July / August 2006
Progress Realized, Challenges Ahead
Over the past several years, clinicians and healthcare organizations have come to understand the critical role that medication errors inadvertent and usually preventable play in jeopardizing patient safety. More recently, patient safety advocates have identified a process known as medication reconciliation as a way to reduce the risk of such errors. Medication reconciliation ensures that information about a patient's drug type and dosage is accurate and available at key points in the healthcare continuum.
While it may be axiomatic that clinicians need to know their patients' medications, in reality, this information is often unavailable when important treatment decisions are being made. Poor or nonexistent communication about medication information at key "transition points" admission, transfer between care settings, and discharge is responsible for as many as 50% of all medication errors and up to 20% of adverse drug events (ADEs) in hospitals, according to the Boston-based Institute for Healthcare Improvement (IHI, 2006).
Given the myriad settings in which patients receive prescribed medications, inaccurate information can occur in many ways, often putting a patient's health in serious danger.
In 2005, the United States Pharmacopeia, the standard-setting organization for prescription and over-the-counter medications, received more than 2,000 voluntary reports of medication errors occurring at transition points (JCAHO, 2006). Of these errors, 66% occurred during the patient's transition or transfer to another level of care, 22% took place at the time a patient was being admitted to the facility, and 12% occurred at the time of discharge.
Examples of medication errors reported to the Institute for Safe Medication Practices (ISMP, 2005) in the past year underscore the high-stakes consequences of simple lapses in communication or in transfer of information:
- A patient who was transferred from one hospital to another received a duplicate dose of insulin because the receiving nurse didn't know the medication had been given before transfer. The patient's medication history had not been provided to the receiving facility until several hours after the patient's arrival.
- Shortly after hospital admission, a patient became lightheaded and fell in the bathroom after a physician prescribed Toprol XL (metoprolol extended-release) at a dose larger than she took at home. The patient required telemetry monitoring and hydration for 24 hours.
- An emergency department patient with chest pain received a 7,000-unit heparin bolus prior to starting a heparin infusion. Upon admission to the critical care unit, the heparin bolus dose was repeated in error, delaying the patient's cardiac catheterization.
- Before discharge, a patient's dosage of Lexapro (escitalopram) was increased to 10 mg daily, but the discharge instructions listed 5 mg daily. When the error was noted, a pharmacist called the patient, who had been cutting in half the 10 mg tablets provided with her new prescription.
JCAHO's New Safety Goal
Based on the growing awareness of medication errors that occur during transitions, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) now requires that accredited healthcare organizations implement formal medication reconciliation processes. The group's National Patient Safety Goal, which took effect in January 2006, requires that organizations:
- Implement a process for obtaining and documenting a complete list of the patient's current medications upon admission. This process involves patient participation. Medications the organization provides the patient are then compared to those on the list.
- Communicate a complete list of the patient's medications to the next provider of service when a patient is referred or transferred to another setting, service, practitioner, or level of care within or outside the organization.
JCAHO notes that medication reconciliation must occur "at a minimum" any time that orders are rewritten and any time the patient changes service, setting, provider, or level of care and new medication orders are written. Healthcare organizations should determine whether the reconciliation process is needed when transitions occur that do not involve new medications or rewriting of orders.
Finally, but significantly, JCAHO underscored the sweeping scope of its newly enacted safety goal. It applies to an estimated 15,000 healthcare organizations that the organization accredits, including inpatient, ambulatory, emergency, and long-term care facilities.
Time Spent Equals Time Saved
Some organizations had made significant headway in creating and implementing medication reconciliation systems well before JCAHO's new patient safety goal.
For example, officials at Luther Midelfort-Mayo Health System in Eau Claire, Wisconsin, implemented a reconciliation system that, over the course of 5 years, lowered discrepancies in medications tenfold and reduced adverse drug events by as much as 20% (Tokarski).
That success didn't occur overnight. Beginning in 1999, with assistance from the IHI, the hospital determined that an average of 200 medication discrepancies occurred for every 100 hospital admissions, or 2 discrepancies for each patient per admission (Tokarski). Doctors frequently were unaware of all of the medications patients under their care were taking.
Today, when a patient enters Luther Midelfort, medications are reviewed, verified, and reconciled. A nurse is primarily responsible for the review, results of which are entered into the patient's medical record. The nurse charged with this responsibility frequently consults with the hospital pharmacist to verify specific medication types and dosages, and the actual reconciliation of medications occurs between the nurse and the patient's physician.
Although the process may seem time consuming and impractical in a fast-paced healthcare setting, the hospital reports that it takes an average of only 11 minutes to complete. Time spent reconciling medications upon admission frequently means that time is saved when patients are discharged because their information is accurate and complete.
At OSF-St. Joseph Medical Center in Peoria, Illinois, a medication reconciliation process has been credited with helping to lower the ADE rate from 5.8 per 1,000 doses to 0.50 per 1,000 doses between 2001 and 2003 (Haig).
Even though the hospital was already seeing improvements in its ADE rates through its participation in an IHI collaborative, those rates dropped immediately following implementation of a computerized medical record system. Adding a physician signature line to the electronic medical record boosted reconciliation level to their earlier levels.
The Challenge of IT Coordination
One of the most challenging aspects of implementing a successful medication reconciliation process is coordinating information not just within one healthcare facility a daunting task in itself but across several healthcare settings. This dilemma is especially significant for older patients, who often take multiple medications and receive care across a spectrum of healthcare facilities.
Bolstered by rapidly evolving health information technology (IT), some organizations are beginning to develop promising approaches. Nonetheless, progress toward optimizing the benefits of IT continues at a more rapid pace within healthcare settings than across them (Bayley, et al., 2005).
To improve the accuracy of medication lists throughout the continuum of care, researchers at PeaceHealth, a health system serving Oregon, Washington, and Alaska, have created a single medication list that's electronically available to healthcare providers, caregivers, and patients and can be updated (AHRQ, 2005). The medication list is part of a community-wide Web-based personal health record called the Shared Care Plan, which allows patients and caregivers to document and retrieve medication lists, advance directives, and other components of a patient's personal medical record.
Although the Shared Care Plan is currently available only in PeaceHealth's Oregon region, its developers plan to make it available to clinics, physicians' offices, nursing homes, home health agencies, skilled nursing facilities, and pharmacies across the system's five regions.
Coordinating care, including medications, for patients discharged from the hospital to home care services is an ongoing challenge. To address this, researchers at Weill Medical College of Cornell University and the Visiting Nurse Service of New York have developed an electronic tool that automatically uploads data about patients' diagnoses, medications, allergies, and other key demographic data from the hospital electronic health record (AHRQ, 2006).
The tool has been expanded to include diagnosis-specific home care orders, such as for heart failure, diabetes, or wound care, and triggers for when physician contact is needed. The completed form is part of the patient's electronic health record at New York-Presbyterian Hospital, an affiliate of the medical college.
Although researchers, working with investigators from the U.S. Agency for Healthcare Research and Quality (AHRQ), are merging data from the hospital and the home health agency to conduct an effectiveness analysis, some successes of the electronic form already are apparent.
For example, the completeness of electronic versus handwritten orders sent to the home health agency has increased significantly, especially for mental status (6% vs. 100%) and functional limitations (28% vs. 94%). Evidence-based orders for home health diabetes care using the electronic form were completed 71% of the time, compared to 6% with handwritten orders. Physician involvement, however, still remains modest.
Clearly, organizational and cultural definitions play their part in promoting the use of medication reconciliation systems, but several IT questions must also be addressed before patients outside of an integrated system like PeaceHealth or Weill Medical College's New York-Presbyterian Hospital can benefit from an accurate, updated and coordinated approach. Investigators working with AHRQ have begun to address some of these issues, but further research is needed to answer these questions:
- How can specialized ancillary information systems be designed with integration in mind?
- What factors lead to increased trust and use of computerized information?
- What are the short-term strategies for bedside clinicians to use with nonintegrated IT?
- What are setting-specific requirements for speed of information access? (Bayley, et al., 2005)
Leadership by JCAHO, IHI, and pioneering hospital organizations that have implemented medication reconciliation systems has gone a long way toward reducing the significant risk of harmful medication errors and adverse drug events. As healthcare organizations implement this important patient safety goal this year and in the future, we can build on their progress by learning how to optimize IT across the spectrum of care facilities.
Carolyn Clancy is director of the Agency for Healthcare Research and Quality. She may be contacted at firstname.lastname@example.org.
Agency for Healthcare Research and Quality (AHRQ). (2005, September). Patient Safety E-Newsletter, Issue No. 12.
Agency for Healthcare Research and Quality (AHRQ). (2006, June 1). Development and evaluation of electronic-transition tools for home health care.
Bayley, K. B, et al. (2005, April). Barriers associated with medication information handoffs. In Advances in Patient Safety: From Research to Implementation, U.S. Agency for Healthcare Research and Quality, Volume 3, April 2005.
Haig, K. One hospital's journey toward patient safety A cultural revolution. Medicine Business of Medicine. Retrieved from www.medscape.com/viewarticle/460721 on June 8, 2006.
Institute for Healthcare Improvement (IHI). Medication Systems. Retrieved from www.ihi.org/IHI/Topics/PatientSafety/MedicationSystems/
Measures/#Outcome%20Measures on June 8, 2006.
Institute for Safe Medication Practices (ISMP). (2005, April 21). ISMP Medication Safety Alert. Retrieved from www.ismp.org/MSAarticles/20050421.htm on June 8, 2006.
Joint Commission on Accreditation of Healthcare Organizations (JCAHO). (2006, January 25). Sentinel Event Alert, Issue 35.
Tokarski, C. Reducing adverse events by improving reliability: A newsmaker interview with Roger Resar, MD, Medscape Medical News. Retrieved from www.medscape.com/viewarticle/493643 on June 8, 2006.