Medication Reconciliation Flowchart
Description of the Patient Safety Problem
Medication reconciliation is the process in which nurses, physicians, and other healthcare professionals work with the patients to ensure that medical information is accurate and complete at the various interfaces of care. Medical reconciliation is necessary in mitigating adverse drug effects, which are a leading cause of morbidity and mortality within health care systems around the globe(Andel, Davidow, Hollander, & Moreno, 2012). Many adverse drugs events occur due to poor communication between medical professionals and between medical professionals and patients especially in cases where care is transferred. Care transfer refers to instances when patients are admitted to a care facility, moved between wards within a hospital or are discharged home or to a residential facility.
Over fifty percent of medical errors that occur in the clinical environment is estimated to occur on admission or discharge. Further, thirty percent of these errors can harm patients. Errors occurring on admission entail obtaining the patient’s medical history, when prescribing medicines, and when recording the medications in the medical records. According to the World Health Organization (2015), 67 percent of patient’s prescription histories recorded on admission are inaccurate. Additionally, up to 80 percent of patients have discrepancies between the prescribed medications and the medications they are taking at home(Elias, Damle, Casale, Branson, Churi, Komatireddy & Feramisco, 2015). The repercussions of inadequate transition from a hospital to home are far-fetching for patients (World Health Organization, 2014). They include adverse drug effects, hospital readmission, and mortality.
Medication Reconciliation at Admission
Description of the Process
Medication reconciliation starts with obtaining the patient’s best possible medication history (BPMH). This means that the health care worker admitting the patient should compile a comprehensive list of medications that the patient has previously taken or is currently taking. They achieve this by interviewing the patients or their guardians, deriving information from referral letters as well accessing previous medical information from electronic health records. The Best Possible Medical History (BPMH) should include all drugs that the patient is taking, both prescribed and non-prescribed. Prescribed medications are those taken under the advice of a prescriber while the latter are not based on a prescribed advice. Complementary (herbal), recreational drugs, and prn medication should be included in the Best Possible Medical History (Elias, Damle, Casale, Branson, Churi, Komatireddy & Feramisco, 2015). Only if a patient or their guardian are not in a positionto describe their medical history before admission should the other sources be utilized to obtain their medication history or to clarify a conflicting piece of information about them (World Health Organization, 2014). It is not professional for a heath care professional to use other sources of information in the place of a thorough interview with a patient or their guardians.
Next, the patient’s Best Possible Medical History is verified and documented. The information should be verified with more than one source including their medication lists, the federal medication database, inspecting their medication containers, or verifying with their home care providers and community pharmacists. The Best Possible Medical History is a record of a patient’s medication information including their generic and brand names, dosage, a patient’s route and frequency of administration (McGonigle & Mastrian, 2012). A BPMH is different from and more comprehensive than the conventional primary medication history. As such, it should be documented in a computer template that prompts for the required information(Elias, Damle, Casale, Branson, Churi, Komatireddy & Feramisco, 2015).
The third step of the medical reconciliation process entails reconciling the Best Possible Medical History with the prescribed medicines. Medication reconciliation on admission is in figure 1 above. It is a retroactive modelwhereby medication admission orders are written before the Best Possible Medical History has been obtained. The BPMH and the admission orders are reconciled, whereby discrepancies are identified and resolved (World Health Organization, 2014).
To begin the reconciliation, patient’s conventional primary medication history is taken and admission medication orders documented before the Best Possible Medical History is created. When created, the Best Possible Medical History is compared retroactively against the admission medication orders. Discrepancies are then identified and resolved as appropriate. The discrepancies are categorized into intentional discrepancies and undocumented intentional discrepancies. Undocumented intentional discrepancies are those which the prescriber makes an intentional decision add, adjust, or stop a medication, but do not document the decision (Giles, Harris, & Parker, 2010).Unintentional discrepancies are those which a prescriber changes, omits, adjusts, or stops a medication that the patient was taking before they are admitted. The reconciliation should occur within 24 hours of admitting the patient.
The final step entails communicating to the patient the Best Possible Medication Discharge Plan at the end of the patient’s episode of care. The plan should also be communicated to their personal care physicians, community pharmacy and the facility that will provide them care next (Andel, Davidow, Hollander, & Moreno, 2012). On receiving the plan, all the recipients should make sure that they update their records so that they reflect an accurate record of the patient’s current medications.
In any clinical process, patients are the only constants. Medication reconciliation, therefore, will only work with the active involvement of patients and their families in the process. Patients are best placed to provide accurate information about their medications(Huser, Rasmussen, Oberg & Starren, 2011). As such, they should be educated about the essence of participating in the medication reconciliation process. They should be encouraged always to speak up if the think that there is a discrepancy or an error with their medication. They should also be advised to keep an updated list of all the medications that they are currently taking. Additionally, they should be advised to always bring their medications and medication records with them when they come to the hospital. Achieving this would require the use of educational tools and materials to support patients in self-maintaining their medication records.
Areas of Improvement
Patient and Family Involvement
After the Best Possible Medical History has been obtained, patients should continue to be engaged in the subsequent steps leading to a successful medication reconciliation process. It is important to notify them of any changes made to their medication records and regimen so that they can have an understanding of how to continue taking their medicines. When they are discharged to home and in ambulatory visits where the patient’s medication has been modified, it is important that they receive counseling on the updated regimen (Howlett & Atkinson, 2012).
The process of medication reconciliation is complex because it encompasses a multitude of professional disciplines across a broad spectrum of care (Huser, Rasmussen, Oberg & Starren, 2011). While the fundamental guiding principle of communication alongside its value to the safety of patients is widely accepted, the medication reconciliation process is sometimes considered as exasperating. As such, the process may be resisted within a care setting if not implemented in a systematic manner. It is recommended that a quality improvement approach is applied in applying medical reconciliation.Medication reconciliation is a matter dealing with information management and the implementation of medical reconciliation systems depends largely on the existing staff in a health care organization as well as the systems and processes established to collect, use, and communicate medication information. It is imperative that information management activities that facilitate medication reconciliation are integrated into a health care organization’s existing systems and processes as much as possible. To provide patients with the safest form of care, it is important that licensed practical nurses and registered nurses follow the steps outlined in the workflow for proper medication reconciliation. This will reduce the rate of infections as well as the possibility of adverse effects occurring in a healthcare facility. Chances to improve the efficiency of the medication reconciliation process need to be identified, prioritized and implemented.
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