According to Klinger (2013), there is a need to improve the safety in critical access hospitals by using strategies that promote the existing Quality Improvement programs. To achieve this, medical reconciliation should be prioritized. Studies have shown that a hospitalized patient is subjected to at least one medical error on a daily basis. This statistic further confirms findings that highlight 40% of medical errors occurring because of inadequate medical reconciliation. Medical reconciliation refers to a process whereby healthcare providers and practitioners liaise with families and patients to ensure that the hospital receives accurate medical information of the patient at the points of care. The process is initiated at the admissions desk when changes are made to the level of care or a change in the care setting, and finally at discharge.
The medical reconciliation process involves three key components. The first component is known as the Best Possible Medication History (BPMH). This involves having a list of all current medications that a patient has been using on a regular basis ( Kuhrt , 2017). The second component involves the use of the list generated when the patient is admitted to a facility, transferred, or discharged. The third and most crucial component involves making a comparison of the BPMH at the point of admission, transfer or discharge in order so that any discrepancies are highlighted and appropriate changes made to the patient's treatment.
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The purpose of medication reconciliation is to avoid cases of adverse drug events (ADE) at the points of care for patients. As such, all unintentional and undocumented discrepancies are eliminated through the reconciliation of medications. An unintentional discrepancy normally happens when a physician or caregiver omits or adds a medication that the patient was taking at the point of admission. Conversely, undocumented intentional discrepancy refers to a scenario where the physician or caregiver intentionally discontinues, changes, or adds medication that a patient was taking before admission but fails to put in the medical records.
Medical reconciliation also helps to prevent medication errors. Some of these errors include incorrect dosages, failure for the physician to prescribe previous medications home medications which are important while the patient is at a hospital, missed or duplicated doses, and failure to list which home medications should be resumed or discontinued once a patient leaves the hospital ( Kuhrt, 2017).
Therefore, the purpose of this paper is to analyze the background of medication reconciliation and look at current and previous evidence-based practices in medication reconciliation and the gaps that have been covered. It will also cover stakeholders affected by medical reconciliation and associated research. This will be done taking into account previous literature review on the topic as well as potential interventions that have been highlighted. This will also involve the design of a Quality Improvement (QI) process and highlight the best management tool to use. Finally, a self-reflection on the important points that the research paper reveals.
Background Information
As is the norm, many clinicians do not consider over-the-counter drugs and dietary supplements as medications. As such, they are, in most cases not included in a patient's medication record. However, medical reconciliation dictates that there is a need to include these drugs in a patient's medication history to avert any issues that may crop up during or after discharge from a hospital. However, these practice has changed over time with recent evidence-based practices advocating for medication reconciliation to include the medications.
As aforementioned, the process of medical reconciliation may seem straightforward particularly for a newly admitted patient. This normally involves the verification of one's medical history and creating a medication administration record for the patient. At discharge, the patient usually receives instructions and is educated on the medication issued by the follow-up physician issued with the medication list. For those in an ambulatory setting, the medication list is usually updated to conform with medications that have been added or removed from the list ( Hughes , 2008). However, it is important to note that the process is not as straightforward as it seems. First, The data collecting process for the patient's medical history varies greatly. Second, the process involves the nursing, pharmacy, and medicine departments with no defined roles for each profession in the reconciliation process. Finally, data collection by nurses and physicians often results in discrepancies as they are documented on different charts and rarely compared to resolve the issues in the patient's history. Therefore, the lack of standardization of the medication reconciliation process leads to variations in the historical
In previous years, the variations in medical records led to safety concerns in medication reconciliation because the lack of knowledge regarding previous medication taken by patients, the lack of an integrated system, and different physician and nurse workflow contributed to the safety vulnerabilities ( Hughes, 2008) . These necessitated medical reconciliation in a hospital and other healthcare facilities .
Traditionally, physicians and nurses have not included making a full inventory of all medications that a patient has been taking and verifying the listed medication with the patient. The lack of a standard operating procedure regarding the constitution of a patient's comprehensive medical history has also hampered the process. Patients and family members also have limited access to pharmacy records and hence cannot act as a good source of information.
Unlike in the past, recent studies have indicated for the need to have electronic systems for hospital records. While paper-based records have served well, they have not sealed the loophole for errors compared to electronic records on information retrieval. An electronic based system reduces errors during a patient's discharge time as a list of all medications used before and after hospital admission can be generated ( Kuhrt, 2017). The list can be printed out and used for patient education programs before discharge. Electronic record keeping systems are continuously being developed and updated to ensure that pharmacies, healthcare providers, families, and patients have a single medication record where all medication issued is reconciled on the electronic system. Electronic record keeping allows for decision making support such as double prescriptions, checking for allergies, and counteracting medications.
Despite the use of an electronic system, more can be done to make the process wholesome based on current research. First, there should be physical coordination among clinicians so that they agree of the medications on the list provided. Second, patient-centric medications ensure that the former is given tolerable medication doses hence boosting adherence. Finally, patient safety can be improved by pruning out medications, which do not add value to the treatment process. This manual process should only serve as a complementary to the electronic system and helps in reducing medication-related errors and improving patient safety.
Stakeholders in Medication Reconciliation To Improve Safety
Cases of medication adherence rates being low have necessitated the need to support patient engagement. The main stakeholders in medical reconciliation include patients, family, clinicians, pharmacists, and pharmaceuticals. Clinicians include doctors, nurses and other healthcare practitioners whose main role is to motivate patients to follow drug regimens (Heath, 2017). Morever, pharmacists and pharmaceutical companies are tasked with the responsibility of coming up with patient-centric engagement strategies that ensure their safety.
For clinicians, it is imperative that they promote patient education to improve medication adherence among patients. Patients need to be taught how to take their medication safely and understand the need to do s regularly as well as completing doses. For some patients, language assistance may be required (Heath, 2017). While engaging the family members, clinicians should understand the information provided as this would increase the patient's medication adherence. It is important that the clinicians identify barriers that hinder patients from taking their medications such as drug affordability and look for ways on how to address them. For pediatric cases, pill palatability may hinder children's ability t take their medication.
Pharmacists also have a role to play in patient education and build long-lasting patient-pharmacists relationships. Medication Therapy Management (MTM) can be implemented where the pharmacist spends between 45 minutes to an hour talking to patients to obtain more information regarding their condition (Heath, 2017). Understanding patients help in coming up with medication synchronization as a strategy of ensuring medical adherence and safety. For pharmacists who do not have the time to sit with patients and engage them, they can discuss the dosage and safety protocols with patients while using nonprofessional terms to make it easier for the latter to understand. Pharmacists should also ensure that high-risk patients have education on how to leave sticky notes, or make use of pillboxes as ways of improving medication adherence. These strategies are essential in building strong patient-pharmacist relationships and aim at improving the overall safety of patients through medication reconciliation.
Other than pharmacists, pharmaceuticals have a role to play concerning patient engagement. Drug manufacturers are aware of their role. They have come up with their patient-centered strategies such as drug scheduling, remote patient monitoring, access services, patient outreach reminders, and medication delivery. These strategies should also be made aware to clinicians for better coordination with patients.
Literature Review
Klinger (2013) highlights the need to improve medication safety management in hospitals by identifying risks leading to medical errors and how best to mitigate them. This can be achieved by introducing a Quality Improvement (QI) programs in critical access areas such as rural areas. The study highlights that tele-pharmacy provides a way of dealing with inadequate staff in rural areas to ensure that safety medication habits are followed. Medical reconciliation can be improved if pharmacists actively participate in hospital committees to offer coordination of medication adherence with other health practitioners.
The role of nurses in medication safety cannot be understated as they act as a link between patients and other medical practitioners ( Hughes , 2006). This is because nurses collect information required from patients such as the list of current medication before admission and provide it to physicians and pharmacists to ensure medication reconciliation is done. The nurses also coordinate the list with family members to ensure that it is up-to-date. As such, nurses play an important role in improving the reconciliation process. Nurses have a trusted patient-nurse relationship that is used when medication reconciliation is required. The process of medication reconciliation is an arduous one that cannot be completed without the input of nurses. This is because nurses are the first and last caregivers when patients are admitted to a hospital and discharged respectively. Therefore, their contribution is highly regarded. It is also important to note that nurses use resources in good faith as a way of ensuring that a patient's medication reconciliation is done as expected.
Quality Improvement
To deal with the issue of medication reconciliation, there is a need to come up with quality intervention process that aims at reducing medication errors through medication reconciliation while at the same time promoting safety and medication adherence among patients. The interventions used involved a combination of several interventions. They are face-t-face education outreach, and the development of patient-clinician programs (Strom, 2011). Face-to-face education outreach involves the setting up of medical camps to create awareness among members of the community and in particular, recently discharged patients on the need to follow up on the drug regimen provided in hospitals. These outreaches are also crucial in assisting stakeholders obtaining information from patients and come up with better ways of improving medication reconciliation in healthcare facilities.
Patient-clinician programs are best run within the hospital facilities. During this program, patients interact with all stakeholders and can gain insights on the importance of medication adherence and medication reconciliation towards improving their health safety. Patients are encouraged to reveal their medical history so that diagnosis and treatment are done devoid of medication errors. The stakeholders in the process include the patients, family members, clinicians, pharmacists, and pharmaceutical companies.
The goals of such a process are to ensure that patients understand the need for medication reconciliation towards their safety. Moreover, the process will also aim to increase medication adherence. Given that this is a continuous process, there is no anticipated timeline of delivery. However, data will be collected periodically at intervals to analyze whether the project has been successful or if it needs areas of improvement.
Data will be collected through interviews and questionnaires during patient-clinician sessions as well as during outreaches. It is expected that after the implementation of the process, medication errors are likely to reduce while medication adherence is bound to increase.
The interventions will have a positive impact on all stakeholders. For the patients, they will have improved health safety due to reduced medication errors. Clinicians will also see improvement in treatment procedures among their patients. For pharmacists and pharmaceuticals, they will have data necessary to come up with programs that are best suited for improving patients-pharmacists engagements. As aforementioned, nurses play an important role in medication reconciliation. Therefore, their input is vital from the start and during the implementation of the process.
During the implementation of the process, the best management tool to use will be the tree diagram based on its simplicity and ease of application. The tool begins with the main issue (medication reconciliation) and goes on to break down the process into finer levels of detail. The diagram illustrates each task to be accomplished and directs how they should be achieved ( Chapman, 2011).
Self-Reflection
The project has been very useful in helping me understand the need for medication reconciliation to improve the safety of patients. It should be noted that the process of medication reconciliation is involved several stakeholders such as patients, family, clinicians, pharmacists, and pharmaceutical companies to ensure its successful application. Each of these listed stakeholders has a role to play. However, nurses play an important role as they serve as the main link between different stakeholders and ensure that medication reconciliation is done from the point of admission and maintained up to the point of discharge. Nurses ensure that the process is smooth and devoid of any bureaucracies. The project has further taught me about the role of patient-engagement for medication adherence to work to be followed. This should be a combined effort by all stakeholders. I have also learned the importance of electronic storage and retrieval of data as a step in the right direction about medication reducing errors. Overall, the project has been very useful towards my development as a healthcare practitioner.
References
Chapman, R. J. (2011). Simple tools and techniques for enterprise risk management (Vol. 553). John Wiley & Sons.
Heath, S. (2017). 3 Stakeholders Driving Patient Engagement in the Pharmacy . Patient Engagement HIT . Retrieved 18 February 2018, from https://patientengagementhit.com/news/3-stakeholders-driving-patient-engagement-in-the-pharmacy
Hughes, R. G. (2008). Nurses at the “sharp end” of patient care.
Klingner, J. (2013). Evidence-Based Medication Safety Quality Improvement Programs and Strategies for Critical Access Hospitals.
Kuhrt, M. (2017). Current medication reconciliation practices miss the mark | FierceHealthcare . Fiercehealthcare.com . Retrieved 18 February 2018, from https://www.fiercehealthcare.com/practices/current-medication-reconciliation-practices-miss-mark
Strom, K. L. (2001). Quality improvement interventions: what works?. Journal for Healthcare Quality , 23 (5), 4-24.
