed to an opportunity to change/improve the process

Most patients are uneducated about their medications. Some just say, "heart medicine", "water medicine, "sugar medicine". Some wives take complete control and the patients know nothing. The providers do not update the computerized medication list after speaking with the patient about patient concerns, eg. patient doesn't tolerate medication and physician tells them to quit taking it, but doesn't indicate this in the medication list in any way.

The medication reconciliation goal is important to patient safety, however the information rises and falls on the information the patient provides to the health care team. In today's environment where we are short of both nurses and pharmacists the expectation of calling different outpatient pharmacies is burdensome and time consuming. There needs to be a major advertising blitz on the television and radio asking people to put together an accurate list of their medications, herbals and nutriceuticals. Physicians, nurses and pharmacists at our hospital see this goal as very burdensome and time consuming.

Needs community wide emphasis Most patients have only a vague idea of their meds Ideal to know all the meds Discharge reconciliation very difficult; impacts Core measures (CHF)discharge instr. Must find every med reconciled on discharge.

Med. Rec is a very valuable process but is a very complicated, time-consuming one. Would have been much easier if computerized software for med rec had been perfected before implementation Too much paperwork and duplication now on med rec form in addition to documenting in nurses admission history . Makes the complicated admission process even more time-consuming.We had to designate one nurse to oversee med rec per shift

I know what a crucial issue this is for patients but the majority of staff and physicians did not realize how significant an issue this is. We rolled out an initial process without input from staff which was not well thought out or correctly implemented and then had to form a task force and repeat a different process again. Then in the middle of the second change, the pharmacy department went with another MAR system and the plans that were made no longer applied. Things haven't gone well and we made this a bigger problem to implement than it should have been. One definitely needs the input of staff members to assure what is decided will work correctly in the system.

While I believe that medication reconciliation is important for patient safety, I think the current requirements are not reasonable, ie. at each transfer of level of care, outpatient procedures, the need for the last provider to send the list to the next provider. Patients need to take responsibility for some of these activities. Patients need to come to health care providers with their information and need to take responsibility for clarifying that information before discharge. Also, physicians want to defer this activity to nurses when they are the healthcare providers who need to order medications. Discussions about medications should occur between patients and physicians.

Due to incomplete medication histories on the Med Recon form, we have caused ourselves more work with this new process by trying to clarify orders. I understand the underlying patient safety goal. But the process is only as good as the home med list created.

Provides safety net that the patient's critical treatments will not be interrupted / neclected because of an acute problem.

While I understand the value of medication reconcilliation, it is at it's beginning phase and has had great actual and potential to cause harm rather than improve safety.

Our process is severely hampered by lack of resources (no additional pharmacy resources were hired to assist w/ this process) and by lack of physician support for educating their colleagues and holding the physicians accountable. This initiative has major issues that must be resolved or it will never be successful at our organization. We need more resources (personnel) and physician accountability.

I think this process will take two years to arrive at something that is workable and consistent for all hospitals and benefits every patient.

One of the main issues of medication reconciliation is physician's assessing and identifying patient's medications but the burden is thrown to the nurses due to physician has "no time" to sit and examine the orders. Physician responsibility & accountability should be emphasized and make them aware that patient safety should be their priority!

Medication reconciliation is important to patient safety. However, the barrier we have is that as a small facility with few staff all the documentation expectations are excessive. The time involved for documentation detracts from direct patient care not to mention the tracking of documentation for PI purposes. I can honestly say that in the 2 facilities I've recently worked, medication reconciliation has not reduced the number of medication errors documented facility wide.

process not working well and probably not as intended

Our patients are having minor, same-day surgery. The majority of them do not have to stop taking "anti-coagulating" medications before surgery due to the minimally-invasive type of surgery we perform. We are having a hard time coping with this new goal. A lot of our patients come in the morning of surgery and are interviewed for the first time then. We ask everyone to bring a copy of their current medication and OTC drugs/vitamins/minerals with them. IF they need transferred to another facility, we do have a transfer form that includes all current medications as well as what was given during surgery.

We have had problems with physician buy in and teamwork among disciplines.

Reconciliation is a very challenging process with many ways to accomplish the end result of a comprehensive med list. The challenge is choosing one road everyone can agree to and follow.

No one is disputing the imporatance of Medication reconciliation however it is a very difficult proposition to put into action.

Problems encountered include: patients that have no idea what meds they are on/patients unable to provide information, poor set up of computer screens - our computer screen provides information box to put comments - this does not carry onto the printed screen, making it difficult to get the information to the physcian. physicians have not bought into the process - continue to largely ignore the information.

It's a time consuming task yet highly important to assure patient safety. It is amzingly suprizing how many times medications are missed due to the lack of medication reconciliation. Furthermore, patient's health significantly deteriorate with transfers to different levels of care and the continuity of care is lost after discharge. It is truly amazing how something such as the medication reconciliation can make a difference between a short and a long, complicated hospital stay.

This is something that has been long over due. Electronic medical record systems makes this an easier process.

While nurses have taken on the primary responsibility to complete this tasks, pharmacist do not seem to have a role in the process and their role is desribed in vauge terms. Policy makers have not obtained valuable input from the nurses and physicians. The result is a complicated, disjointed, and time consuming process in which compliance is low.

Initial perception was just another piece of busy work however once implemented staff and physicians identified the importance of the process and that the process had been ongoing just not in a formal manner of documentation.

While the intent of the process is admirable the burden of the work is out of proportion to the benefit. The system does not prevent pt's from being discharged without the right Rx, it still depends upon patient recollection and does not address the tremendous variety of caregivers, care facilites, pharmacies, and Rx changes patients encounter. A mandate was added withoug any resouces to provide for it. Some form of universal communications system would be so much more helpful.

This was obviously meant for mainly "direct practice" providers. I think that faculty in universities should also be learning about this initiative, in order to introduce the concepts to their students.

To me the value of the process is obvious, but the process depends upon an unreliable patient, generally speaking, for the information. The acute care community hospital does not have the resources to effectively "make up" for the lack of good information from the patient. Patients must take more responsibility for their medication information but the hospital is being penalized NOW for an environment that they have little control over. We just try to view it that we are doing the best we can with the information that we are given.

Complicated form and process negatively implact clinician compliance in performing this important assessment.

Very little info is available from JCAHO. If they are to require a process, they should provide better guidelines as to what they want done, and HOW to go about it!

In our process, we utilized "small test of change" to get feedback from frontline staff several times to develop our form before rolling out to other facilities. We also engaged local retail pharmacies and nursing homes to promote to the public to utilize a medication record list (available on our website and wallet size cards. We encouraged the public to present their medication list whenever they came to the hospital.

I understand the intent of the NPSG but the burden of the process is on nursing. Nursing obtains the list of home meds, they enter on form for physician review but end up calling the physician, and is the one who truly reconciles and calls physicians. The lack of a national concensus to reach the public on the importance of keeping a list of current medications would be benefical. We recently had a unannounced JCAHO survey and with 3 surveyors we got 3 interpretations. We are not a teaching facility and do not have house staff around the clock which is a disadvantage for us in meeting the 24 hour deadline.

I believe that a little more direction from JCAHO would have been helpful. Many institutions have their process in place then they send-out updated guidelines which may result in a change for all concerned. I wonder about the true importance for the outpatient setting when there is a medication added. The process at our place is very time-consuming and does not often get completed because of that. My concern is - is med rec really taking place and are we getting an accurate list of home/discharge meds for our patients and is this home list being documented in the chart?

The patient should be required to bring a medication list with them to the hospital during pre-operative workups in the outpatient department. The pre-operative nurse could obtain this, put it on the initial assessment, and give a copy to the patient. If the patient does not have this information, the patient should be required to sign a form that would allow the physician to contact the pharmacist where the patient receives medications. I do not find a need for reconciliation between faiclities because all of the medications the patient is currrently taking is on the discharge form. People need to take responsibility for their own medications. The healthcare team can support through education. I do not believe it is the physician's responsibility to search for a list or information. Patients should be educated that they need to take a list of their medications with them. Actually, they should be educated to keep a list with them at all times. It is putting too much extraneous responsibili9ty on the healthcare staff to have to reconcile these medications. As stated, there is no problem with discharge, it is the actual admission that presents a problem.

But...the physicians are making this a "NURSING" issue. They don't want to be bothered. It's VERY time consuming on the RN's part. We have enough paperwork already. Yes, it's important, but nurses need some help. Getting patients to be responsible and knowledgeable about there meds is another BIG issure. They need to KNOW what they take and why.

The end result is what we need to focus on. Staff tends to get hung up on the growing pains of a new process. The concept of med reconcilialtion is great for patient safety. We just need to remember the patient when we are unhappy with fine tuning the process.

It's only as good as the effort we put into it and the availability of the information.

The process at my hospital is a new one, in which physicians check yes or no on a paper form listing medications. This form is then reviewed by the nurse, photocopied and sent to the pharmacy as a physician's medication order. The doctors are generally reluctant to change to this new process. They can also electronically order medications, but are required to still fill out the paper form. If there was one electronic medication reconciliation/order form, that would probably increase their compliance with the new policy. It would also be less time-consuming for doctors, nurses and pharmacists.

I think patients expect this has been done for years. Many physicians, nurses and pharmacist have done this for years but without specific documenation as to such. The problem is that some do not take the time for the process and errors occur.

I blieved it is unsafe to have a nurse hand write,( causing more errors)a complete list of medications the patient is to take on the new floor, when we have a typed medication form with the medications clearly stated. If they are not to be coniuned they should be disconitued as we have always done. We should gather a list of the medication a patient is on at admission and reconcile it atdiscarge. This writing and re-writing with every transfer with in a hospital is bad for safety. Even thing should be typed these days to include MD orders. When is JACHOgoing to demand the MD do their jobs and stop amking nurses do more while MD's do less and less.

THIS IS AN EXTREMELY DIFFICULT TASK. THERE ARE MANY EXCEPTIONS AND "OUT OF NORM" SITUATIONS THAT MAKE MED RECONCILLIAITON EXTREMELY CHALLENGING

The main problem with medication reconciliation is that patients expect any health place to know their meds and they assume it's not that important exact dosages or times a day. It is mind boggling how patients are clueless of THEIR role in THEIR OWN health care.

This is a very hard process to implement, regulate and track in our facility. Some of the NPSG were very straight forward - this one is not. While I think most of our staff feel it is important and do some level of reconciliation, the process is still foggy.

I have seen cases where the information was unreliable or misrepresented by the patient or their family member on admission. The physician was not familiar with the patient's full history, so the medications were authorized. Later the patient remembered some fact or the nursing staff uncovered some aspect of their history that revealed contraindication for particular medicine(s). My thoughts would be that a patient would have to present acceptable evidence of medication prescription, i.e.: a certified medication listing or contact with the prescribing practitioner. This would undoubtedly cause some delays, but ultimately it would result in most people carrying up-to-date medication lists. An acceptable period would be dependent on whether the patient presented with a current acceptably documented medication list or presented with no such list thereby necessitating professional inquiry. A national data bank could resolve related problems to include doctor hopping and drug abuse. A certifiable medication list would ultimately lead to time savings for the nurses and physicians. The untimate benifit would be a reliable reconciliation process, which was the original intent.

Not as applicable to Labor and Delivery as a medical floor. Our doctors do not seem to look for med rec sheets or sign them off on a regular basis.

It is only as good as what the patient tells you and most times it is inaccurate even after we review it with them. For outpatients, the physicians for the most part will not participate in the reconcillation and the burden falls 100% on the nurse.

This is a new 25 bed, critical access hospital and we have just been open for 3 weeks. All above mentioned processes are not in place but we are working towards a better daily functioning process with the physicians and pharmacy.

we are not JCAHO accredited

The main problem with the med rec in my opinion is that the info on the form is being gathered by more than one person, even with the multi-disciplinary form. The mds/pas/nps still gather the info and write it out in their h&ps. Therefore, the pt is being asked the info more than once, so it is annoying to them and the RNs feel it is somewhat of a waste of time if (for the most part) we are the only ones using the sheet.

I think this would be quit valuable on a med floor

I felt at a bit of a lost because I am unaware of med reconciliation policy, although I was shown something a couple of weeks back that requested I enter a pt's meds in the computer upon a visit to us and this needs to be updated everytime that pt comes in to see us. I'm sure this task is an initial attempt at creating a med recon policy, but I know of nothing formal in this regard. We always assess our pt's meds when they arrive, nonetheless and alert the MD if what they order does not match this.

Some nurses still do not feel it is their responsibility to get an accurate history. Also, the pharmacy may have one list, the physician's office another, and the patient taking them on yet another schedule. When a nurse has 6-7 patients, there often isn't time to spend on getting medicine schedule correct. We depend on physicians. Sad, but true.

Our institutions biggest problem is they cannot get beyond the JCAHO NPSG to see the importance of reconciliation to med safety. We recently completed a wildly successful pilot in out ED for admission histories and reconciliation form completion done entirely by pharmacists. The accuracy of pharmacists histories versus physician and nursing histories were not comparable. Pharmacist got the home meds restarted earlier and there were less clarifications needed. When presented with results our hospital and pharmacy administration said "thats nice, you can't have any more FTE's it costs too much". Needless to say the nursing and ED administration loved the program but doesn't have the budget to continue. So, number one barrier by far is "minimum effort" to comply with JCAHO.

As the coordinator reponsible for implementation of this NPSG, it would be very helpful for ISMP to publish some articles in the ISMP newsletter on actually errors that occured related to not completing medication reconciliation. A video (similair to the one "Do No Harm") from ISMP would also be valuable. What really changes behavior is an actual real life patient story shared and not the policies/procedures. I would like to see a story similair to "Bens" story on lack of medication reconciliation which resulted in real patient harm. Thank you for all the work you do!!

Medication reconciliation is often very inaccurate and incomplete. Through a pilot study I have found that the best source for medication reconciliation is the patients retail pharmacy. However, the nurses, resident physicians and attending physicians all state they are too busy to call the retail pharmacy.

Ideally this is a very important aspect of patient safety. Unfortunately, in reallity the abilty to apply this process becomes quite complicated and bogged down.

Nursing had to take the lead on this national patient safety goal. Physician's use the form as an order on discharge only. Nurses collect information and physicians clarify within 24 hours or the nurse calls the physician to clarify. We continue to have nursing homes question how to use the form and the need to clarify when we discharge the patient to the nursing home.

Experience has made errors and potential for errors more transparent, measureable and increases the chance for meaningful process improvements.

In the acute care setting of a hospital, the task of completing medication reconciliation form in a critical patient does not seem to be of the utmost importance. The reconciliation is a good process to implement upon discharge so that the patient has a clear understanding on what to do with the medications at home.

Our reconciliation process is paper, but inpatient ordering is via CPOE - so orders MUST be separate from documenation of reconciliation. Outpatient electronic lists aren't well supported by our EMR yet. Our IT plan has included points necessary for moving to all electronic documentation of the med reconciliation process (which is very fast & easy via our CPOE/EMR vendor, Epic) over the next few years. Best part was eliminating a lot of other double documentation & consolidating documentation of all disciplines onto 1 form. Also, made discharge med ordering much easier for physicians. (work is done up front).

One of the biggest challenges is deciding if every department and service "must" use one process and form or guiding each to fulfill the intent but not force one form. There are advantages and disadvantages to each.

We still struggle with accuracy and timeliness. Lack of accurate info from patients is a huge barrier. Another is poorly worded and/or documented MARs from long term facilities. But we keep at it and we continue to improve - even if it is a slow process.

Reconcilliation from not in effect yet. Trial period only from ED to floor.

The most difficult component is addressing the discharge reconciliation in a timely manner. Patients want to leave quickly. Our believe is that the prescriber is the most important individual to address discharge reconciliation. This may be our biggest barrier especially among surgeons.

Too many unknown medication variables regarding what the non-compliant patient may or may not be taking. General Medication compliance studies show that patients may only be compliant 30% of the time. The patient is the most important element in Medication reconciliation and can only be as good as the patient. When the average patient take 20-30 different medications as a result of today's pill oriented culture from not only multiple prescribers, different pharmacies, and own choice this task will be even make it more impossible to treat patients. There is no central database to go to to get complete and accurate information to ensure that what is prescribed is actually taken or needed by the patient.

This is a huge process change and we are still working out the kinks. Our discharge summaries dictated much later at times do not always match the med reconciliation discharge report. This is our biggest problem. We have a handle on the admission and transfer parts. We will be utilizing a 4th year Pharmacy intern on this project starting May 1. Hopefully the extra help will benefit the process.

Way too much effort for small incremental gain.

The physicians should be the ones responsible for filling the forms out. The forms at my hospital shift the responsibility of medication ordering from the doctors to the nurses. At my institution the nurses are responsible for filling the forms out, often with incomplete/unreliable information from the patients or their family, and the doctors are only responsible for checking boxes next to the medications they want to continue. It would be safer for the doctor to bring the patient chart from their office and use that as a cross-reference to order the patients' medications. This would ensure that medications are appropriately ordered and that nothing gets missed.

Has created huge burdens on nursing and pharmacy staff in our electronic medical record, as physicians are not doing computerized order entry on regular basis or prescribing on line on regular basis and asking nursing or pharmacy to perform this role for them.

Regarding the questions 6, 7, 8, in our organization there has ALWAYS been a reconciliation process among the clinicians for patient medications. This has always been necessary for quality care. The formal process with standardardized documentation will be implemented later this spring.

It has been very difficult to get many of our physicians on board with this process, especially many surgeons who are unwilling to write orders in a chart to continue or discontinue meds they may not be as familiar with, do not typically prescribe. They prefer to defer to the primary or hospitalist, which delays the process. The more hand offs that have to occur with the more time that elaspses, the higher the chance the entire list will not be reconciled completely.

I believe medication reconcilation is an important patient safety goal. However, physician cooperation with the process has been horrendous. Difficulties our facility encountered included electronic documentation in some places and paper documentation in other areas. Physician negativity has by far been our biggest obstacle.

More time is needed to prepare and implement to satisfy the standard than was allotted, as it is a major change involving many systems, and technology and budgetary challenges.

We do not have the staff support to have a pharmacist directly involved in the med history at admission and instruction/counseling at discharge,but it is apparent how valuable this would be for admissions,discharges, and transfers.

our system (on admit) makes a lot more work but is very ineffective causing the work to be re-done; the intrahospital transfer system is computerized and pharmacy driven so it is easy and effective.

Process still needs to embraced bythe physician so that they actually look at the form and order accordingly. Physicain by in by education at the medical staff meeting level may help. The message needs to come from fellow physicians to see the importance of such a process. Hospital pharmacists really need to step up to the plate and takde some ownership in this process and "actively" assist in the reconciliation process. Maybe part of relicensure should include mandatory education regarding the reconciliation process. I have been a nurse for 30 years and know that this can literally save thousands of lives and prevent many adverse reactions.

I work in an outpatient clinic. It is very difficult when patients don't bring a list of medications, or say "nothing has changed" only to find out that 4 medications have been adjusted. We have started getting copies of discharge instructions with medications listed within the last year, which has helped a great deal for a newly discharged patient. We try to work with visiting nurse services whenever possible to double check doses. We also call pharmacies to find out exactly what the patient is on, or has been prescribed. It is very time consuming and ultimately delays optimal treatment when adjustments can't be made at a visit because meds are unknown. I'm sure you have heart similar comments for years. With the new Medicare D formularies, even more changes are necessary, making our jobs that much harder.

Our med rec process was implemented with very little difficulty. Staff bought in quickly and there was minimal pushback from physicians. The accuracy of the information is difficult to ensure since patients can be unreliable and the chart documentation may not indicate discontinued medications. We also send out the form to patients in advance of their visit to our facility so they can fill them out when they have their meds with them.

Even with nsg putting in the information the expectation that it is correct is wrong. The physcians still write continue home meds - the information from the patient is still not reliable and nurses in whom English is not a first language or who are not familiar with medications are putting in wrong spelling etc. THE PHYSICIAN needs to reconsile the home medications and needs to be aware of what medication the patient is on in the hopsital when they are being transferred to a different level of care. With continuing pressures being put on nsg without the proper back up from physicians and pharmacists and with the increasing complexity of electronic medication screens - (not being nurse friendly!) increasing pressure is on nsg to provide the proper medications at the proper times without input from nursing. With the major contributors to medication administration in my hospital being IT and pharmacy admistrators who have no concept of the difficulty in obtaining, clarifying and reconciliation of medication nurses are becomming increasingly frustrated with the entire process

Since I am a full time faculty, teaching UG and graduate students, I appreciate receiving your periodic news releases. I do have UG senior nursing students in a major cancer center hospital, but do not have a faculty practice within a hospital; thus the absence of my responses to your survey.

Do feel like the burden of this should be with the Practioner/Physcian--but it falls on nursing to be the gate keeper. Increases time between transfers/admits/discharges. We are expected to do this with the outpatient population as well--sometimes the data collection/reconcilliation/paperwork, takes twice as long as the procedure!

The area of out patient exam in Diagnostic Imaging and the use of contrast agents (oral, IV,intra-thecal,urethral or rectal- to include radio-pharmaceuticals. What is the expectation on pharmacy interface with Imaging/Radiology and how are contrast agents to be ordered/documented when they are a standard or routine component of the Imaging procedure. What role is expected for the radiology technologist as there may be no other provider present in some settings? ie. telemedicine.

We are experienceing great difficulties with the reconciliation paperwork as it is also a physicians order sheet and this just is not working out.

Providers need to understand the importance of Med Reconciliation. I don't think that the providers appreciate how easily a patient can be confused by "medical terms" and names of medications. Often it is not made clear to the patient what or how s/he is to take his/her medications. The Med Reconciliation process is important if just for this reason.

We are in a state of transition from paper to computer order entry & documentation, so many of these answers are subject to change. Nurses have been performing reconciliation activities on an informal basis for years--usually when reviewing the orders with patient & family at admission, or during med passes. Discrepancies or omissions usually resulted in a call to the attending or a note on the front of the chart. And perhaps a report to ISMP! Our new reconciliation process should prove far more efficient, especially when all attendings finally use the form. The reconciliation activity has been added to the computer generated nursing task list as part of the admission order set. The questions about reconciliation at discharge were very interesting to me--there is a lot of room for improvement in that area, especially with patients discharged home and back to the care of their PCP. How quickly do the PCPs receive the discharge summaries? How do they become aware of any medication changes? How many patients make & keep follow-up appointments? How many patients actually take their meds as prescribed? One thing that I miss: our previous nursing admission assessment included information about OTC, vitamins, herbal supplements & so on. The medication reconciliation form does not include a section to prompt questions about the use of these items.

see viii above

Physicians did not want ot sign the form as they felt it made them responible for meds they did no prescribe. It was very difficult to find a process that met the goal and pleased the physicians.

I feel that the pharmacist taking the initial medication history and being involved at all levels of the process is key. Currently our nurses take the history & reconcile meds, the physicians often overlook this important step, and the pharmacists do not feel they should be the key point person. Better teamwork would be great!!
I work in telephone traige as a staff nur