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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.
View the IHC toolkits and their contents.
Resources for providers to ensure safe and effective long-term anticoagulation therapy in all care settings.
Information on how to deploy the NQF 30 Safe Practices.
Information that discusses how to better communicate medical information to patients.
Information on the monitoring and reporting of HAIs.
This process improvement method can help providers deliver more efficient care that saves resources and improves quality.
Details on the principles and components of a patient centered medical home, including the business case and how to become one.
Resources for providers to avoid adverse drug events.
Resources for the safe administration of narcotics and opioids.
Information and resources for providers in their efforts to assist patients with tobacco cessation.
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