Practitioners Agree on Medication Reconciliation Value, But Frustration and Difficulties Abound
More than 1,400 healthcare providers responded to our April/May 2006 survey on medication reconciliation, primarily nurses (75%) and pharmacists (21%) from hospitals (89%) and outpatient settings (6%). Most respondents (91%) were familiar with the Joint Commission National Patient Safety Goal (NPSG) related to medication reconciliation, but only three quarters had attended inservice education about the process. Pharmacists, and managers or administrative professionals, were most familiar with the NPSG and had attended inservices more frequently than nurses and staff-level practitioners, despite the significant role that staff nurses play in reconciliation. Respondents from long-term care and those who reported that a medication reconciliation process upon admission had not yet been implemented were the least likely to be familiar with the NPSG (52% and 79% respectively) or to have attended an inservice on the process (31% and 43%).
More than a quarter of respondents reported that a medication reconciliation process upon admission had been in place for a relatively short period of time (3-6 months). Just 18% reported a duration of more than 1 year. Similar results were found with medication reconciliation upon transfer and discharge, with the most common duration cited as 3-6 months (23%). Again, only 19% of respondents reported a transfer reconciliation process in place for more than 1 year, and 17% reported this duration for discharge reconciliation. Thus, many respondents were in the beginning stages of developing a workable medication reconciliation process.
The distribution of responsibilities for the different aspects of the admission, transfer, and discharge medication reconciliation process can be found in Table 1.
|Medication Reconciliation Process: Who is primarily responsible for the following:||Nurse||Pharmacist||Physician/ Prescriber||Medical Records||Other||Don't Know|
|a. Collecting an initial medication history||92%||6%||30%||1%||3%||0|
|b. Assuring the medication history is accurate||76%||21%||45%||1%||2%||3%|
|c. Reconciling medications between the history and admission orders||63%||26%||50%||1%||2%||5%|
|d. Reconciling medications upon transfer of a patient to another level of care||67%||21%||51%||0||2%||5%|
|e. Reconciling medications at discharge||67%||12%||57%||0||2%||6%|
|f. Sending the patient's discharge medication list to the patient's physician/next provider||50%||4%||18%||9%||10%||24%|
Of particular interest is that roughly a quarter of respondents did not know who was responsible for sending the patient's discharge medication list to the patient's physician or next provider upon discharge from an inpatient or outpatient setting. Similarly, many respondents were unsure of the time in which medications must be reconciled. Thirty-six percent of nurses were unsure of the required timeframe, as were 49% of staff-level respondents, and 63% of practitioners working in outpatient/office settings. The most common timeframe for reconciliation reported by all respondents was within 24 hours of obtaining an admission medication history. Less than 15% of all respondents required a different timeframe depending upon the critical nature of the drugs on the patient's medication history, with one exception: 27% of homecare respondents employed different timeframes for reconciliation of critical drugs. But again, about a third of hospital respondents and two-thirds of outpatient/office practice staff were unsure of the required timeframe for reconciling medications after admission to the service.
More than half of all respondents documented the reconciliation process on paper; about one in ten used computer documentation; and a quarter employed both paper and computer documentation. Results were split regarding the prescribing of admission medications on the same form or screen used to document the initial history, with 32% using and 46% not using the same form or screen. However, another 14% reported that the patient's initial medication history form or screen was sometimes used when prescribing admission orders, suggesting inconsistencies that could lead to overlooked orders.
The relative importance of success factors and barriers encountered by respondents during the implementation of medication reconciliation process can be found in Table 2.
|Teamwork among disciplines||57%||Unreliable patient||42%|
|Clearly defined protocols||39%||Lack of physician leadership||31%|
|Centralized history form/screen||32%||Lack of teamwork among disciplines||30%|
|Awareness of the role of each contributor||24%||Extra burden||21%|
|Reasonable expectations for "complete" history||23%||Documentation from other sources||19%|
|Easy communication with outpatient providers||15%||Lack of frontline staff input into process||17%|
|History collection by pharmacist||10%||Lack of administrative leadership||15%|
Regardless of the respondents' profession, staffing level, or facility in which they worked, teamwork among disciplines and clearly defined protocols were ranked the most important factors for success. In fact, there was almost no variation in the relative ranking of success factors among all respondents, even those with reconciliation processes in place for differing lengths of time, from 0 months to more than 1 year. Although the most significant barriers encountered by all respondents included unreliable patients and lack of physician leadership, the ranking varied among respondents from differing professions, staffing levels, and workplaces. For example, staff in outpatient settings reported that not having clearly defined protocols was a more significant barrier, and that not having physician leadership was a less significant barrier, than staff from inpatient settings.
While the vast majority of respondents (82%) felt that medication reconciliation is of great value to patient safety, more than 300 insightful comments submitted with the survey clearly showed a high level of frustration and difficulties with implementing these processes. Excerpts of a few selected comments can be found in Table 3. We encourage you to read the respondents' comments. As with narrative descriptions included with error reports, the respondents' free-text comments help paint a more vivid picture of the challenge we still face with implementing medication reconciliation. For more on medication reconciliation, please see our April 21, 2005 newsletter.
|We have spent more time on the forms and this process than on any other safety project. We have also had to increase staffing in pharmacy without reimbursement from insurance or another payer.|
|This is a very hard process to implement, regulate, and track in our facility. Some of the NPSGs 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.|
|This is a complex process that, when applied universally, creates points of contention with the medical staff, especially surgeons. Unfortunately our information system vendor is not providing the solutions required.|
|Policy makers have not obtained valuable input from nurses and physicians. The result is a complicated, disjointed, time consuming process in which compliance is low.|
|Until there is a national database for patient medication histories, reconciliation will be continue to be problematic for all.|
|We had an interdisciplinary team implement the process, but it seems like every unit is different and has its own cultural reaction to the change.|
|We still struggle with this whole process. We need to come up with a way to get medical staff fired up over this.|
|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. There needs to be a major advertising blitz on the television and radio asking people to put together an accurate list of their medications.|
|It would have been easier if computerized software for medication reconciliation had been perfected before implementation. There is too much paperwork and duplication now.|
|Leadership and providers don't agree with the necessity of medication reconciliation. Therefore, our current process meets a superficial "check the box" requirement for inspection purposes only.|
|Until nursing leadership makes it a priority for nurses, and hospital administration makes it a priority for physicians, I fear we will swim in circles on this issue.|
|I really feel that the reconciliation on admission is an accident waiting to happen. We have had some severe near misses. Physicians take these reconciliation sheets as gospel.|
|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.|
|I know this is needed, but it is very stressful trying to get it done along with all the other safety issues and caring for other patients. To make this happen, I think the government should be looking at ways to reimburse hospitals for this process so more staff could be available to make this happen.|
|I think that faculty in universities should also be learning about this initiative to introduce the concepts to students.|
|A resource intensive process to start, this will take a culture shift to get everyone on board. This is a journey that will take 12-24 months to get significant measurable results.|
|Perhaps JCAHO will give healthcare systems a little more time.|
|I may never know, but I am sure I have prevented medication errors in the home by reconciling medications.|