The current processes for recording drug histories have been described as inadequate, potentially dangerous and in need of improvement. In some cases the only history recorded is the medicines ordered on the inpatient medication chart. Errors can be introduced into a patient's medication regimen whenever there is a transfer of care, particularly on:. Discrepancies commonly occur between the drugs a patient is taking on admission and those ordered on the medication chart. Patients over the age of 65 years and those taking several prescription medicines have a significantly increased risk of medication errors.
At least one in six patients have one or more clinically significant medication discrepancies on transfer, for example when a patient is transferred from intensive care to a general ward.
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Discrepancies also commonly occur at discharge when prescriptions are written and discharge summaries prepared. A year-old woman with a regular general practitioner was prescribed several medications, including atenolol 50 mg daily, after a myocardial infarction. Six months later she saw a cardiologist for a review of her treatment. She was asymptomatic, but the cardiologist prescribed metoprolol 50 mg twice daily. The cardiologist did not have a complete list of her medicines. As she was now taking two beta blockers, the patient subsequently developed symptomatic bradycardia.
An elderly man was admitted to hospital via the emergency department. The patient had recently started warfarin for atrial fibrillation so his INR was measured. The INR was 4. No warfarin was ordered during the admission.
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The discharge prescription and summary were written from the inpatient medication chart so did not include warfarin. There was no reconciliation with the admission history.
A medicines list for the patient was prepared by hospital pharmacy staff from the discharge prescription and placed in the bag with a month's supply of discharge medicines. No follow-up appointment was made with the general practitioner. Five days later the patient suffered a stroke. Medication reconciliation is a process designed to improve communication and promote teamwork.
This has the objectives of preventing medication errors associated with the handover of care 19 and maintaining continuity of care. It is described as the formal process of obtaining, verifying and documenting an accurate list of a patient's current medicines on admission and comparing this list to the admission, transfer and discharge orders, to identify and resolve discrepancies.
There are a number of discrete steps Fig. The process is based on the safety principle of independent redundancies — having independent checks, generally by different providers, for key steps in the process. Table 1 Steps in the medication reconciliation process on hospital admission. A 'best possible medication history' is the cornerstone of the medication reconciliation process. It is described as a comprehensive drug history obtained by a clinician that includes a thorough history of all regular medicines used, including non-prescription and complementary medicines, and is verified by more than one source.
A structured process for taking the history, that involves the patient or carer or family, using a checklist to guide the interview, and that verifies the history with information from a number of different sources, provides the best assessment of the drugs a patient takes at home. Sources used to obtain a comprehensive history are listed in Fig.
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Patients being admitted to hospital should be advised to take their medicines containers and current medicines list. Ideally the best possible medication history is completed before any drugs are ordered and is used when the medication chart is written up. For unplanned admissions the history is usually completed after the initial medication orders have been written and is used to reconcile the orders.
In the community the general practitioner can refer to the community pharmacy for a list of dispensed medicines or request a Home Medicines Review to determine the medicines currently taken.
This best possible medication history should be reconciled with the current medication list in the patient's record and their condition. A standardised form for recording the best possible medication history and reconciling any discrepancies is essential for effective medication reconciliation. Whether electronic or paper based, the form should be kept in a consistent, highly visible position in the patient's notes and be easily accessible by all clinicians when writing medication orders and reviewing the patient.
Computerised systems e-prescribing may prevent many of the medication errors that occur at transfers of care but these systems are not without their problems. They still require someone to enter an accurate list of drugs and allergies.. Medication lists in electronic records can lag behind prescription changes and be incomplete.
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Outdated, unverified or inaccurate information may be transferred indefinitely when using copy-and-paste facilities, so reconciliation is still required. Medicines should be reconciled as soon as possible, 5 at least within 24 hours of a patient's admission to hospital or earlier for high risk drugs.
Any changes to orders are documented. Whoever performs the task should be trained and competent in the process. In the community, medication reconciliation should occur on receipt of information about the discharge medication. The general practitioner can compare the medication history in the patient's notes with the discharge medicines list provided by the hospital, reconciling any differences and updating the patient's record.
Similarly when changes are made to a patient's medicines such as dosage alterations, medicines ceased or new medicines prescribed, the current medication list in the patient's record should be reviewed and updated. This reduces the risk of inaccurate medication information being transferred to other care providers in referrals. Providing patients or carers with an updated list when medicines are changed and encouraging them to maintain their own medicines list is an important component of the medication reconciliation process.
A medicines list is available from NPS. Engaging the patient is one of the best strategies to prevent reconciliation errors and a patient-centred approach to medication reconciliation is recommended. When patients present a list of their medicines, or the medicines themselves, on admission to hospital the risk of medication errors and harm is reduced. Individual hospital studies and a number of large-scale initiatives in the USA and Canada have shown that medication reconciliation significantly reduces medication errors and adverse events.
Errors prevented by medication reconciliation include inadvertent omission of therapy, prescribing a previously ceased medicine, the wrong drug, dose or frequency, failure to recommence withheld medicines and duplication of therapy after discharge. A standardised process for medication reconciliation reduces the work associated with the management of medication orders.
Time savings for nurses of 20 minutes per patient at admission and pharmacists of 40 minutes per patient at discharge have been reported. A formalised system of medication reconciliation could have prevented the events described in the cases. In see case 2 if the doctor's plan to recommence the warfarin had been documented in the patient's medication management plan, the error would have been identified if the plan had been used to reconcile the drugs ordered on discharge. The process of medication reconciliation, using a formalised structured approach involving patients and carers and conducted in an environment of shared accountability, can reduce the morbidity and mortality of medication errors that occur at interfaces of care.
Medication reconciliation is a cost-effective use of the health dollar and an important element of patient safety. Model-based cost-effectiveness analysis of interventions aimed at preventing medication error at hospital admission medicines reconciliation. J Eval Clinical Pract ; Making inpatient medication reconciliation patient centered, clinically relevant and implementable: a consensus statement on key principles and necessary first steps.
J Hosp Med ; Assuring medication accuracy at transitions of care: medication reconciliation. Canadian Safer Healthcare Now! Medication Reconciliation Initiative. Institute for Healthcare Improvement, US. Prevent adverse drug events with medication reconciliation. Massachusetts Coalition for the Prevention of Medical Errors. Reducing medication errors in acute care facilities — reconciling medications.
Northwestern Memorial Hospital, Chicago. Agency for Healthcare Research and Quality. Reasonable care is taken to provide accurate information at the time of creation. This information is not intended as a substitute for medical advice and should not be exclusively relied on to manage or diagnose a medical condition.