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Medication Reconciliation
IHC, in cooperation with health care providers across the state, has developed the following Medication Reconciliation toolkit. The toolkit is a compilation of forms, policies, and staff and patient education materials to support adoption of reconciliation procedures.
We would like to thank those organizations who have shared their materials. We ask that organizations using example materials to properly attribute them. Please contact IHC if your organization would like to share materials related to Medication Reconciliation.
Contributing Iowa Hospitals:
- Allen Memorial Hospital- Waterloo
- Buena Vista Regional Medical Center - Storm Lake
- Guthrie County Hospital - Guthrie Center
- Iowa Health System - Des Moines
- Mercy Medical Center - Des Moines
- Mercy Medical Center - North Iowa - Mason City
- St. Luke's Hospital - Cedar Rapids
- The University of Iowa Hospitals and Clinics - Iowa City
- Trinity Regional Medical Center - Fort Dodge
Case for Change
Preventable medication errors are associated with one out of five patient injuries or deaths. Estimates reveal that over 46% of all medication errors occur on admission or discharge from a clinical unit/hospital when patient orders are written. A recent Institute of Medicine report estimated the extra medical cost of treating adverse drug events occurring in hospitals alone amounted to $3.5 billion a year. This estimate does not take into consideration lost wages and productivity or additional health care costs.
Medication reconciliation is a process designed to address this deficiency in the delivery of health care. Accurate and complete medication reconciliation can prevent:
- Inadvertent omission of needed home medications
- Failure to restart home medications following transfer and discharge
- Duplicate therapy at discharge
- Errors associated with orders with incorrect doses or dosages.
The reconciling process has been demonstrated to be a powerful strategy: Research showed that a series of interventions introduced over a seven month period successfully decreased the rate of medication errors by 70% and reduced adverse drug events by over 15%. In another study, the utilization of pharmacy technicians to initiate the pre-surgery reconciling process reduced potential adverse drug events by 80% within three months. In yet another case, an adult surgical intensive care unit implemented a medication reconciliation process to reduce medication errors in discharge order. By week 24 of the study, nearly all medication errors were eliminated.
A successful reconciling process also reduces time associated with the management of medication orders. A recent study showed that after implementation, nursing time at admission was reduced by over 20 minutes per patient. Furthermore, cases establish that initiating and following a systematic approach to medication reconciliation through the course of hospitalization reduces pharmacist time at discharge by over 40 minutes.
IHC, in recognizing the need for medication reconciliation, has developed a “tool kit” which provides examples of medication reconciliation forms, hospital policies, and staff education tools that can be utilized by all health care providers in the state. We want to thank those facilities that contributed to the tool kit and extend an invitation to anyone who would like to submit a form from their facility.
Sources:
- Michels RD, Meisel S. Program using pharmacy technicians to obtain medication histories. Am J Health-Sys Pharm. October 1, 2003;60:1982-6. Early version appeared under title “Use of Pharmacy Technicians to Reconcile Patients’ Home Medications” as Am J Health-Sys Pharm Best Practice Awards, 2002.
- Pronovost P, et. Al. Medication reconciliation: a practical tool to reduce the risk of medication errors. Journal of Critical Care. 2003 Dec;18(4):201-205.
- Rozich JD, Resar RK. Medication Safety: One Organization’s Approach to the Challenge. JCOM 2001; 8(10):27-34.
- Stencel, M “Medication Errors Injure 1.5 Million People and Cost Billions of Dollars Annually.” The National Academies, July 20, 2006.
Project Description
Keeping an up-to-date medication list for all patients is important to help reduce the amount of medication error during hospital stays. Studies have found that as many as 46% of admissions will have at least one omitted medication from a patient’s regular routing.
Any instance of a patient transition opens up the opportunity for missed or incorrect information. These are just a few examples:
- Admission
- Discharge
- Transfer
- A visit to a different doctor
Recognizing this problem, the Iowa Healthcare Collaborative (IHC) is producing a Medication Reconciliation Toolkit for health care providers in the state. IHC hopes that this resource will offer more information on the issue as well as practical solutions.
Project Team
The project team includes physicians, nurses, representatives from hospital pharmacies, hospital management, and other various health care providers.
Goals
The team noted that many organizations are currently working on internal processes for reconciling medications at the time of admission. The team identified areas of improvement in reconciliation which included time of admission, time of discharge, and community outreach.
Status
The team has gathered information on current admit and discharge processes of hospitals, both in Iowa and nationally. The team has posted protocol examples for health care providers attempting to improve medication reconciliation in their respective facilities. The forms selected contain all of the data elements needed to successfully manage patient’s medications upon admit and after discharge from the hospital.
The team also focused on community outreach. Patients are a vital member of the health care team. As part of this team, they play an important role in their own safety when receiving health care either in a hospital or clinic. IHC, in collaboration with several providers across Iowa, has worked to develop an informational brochure and a personal medication wallet card so patients can easily monitor their medications.
Tool Kit
Implementation Planning Tools
Mercy Medical Center, Des Moines, IA (PDF 432KB)
Improving Medication Reconciliation Across Settings: Using Six Sigma Methodology
IHI: How to Guide on Medication Reconciliation (PDF 182KB)
Massachusetts Coalition for the Prevention of Medical Errors
Getting Started:
Implementation tools:
Forms & Policies
Hospital Policies:
- Allen Memorial Hospital, Waterloo, IA (PDF 12KB)
Admission: We created a process that allows both nursing admission documentation and the potential for a physician order. We started on paper and moved that process to the computer with a computerized nursing admission with a report that can be printed to create the paper physician order sheet. By adding this information to the computer system, it has allowed this information to be a part of our transfer/discharge report to help physicians review the pre-hospital meds at all stages of reconciliation.
Transfer/Discharge: We already had a computerized medication profile, so we used it to create a report that can be printed from our system that the physicians can review, complete and sign as actual orders. This report includes the pre-hospital list to help physicians see what the patient was on prior to admission. The pharmacy has done a lot of work with the way the medical profiles appear in the computer system to make the report more user-friendly and prevent errors.
Overall Process: The process is standard throughout the facility for inpatients and OPO patients. This helps physicians to know what to expect and what to ask and look for to reconcile medications.
- Buena Vista Regional Medical Center, Storm Lake, IA (PDF 16KB)
Medication reconciliation policy implemented in a critical access hospital.
- Grinnell Regional Medical Center, Grinnell, IA (PDF 15KB)
Guide to Reconciling Medications.
- Iowa Health System, Des Moines, IA (PDF 59KB)
Current medication reconciliation policy developed by an interdisciplinary team representing inpatient, outpatient & ambulatory settings.
- Mercy Medical Center, Des Moines, IA (PDF 24KB)
Current medication reconciliation policy addressing medication reconciliation upon admission, transfer, and discharge and guidelines for initial patient interviews.
- St. Luke's Hospital, Cedar Rapids, IA (PDF 32KB)
Medication reconciliation policy addressing reconciliation upon admission, transfer within the facility, and discharge.
- Trinity Regional Medical Center, Fort Dodge, IA (PDF 92KB)
Medication reconciliation policy addressing reconciliation upon admission, transfer within the facility, and discharge or transfer to another facility.
- University of Iowa Hospitals and Clinics, Iowa City, IA (PDF 25KB)
An interdisciplinary procedure for conducting medication reconciliation in a large teaching facility.
- Luther Midelfort, Eau Claire, WI Medication Reconciliation and Discharge Medications Policy (PDF 45KB)
An interdisciplinary procedure for conducting medication reconciliation within 24 hours of admission and at the time of discharge in order to generate an accurate medication list and thereby decrease adverse drug events.
- University of Massachusetts Memorial Medical Center, Worchester, MA (PDF 22KB)
Preadmission Medication List Verification and Order Form Guidelines.
Staff Education Materials
Example Process Flow Charts
- Luther Midelfort, Mayo Health System, Eau Claire, WI (PDF 13KB)
Medication reconciliation reviews may be conducted during the admission process, often by nurses on the admission unit, to identify unreconciled medications and potential errors or adverse events. This flowsheet helps nursing personnel perform a medication reconciliation process when patients are admitted to an intermediate care unit, either directly or as transfers from other inpatient care units.
- University of Massachusetts Memorial Medical Center, Worchester, MA (PDF 15KB)
Admission Medication Reconciliation Process for Elective Orthopedic and Emergent Medical through ED.
Admit Forms
- Grinnell Regional Medical Center, Grinnell, IA (PDF 16KB)
Medication reconciliation inpatient admission form.
- Guthrie County Hospital, Guthrie Center, IA (PDF 24KB)
A medication history form used on admission.
- Mercy Medical Center, Des Moines, IA (PDF 123KB)
A three page medication reconciliation/physician order form used on admission.
- University of Iowa Hospitals and Clinics, Iowa City, IA (PDF 50KB)
This one page form helps pharmacy personnel perform medication reconciliation on admission.
- Luther Midelfort, Mayo Health System, Eau Claire, WI (PDF 100KB)
This form aids nursing and pharmacy personnel in performing medication reconciliation when patients are admitted to an intermediate care unit, either directly or as transfers from other inpatient care units.
- Mercy Health System, Janesville, WI (PDF 38KB)
This one page form helps nursing personnel perform medication reconciliation on admission.
- South Carolina Hospital Association (PDF 28KB)
This is a one-page form that reconciles home [pre-admission] meds with admission meds; this version of the reconciliation form allows the MD to use the form to write admission medication orders.
- Winter Haven Hospital, Winter Haven, FL (PDF 51KB)
This form was developed to obtain a list of "medications as at home" prior to admission, and it has been used extensively in all outpatient areas and on a medical/surgical unit; developed by Winter Haven Hospital (Winter Haven, Florida, USA).
Admit/Discharge Forms
- Buena Vista Regional Medical Center, Storm Lake, IA (PDF 22KB)
This one-page form was developed to aid in reconciling medications upon admission and on discharge.
- AnMed Health, SC (PDF 20KB)
This is a one-page form that reconciles home [pre-admission] meds with admission meds, and with discharge meds. The difference in this form and the standard Medication Reconciliation Form is that this one allows the MD to use the form to write discharge medication orders.
- United Hospital System, Kenosha WI (PDF 46KB)
A one-page form for admission and discharge reconciliation with a physician signature to verify review of discharge reconciliation.
- University of Massachusetts Memorial Medical Center, Worcester, MA (PDF 167KB)
This medication reconciliation order form can be used as a tool for reconciling medications at admission and discharge.
Discharge Forms
Columbia St. Mary’s, WI (PDF 167KB)
A five-page electronic record discharge reconciliation/order form.
Transfer/Post-op Forms
Columbia St. Mary’s, WI (PDF 126KB)
A three-page electronic record transfer/post-op reconciliation/order form.
Ambulatory Forms
St. Mary’s Medical Center, Green Bay, WI (PDF 45KB)
A one-page admission/post-op/discharge reconciliation/order form.
Community
Medication Brochure and Wallet Card
Grinnell Regional Medical Center, Grinnell, IA
Questions every patient should ask.
Success Stories
- Buena Vista Regional Medical Center, Storm Lake, IA
Buena Vista Regional Medical Center, Storm Lake, IA. Ongoing data collection since March, 2006 shows continued compliance at 99-100% for completion of the Med Reconciliation process on the inpatient Medical-Surgical Unit. We are currently developing the process for compliance monitoring for the other inpatient units and ambulatory settings.
Additionally —
Medication reconciliation is carried out into the community setting via the use of follow-up discharge phone calls. Patient Care Coordinators make a telephone call to each patient discharged from the medical-surgical unit, within 24-48 hours of discharge. Included in this phone call is an additional review of the medications ordered at the time of discharge, and the patient is asked whether all prescriptions were filled and whether they have any additional questions or concerns about the use of their medications. This provides an opportunity for futher clarification, teaching and verification of medications ordered at the time of discharge.
Prevent Adverse Drug Events (Medication Reconciliation)
Buena Vista Regional Medical Center – Storm Lake, IA
Availability Status: Available to answer requests
Licensed Beds: 54
Teaching / Non-Teaching Status: Non-teaching
Urban / Rural Status: Rural
Start Date of Intervention Work: November 2004
Mentor Contact Name: Michele Kelly, RNC, MSN, Dir. of Quality
Mentor Contact Email: kelly.michele@bvrmc.org
Mentor Contact Phone: 712-213-8604
Additional Information:
- Developed and implemented medication reconciliation process throughout all inpatient areas. Currently working on expansion to outpatient care areas.
- Process includes use of standardized medication reconciliation documentation form that is initiated within 8 hours of hospital admission, updated throughout hospitalization, and again at the time of discharge.
- Process includes gathering patient medication history, verification of history, and reconciliation with medications ordered at time of admission, transfer and discharge.
- Medication Reconciliation Policy developed to describe guidelines for use of documentation tool.
Process:
As of March 2006, current data shows 99% compliance with use of Medication Reconciliation Tool for inpatients on pilot unit (Med-Surg). Baseline data from 10/2004 (prior to implementation)--0% compliance as no process for medication reconciliation existed.
Outcome: Data for Medication Variances for calendar year 2005 show no adverse drug events related to medication reconciliation process.
- Guthrie County Hospital, Guthrie Center, IA
In my days as a geriatrics pharmacy resident, I spent most of my time providing clinical services on a geriatric rehabilitation unit, including discharge medication education. So, it seemed logical that the first clinical pharmacy service I should implement when I started at Guthrie County Hospital, Iowa, would be discharge medication education. For those of you considering or currently implementing a discharge medication education program, read on for a few ideas and lessons learned.
- Gain administrative support. Like many rural hospital pharmacists, I report to the hospital’s administrator. I didn’t ask permission to provide discharge medication education; I consider it my responsibility as a pharmacist to provide education to patients about their medications. However, I did inform the hospital administrator of my plan and that I would be coordinating my efforts with the nursing staff. Make sure that your hospital administrator understands that you, as the medication expert, should be providing medication education whenever possible. You won’t be reimbursed for your education to inpatients, but sharing your knowledge certainly enhances patient care. Discuss placing a question on the hospital’s inpatient satisfaction survey pertaining to the opportunity to discussing medications with a pharmacist. Your administrator will be sold on your educational efforts when the patient satisfaction surveys come back positive.
- Gain nursing support. Remember that, historically, nursing staff has taken ownership of the discharge education process, including discharge medication education. Nursing staff needs to understand and contribute to your plan to provide discharge medication education, as this will be a change in their process. My experience has been that the nurses’ response was positive; in fact, they seemed to be happy to turn the responsibility of medication education over to a pharmacist. However, don’t be surprised if you receive a mixed reaction, as some nurses may feel that this is encroaching on their territory.
- Decide how will you target your medication education efforts. Decide if you will provide discharge medication education to all patients or use criteria to determine which patients will benefit most from your time and knowledge (based on number of medications, complexity of the regimen, specific disease states or high-risk medications, etc.). My goal is to provide education to all patients being discharged, with the exception of patients who are either being admitted or are returning to a long-term care facility. Since the vast majority of rural hospitals operate without 24-hour pharmacy services, you will also need to think about how discharge medication education will be provided when a pharmacist is not on site.
- Choose the right implementation tools. Do you plan to incorporate written educational materials or demonstration products into your verbal education? Pharmaceutical representatives are great sources of free written information, placebo metered-dose inhalers and injection demonstration kits, just to name a few. Also consider what the patient might need in terms of helping them to adhere to their medication regimen at home, such as medication organizers ("pill boxes"). I approached our hospital’s charitable foundation board with a request to purchase pill boxes of different sizes (one dose per day, two doses per day, four doses per day) to give to patients for free in an effort to improve medication adherence. The hospital’s logo is printed on each organizer with the statement "Provided by the Guthrie County Hospital Foundation," so it is good promotion for the hospital and the foundation. We purchase them in bulk so that we get the best price. It has proven to be a very successful program.
- Know the discharge destination. It is important to know the patients’ discharge plans ahead of time whenever possible. Some possible discharge destinations include going home independently, going home with family or other caregiver support, going home with public health nursing services or moving to a long-term care facility. Knowing the discharge plan will help you determine who needs to be present during your medication education session. For example, if the patient is going home and the adult child will be managing the medications, the adult child should be available to ask questions. Another reason to be aware of the patient’s discharge plan is to prepare for the patient’s medication-related needs at home. For example, patients newly diagnosed with diabetes will not only need education regarding their new medications, but will probably also need your assistance in obtaining a glucometer and supplies. The ideal forum for receiving discharge information is interdisciplinary care planning meetings where discharge planning is coordinated. If your pharmacist staff is not already attending these meetings with other healthcare professionals, I strongly suggest you consider it.
- Coordinate with the discharging physician. One of the many advantages to practicing in a small hospital is the familiarity and availability of the pharmacy and medical staff. Whenever possible, try to communicate with the discharging healthcare provider while he or she is writing discharge medication orders or during rounds to be sure that you understand the intentions for the discharge medication regimen. I find that the most effective method for accomplishing this is to review the admission medication history with the physician and ask which medications are to be continued and if there are any to be discontinued. I then go through new medications and dosing changes and obtain written prescriptions for those. If you will be sending a discharge medication list home with the patient, it is a great idea to have the physician review it with you. Getting your questions regarding the discharge medication regimen before the education session will prevent frustration both for you and for the patient who is likely to be in a rush to get out the hospital door.
- Coordinate the discharge with nursing. Work out a system between nursing and pharmacy staff to make the discharge as efficient as possible. Remember that medication education is only one component of the discharge process and so you will need to coordinate with nursing, and possibly other disciplines, to assure that you are all able to complete your "piece" of the discharge. Regardless of the coordination system you come up with, it should involve notifying the pharmacy as soon as possible once it is decided which patients are being discharged and, if known, what time.
- Communicate the discharge medication regimen. Obviously, it is important that the patient have a copy of his or her discharge medication regimen. I am sometimes responsible for preparing the discharge medication list for those patients whose regimen is particularly complex. I always am sure to place a copy in the chart and I send one copy to the discharging physician’s clinic, in addition to a copy for the patient. I also provide a copy to the public health nursing staff if the patient will be followed by them.
- Document, document, document. We all know the saying: "If it isn’t documented, it didn’t happen." Be sure to chart your education with the patient and/or anyone else who was present, in addition to the discharge medication list. You should also document the points you stressed about each medication including possible drug interactions and adverse reactions, time of day to take the medications, storage conditions, etc. Document your assessment of the patients’ and/or caregivers’ understanding. Your hospital probably already has a discharge instruction form for documentation; take a look at it and see if it will meet your needs for documenting medication education.
- Regional Medical Center, Manchester, IA
Our facility (RMC, Manchester) committed to IHI 100,000Lives Campaign in the spring of 2005. Phase I included development of a tool to obtain as accurrate medication history as possible from the patient presenting in ER, OR, Ambulatory Surgery, Medical-Surgical and Intensive Care units. This tool was developed by the Patient Safety Committee, co-chaired by our Pharmacy and Quality Managers. This committee also has a physician champion that is very actively engaged in all of our patient safety initiatives. This tool is in triplicate, which also functions as a physician order sheet thus avoiding potential for transcription errors. This process has slowly but steadily evolved to the point that all physicians, nurses, and pharmacists are involved in the intended use of this document. From that, we developed a discharge record specific to medication the patient was to continue on at home following discharge. It is in larger print, and utilizes symbols like a stop sign that indicates to the patient what medications have been discontinued. A copy is sent to the physician’s office after the patient is discharged.
In the spring of 2006, our Patient Safety Committee, under the direction of our physician champion, and at the request of members of our Medical Staff, accepted the challenge to begin Phase II of 100,000Lives Campaign. Phase II involved marketing and engaging patients in our community to know what medications they were taking, why they were taking them, and how to take them. This involved the development of a medication card that could be given to patients at various access places from all medical providers, and businesses in our community. The committee reviewed the medication reconciliation tool kit that was available online from the Iowa Healthcare Collaborative. Having this toolkit available to us proved to be invaluable from the standpoint of not having to spend hours re-inventing the wheel. The committee reviewed the medication card and made the changes we felt most appropriate for our community. From there it was taken to our Medical Staff for further suggestions. Their direction and support was very encouraging, and they continued to push for a product that they could give and educate the patient/public on in relationship to them taking ownership of their medications.
The physicians asked for more space for medications to be written so the elderly patient could read and write on it, space for a brief medical/surgical history, and allergies that would fit into a male/female billfold. We decided to make ours slightly larger, with a different layout from the toolkit, and found that when folded properly we could fit it into a baseball card sleeve protector. These were less expensive than the ones suggested in the toolkit. The trade off was that the base ball sleeve was flimsier; but still effective. We placed our hospital logo on the sleeve, and saved a lot of room on the card itself. The final product with a full marketing plan was taken to our full Medical Staff in August. The Medical Staff unanimously voted to support this initiative, and voted to put $1000 from their fund to help with advertising and printing of the cards. The hospital and hospital auxiliary have equally donated funds to help sustain this project.
Manchester has a population of 6,000. Our service area is approximately 22,000 people. RMC hosted an Open House to members of this service area in September. One identified stop on the tour was our Medical Staff meeting room which contained a brief presentation on Medication Matters project and distribution of the cards. Over 600 cards were distributed that day. Since then, we have hosted a breakfast brunch for all medical providers (dentists, pharmacists, optometrists, chiropractors, physicians, mental health providers) in our area to promote this initiative and provide them with a holder and packet(obtained from the IHC website containing the medication card). All of the local pharmacies have also assisted with providing funds to educate and market this initiative on our local radio station and in the local newspapers. I have attached copies of these advertisements. To date over 5000 of the cards have been distributed by these providers. The hospital has committed to continue to be the contact and supplier of the medication cards for the participating providers. We have even developed an audiovox message regarding this initiative ( see attached),the message plays on our hospital phone system, so when a caller is on hold, we educate on the use of the card and where to obtain one. We have also had various written articles from our pharmacist in the local papers.
Hopefully, now we will see patients use the card……….so far we have seen some useage as people come in for surgery and scheduled procedures. There is still a lot of work to be done to educate the public. We monitor how many cards we distribute to each provider, so we can receive feedback on whether or not they are offering the card, and have it available to patients. Thanks again to the efforts of all the people involved in placing the toolkit on the IHC website!
100,000 Lives Campaign - Iowa Mentor Hospitals in Preventing Adverse Drug Events
Buena Vista Regional Medical Center, Storm Lake
Kossuth Regional Health Center, Algona, IA
St. Luke’s Hospital, Cedar Rapids
Resources
Articles
Massachusetts Coalition for the Reduction of Medical Errors (PDF 15KB)
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