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Patient Safety and Quality Healthcare
November / December 2006

Feature Article

Using Clinical Decision Support to Improve Medication Reconciliation

What is the most common denominator in medication errors? Poor communication about prescribed medicines at key transition points of the medication use and reconciliation process: admission, transfers between care settings, and discharge. Data collected from hundreds of hospitals have shown that communication breakdowns surrounding medical information at transition points result in as many as 50% of all medication errors in the hospital and up to 20% of adverse drug events (IHI, n.d.).

Medication errors occur at many points during the care process, and hospitals continue to struggle with medication reconciliation despite its having been a JCAHO National Patient Safety Goal since 2005. Medication reconciliation is not just about compiling lists, however. To truly improve patient safety, medication reconciliation also must involve clinical decision support and the Five Rights of medication safety:

  • Right Medication

  • Right Dose

  • Right Time

  • Right Route

  • Right Patient

The Institute of Medicine (IOM) report, Preventing Medication Errors (2007, released July 2006), focused the nation's attention once again on the problem of medication safety by highlighting what many in the health arena have known for some time: Every year, millions are hurt or killed by medication errors.

The report recommends using electronic prescription and clinical decision support (CDS) software, with point-of-care reference information accessed via the Internet or PDA. While ubiquitous electronic prescribing may prove difficult to achieve initially, the report does emphasize that CDS that is readily available can help clinicians pick the best drug and avoid adverse drug interactions.

Decision support in the form of evidence-based clinical knowledge delivered in the right format to the right person at the right time can help providers enhance their medication reconciliation strategies by taking steps to ensure patients receive the correct medication and accurate dosage. For example, CDS can alert clinicians to the need for a dosage adjustment based on advancing age or declining renal function. Similarly, decision support tools can alert a clinician to reassess the need for medications such as antibiotics that appear to be used for longer than indicated.

As patients move through different care settings, drug, disease, and condition management knowledge tools imbedded within various applications can help clinicians and patients alike reconcile medications, avoid errors and the potential for patient injury, and even promote best care practices. CDS-driven knowledge accessible at the point of care can identify drug-to-drug interactions, inaccurate dosage ranges, and appropriate monitoring of therapeutic benefits and harms.

Following are some specific strategies for using CDS solutions to enhance the value of a medication reconciliation program:

Document the regimen's rationale. During the patient's admission interview and examination, be attentive to prescribed medications and the reasons for their use. During this front-end meeting, it's common to encounter a patient who has taken a drug for years with no recollection of why. For example, the patient may have been prescribed an anti-depressant 10 years ago and hasn't been asked recently why they are taking it or if they still need it. Or, the medication itself is not commonly prescribed and even the patient is unable to remember its name. In these instances, drug reference information and education tools such as "pill image identifiers" can help determine which medication the patient is taking and why. Researching the patient's medication history, attaching a diagnosis to all medications ordered for a patient, and evaluating the drug's medical necessity at admissions — and at each transition point going forward — supports patient safety by ensuring that the patient's medication regimen is easy to understand and follow.

Detect off-label indications. Understanding the rationale and evidence supporting a potential off-label use is critical for clinicians as part of the medication reconciliation process. Unbiased knowledge-reference information can help pinpoint off-label uses of drugs in the patient's regimen. Discovery and adoption of new uses for marketed drugs often precedes FDA approval of such uses. Furthermore, some manufacturers fail to seek FDA approval of indications, as the FDA-application process may be cost prohibitive. Identification of off-label use is important so that a patient is not incorrectly assigned a diagnosis that may be the typical use of a drug.

Deploy CDS alerts. Proactive CDS alerts imbedded within the hospital's computerized physician order entry (CPOE) system can also help with errors of omission as many patients admitted to a hospital are taking non-formulary drugs. The pharmacist or attending physician usually performs a therapeutic substitution for a drug included on the hospital's formulary. A targeted patient-specific alert triggered during this process notifies the clinician of problems for which they might not otherwise be aware. For example, the alert flags a therapeutic duplication, meaning it proactively notifies the clinician when the patient has been ordered two of the same medicines, albeit with different names, to prevent an adverse reaction. Or, the drug substituted for the non-formulary medication may result in a drug interaction, despite being in the same drug class. Whatever the alert, clinicians can react more quickly to prevent a harmful interaction or administer antibiotics immediately and earlier in the care process, potentially decreasing the patient's hospital stay and costly therapies and the chance for a prolonged illness.

Other CDS alerts and interventions that should be included during workflow and medication administration processes and imbedded in CPOE systems are drug-drug, drug-alternative medicines, drug-food, drug-disease, drug-ethanol, drug-tobacco, and drug-laboratory interactions; previous allergic reaction screening; dosage checking; clinical conditions; and pregnancy- and lactation-related warnings. Alerts and interventions must be targeted and appropriate so that clinicians are alerted only to conditions that require attention. Excessive alerts, although well-intentioned individually, may cause alert fatigue, a condition in which clinicians are so inundated with warnings that they may fail to recognize one critical to a patient's care.

Inform and engage patients. Drug and disease education materials help patients understand their underlying conditions and reasons for taking the medications. Effective educational materials help patients make sense of medical complexities, reduce anxiety, and increase compliance with instructions (Tarn et al., 2006), thus transforming communication into actions that will improve health. The best-case scenario is having those materials (e.g., diagnosis and condition management education) clinically consistent with decision support resources so that all care team members are supported by the same recommendations and answers.

Develop a workflow-optimization system. Reconciling medications across all care settings is a primary challenge of providers. With the growing adoption of e-prescribing and clinical applications, a case can be made for a system integrated into provider workflow that: queries repositories for filled prescriptions, presents lists of recently prescribed (and dispensed) medications, and combines real-time patient information with authoritative decision support reference information during admit/transfer/discharge workflows.

This workflow-optimization system will: 1) display all current information known about the patient's medications, 2) enable clinicians to continue, modify, add, or discontinue medications, and 3) document results and the potential generation of the proper medication orders and electronic prescriptions to "close the loop."

Ideally, this system promotes a collaborative communication framework connecting providers and patients who all understand the status of a medication at any given time and the reasons supporting any changes at each step of the medication reconciliation process.

Case Study: Saint Joseph's Endeavors to Reconcile Medications
Many healthcare organizations are struggling to comply with the JCAHO accreditation requirement to accurately and completely reconcile medication lists across the care continuum. One California provider, Saint Joseph's Medical Center in Stockton and part of Catholic Healthcare West, is working toward this goal, implementing a medication reconciliation form program as part of its patient safety initiative to reduce adverse events and errors.

St. Joseph's Medical Center is a not-for-profit, fully accredited, regional hospital with 294 beds, a physician staff of more than 400, and more than 2,400 employees. Specializing in cardiovascular care, comprehensive cancer services, and women and children's services including neonatal intensive care, St. Joseph's is the largest hospital and private employer in Stockton.

The aging of the baby-boom generation is an oft-cited reason for increased medication use, and St. Joseph's is already seeing an increase in elderly patients. Once properly questioned and prompted about their use of alternative medicines and vitamin supplements, many of these older patients reveal taking more drugs than are documented on their initial intake forms, according to William "Bill" Yee, Pharm.D., clinical information coordinator at St. Joseph's.

These trends, in addition to findings from a former pharmacy resident's research project, have helped propel this community hospital to take action "one process at a time" to work through the challenges associated with medication reconciliation.

The goal of the resident's 2-year study was to determine the accuracy of patient medication histories and allergies obtained on admission or in the emergency department (ED). The resident interviewed each patient for 45 minutes to obtain the most accurate list possible of current medications, including prescription and over-the-counter medicines. In some cases, other sources of information, such as the patient's retail pharmacy, also were contacted.

The resident compared the accuracy of the patients' medication histories that she collected to the medication information documented on charts by the admitting nurse or physician. The cross analysis revealed the patients' prescribed drugs matched less closely when the intake was performed by the nurse or physician as opposed to a pharmacist. At best, the admitting nurse's medication history matched the pharmacist's history 46% of the time. Many of the discrepancies were associated with important details such as dose, route, frequency, and reason the patient was originally prescribed the medication.

"If we were to compile medication reconciliation lists for our ED patients, who make up nearly half of hospital admissions, it would take approximately two full-time pharmacists to conduct a complete medication history equivalent to 45 minutes per patient," said Yee.

Since the study, St. Joseph's Medical Center has deployed a medication reconciliation form and process, completed upon admit and reviewed on transfer and discharge. Physicians and pharmacists now play a more integral role in this process, an action noted in another study conducted by Chicago-based Northwestern Memorial Hospital (NMH). In that study, pharmacists were found to be in the best position to perform medication reconciliation. NMH researchers determined that obtaining complete and accurate medication histories of patients and instituting a medication reconciliation program are vital to reducing medication errors (NMH, 2004).

"Tackling the transfer part of medication reconciliation was fairly simple," said Yee. "Our pharmacy software system prints out a medication profile. Whatever drugs the patient is currently taking since the time of admission are documented on this profile and sent up to the floor. At the time of transfer, the attending physician must initial line by line the medications they want the patient to continue or discontinue before the patient moves to another floor. This new system is working out nicely."

The hospital has introduced a new medication history form in admissions, also heavily involving the physician to review "line by line" the recommended medications. In September, another element of medication reconciliation was rolled out to accurately reconcile medications at discharge. Plus, patients are given copies of all forms, including medication lists, to take to their next destination.

St. Joseph's Medical Center continues to depend on nurses to document patient medication histories in the ED and admissions. Pharmacists now assist nurses with collecting medication histories in difficult or complex patients. "We're (pharmacists) hoping to get more involved and further decrease potential errors in the coming year," said Yee. "It's our goal to secure funding to hire a pharmacist full-time in the ED and to involve our inpatient staff more in the medication reconciliation process."

With pharmacists more closely involved in collecting medication histories, it is hoped that they will be able to better detect drug-disease interactions and optimize patient therapies. In the current nurse-generated history, the capturing of patient diagnosis and the reason for prescribing the medications is questionable. "In the pharmacy we don't always know what type of background diagnosis these people have, and sometimes they don't even know," said Yee.

The resident's study also concluded that the hospital needs a single repository for patient medication and allergy histories. "Depending on what section you're reading in the chart, you can get a totally different answer about the patient's medication and allergy history," said Yee. He added that this process will change over the next few years as the hospital prepares to implement an electronic medical record system that automates enterprise-wide tracking of patient medications. In the interim, the medical center is endeavoring to make the medication reconciliation form the single source for medication histories and allergies.

A major challenge of a community hospital setting such as Saint Joseph's is that medication use histories are generally unavailable from one outpatient source. Unlike an HMO or Veterans Affairs setting where medication histories are centralized and easily accessible from inpatient and outpatient sources, patients receiving care at community hospitals can get their outpatient prescriptions filled at any of the local multitude of retail pharmacies. Therefore, the community pharmacist's participation in medication reconciliation is essential when the patient transitions from outpatient care to acute care to home. Depending entirely on the patient to recollect accurately their medication history may lead to data inaccuracies and introduce error and adverse events.

CDS Boosts Overall Medication Management
Clinical decision support resources implemented within a medication reconciliation program can empower clinicians and patients with the information they need to make decisions that drive safe and effective medication use, and simplify and improve medication management for everyone concerned.

Nurses play an important role in the admission of patients and initial intake of patient information. Physicians and pharmacists can contribute to this process in terms of documenting medication histories and reviewing the finer details of dosage, route, frequency, and indication that a nurse may not have had the time to capture. But most importantly, it's the sharing and communication of that information — what medications have been taken, why new ones are ordered, how they should be taken, and the anticipated benefits and possible side effects — among all caregivers and the patient that can make or break a hospital's journey to improving patient safety.

Moreover, decision support tools tightly imbedded into workflow provide intelligent and relevant guidance to medication reconciliation. By ensuring the accuracy and relevancy of the medication, dosage, and diagnosis at all care transition points, CDS tools encourage physicians, nurses, pharmacists, other clinicians, and the patients they serve to share and update the all-critical medication list. CDS, embraced as an integral component of the hospital's organizational workflow, is an essential part of good medical practice, care management, and error reduction.

Gina Moore is director of the clinical specialist team for Thomson›Healthcare. She may be contacted at


Institute for Healthcare Improvement (IHI). (n.d.). Errors from unreconciled medications per 100 admissions. /IHI/Topics/PatientSafety/MedicationSystems/Measures/Errors+Related+to+Unreconciled+Medications+per+100+Admissions.htm

Institute of Medicine (IOM). (2007). Preventing medication errors: Quality chasm series. P. Aspden, J. Wolcott, J. L. Bootman, & L. R. Cronenwett (Eds.). Washington, DC: National Academy Press. Prepublication copy available at

Northwestern Memorial Hospital study demonstrates way to reduce medication errors, better protect patients (NMH). (2004, August 16).

Tarn, D. M., Heritage, J., Paterniti, D. A., Hays, R. D., Kravitz, R. L., Wenger, N. S. (2006). Physician communication when prescribing new medications. Archives of Internal Medicine, 166(17), 1855-1862.

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