Preforming Medication Reconciliation: The In’s and Out’s to Making It Successful
While on one of my rotations, transitions of care was at the forefront of our duties for the unit. One of the biggest topics and skills we practiced as students was performing a proper medication reconciliation. I thought it would be useful to lay out some steps and helpful hints at making this successful! [NB. This is more from the inpatient perspective]
So what exactly is medication reconciliation? Medication Reconciliation or “Med Rec” is the process of creating the most accurate list of all medications a patient is taking, comparing the internal medical record with lists and information obtained from the patient, outpatient providers, and external pharmacies, and resolving any discrepancies that may exist. By forming the complete picture - What medications is the patient on currently or have been on in the past? How were they prescribed? How is the patient really taking them?, etc. - we are able to share and utilize this information at all points of care to ensure safety and proper continuity of care. Reconciling a patient’s medications can reduce prescribing errors, omissions or even duplications, and various adverse drug events. Studies have shown that when student pharmacists perform medication reconciliations for their patients, a significant number of discrepancies can be avoided during transitions of care. Medication errors are a leading cause of injury to hospitalized patients. Shockingly enough, 60% of hospitalized patients have at least one discrepancy upon admission, and reports exist showing that up to 40% of medication errors are in some way attributable to a lack of proper medication reconciliation.
What’s our goal? In the end, we are looking for a sole, complete list, that is explicit in exactly what and how medications were being taken by that patient. This needs to be centrally located and accessible to all providers at any point in time, and easily updated as new and changing information becomes available. A quote I love to bring up is from former Surgeon General C.E. Koop, “Drugs don’t work in patients who don’t take them.” Why did I bring this up? Well it’s important to remember to only document what the patient is ACTUALLY taking - if it was written twice daily yet they are only taking it once a day, then what is the point of documenting how it was prescribed, but not how it was actually taken? Again, drugs don’t work in patients who don’t take them…at all or improperly!
For a medication reconciliation to be successful, it is best to follow a systematic approach, but know that you will always need to be flexible for the process to be successful. Now here is a system we agreed upon and is very straightforward. Please note, this was a system adapted from processes outlined by the North Carolina Center for Hospital Quality and Patient Safety and the Institute for Healthcare Improvement at Cambridge, Massachusetts with examples by Kaleida Health at Buffalo, New York. [The links and references to see those in their entirety will be posted below]
Step 1: Collect
- Get the background on the patient.
- Do NOT walk into that room without having a solid idea of why the patient is admitted, what their hospital course has been so far, what their prognosis is like, etc. They expect you to know things, all sorts of things, so be prepared. This also allows you to have a better context as to why they were on those prescriptions at home, and you may find certain questions you will need answered about their medications.
- Ask the patient if they have a medication list or their home medications physically with them.
- If so: review that list or bottles with them, let them do as much explaining about each of the medications as possible, including when and why they take it.
- If no list or set of bottles is available, then ask the patient about each medication they take at home.
- In either of these scenarios do NOT forget all the information you need to gather about each of the medications, or the other information such as non-prescription medications, allergies, pharmacy information, etc.
- If the patient is unable to provide the history, do your best with the situation:
- If family members are present and capable of answering reliably, then interview them.
- Reach out to the patient’s pharmacy for a complete record of the medications and last fill dates.
- Contact the primary care provider for the most recent copy of the patient’s medications.
- Assess adherence with each contact:
- Ask how many doses they think they miss a week. Inquire on how they take their medications - do they have a pill box or any help at home. Many times they’re worried about admitting to missing doses or not taking medications at all, so make it clear that it’s best to have all the correct information we can.
- From a face-to-face interview you can get a good idea of the patients’ actual knowledge of the medications. If they fail to respond to open-ended questions, and are just nodding yes to everything you ask you can assume they most likely have little idea of their medications.
- Family members/caregivers:
- They can be a valuable tool in assessing the picture at home, make sure to ask them as much as possible - they may even be more accurate than the patient.
- Calling the pharmacy:
- Ask for the last fills, does it look like the patient was picking up monthly supplies regularly or are there gaps or a prescribed 30-day supply is picked up every other month.
- Still confused? Have the patient bring in the bottles (if they have someone who can) and compare the amount left with the fill date to assess patient adherence.
- Only document what the patient is ACTUALLY taking!
- With any interview, you should remember a few things when questioning the patient or family:
- Confidentiality is important, and not taking that into account when you enter a room can lead you to a very sticky situation fast. When you introduce yourself as you enter, inquire who is in the room with you - many times when you introduce yourself to everyone they will let you know their relation to the patient. Ask the patient if it’s alright to discuss their medications with everyone present.
- OPEN-ended questions. This is absolutely crucial to ensure you are getting accurate information from the interviewee. Do your best to ask questions that entice them to open up and explain in their own terms - you do not want to put words in their mouth (so-to-speak) for them to just nod their head to.
- For example, ask questions along the lines of “What prescription medications are you currently taking?” instead of running down a list saying something like, “So, you take atorvastatin 80 mg once daily in the evening, yes?”
- Be sensitive. For them this may be a new experience, being in a hospital can make many people anxious and these can be some of the most stressful experiences of their lives.
- Do not judge. If a patient admits to using an illicit substance, skipping doses because they “know better than the docs,” or any other seemingly absurd idea in our eyes, do not react inappropriately or say something rude.
- At the close of any interview, ask the patient if they have any questions (be ready for anything!), and make sure the patient knows you are available to help in any way or if new information arises that they can reach you to update.
Step 2: Compare
- Medication histories from various sources must be compared.
- You should be looking at the information previously recorded in the EMR and comparing that to the information given by the patient or patient’s family members, the patient’s pharmacy or primary care provider.
- Look for discrepancies amongst the documentation, and any explanations for them by piecing together all the information you’ve been given.
Step 3: Resolving Discrepancies
- What is a medication discrepancy? Simply put, what the patient is actually taking, and the medication lists you have, do NOT match up.
- Identifying discrepancies is what all your hard work so far has been culminating too! Identify using all the pieces of the puzzle (so-to-speak) to find where medication regimens were changed, added, discontinued, or otherwise altered.
- Identifying when or when not to intervene on a medication discrepancy is crucial.
- Examples of when NOT to intervene:
- Similar or alternative med is ordered based on formulary (e.g. atorvastatin being used in place of rosuvastatin)
- Prescriber’s decision to change route, frequency, dosage, etc. (e.g. switching from a PO to an IV diuretic for an acute CHF exacerbation admission)
- Examples of when to intervene:
- Medication omission (e.g. antidepressant is not ordered on admission and no clinical explanation is given as to why)
- New medication is added to the patient’s list on discharge without clinical explanation (e.g. Lovenox for DVT PPx in the ICU being continued on discharge without any clinical indication of such)
Now for some of the fun stuff – when things get messy! More than likely, things will not go exactly to plan. Obviously, it would be impossible to cover all the possibilities you will encounter, but here are a few more common situations you may find yourself in and some suggestions on how to handle them.
Patient is intubated +/- altered mental status
Seek out family members that may or may not be present to interview; find the patient’s primary physician and contact them; call the patient’s pharmacy for a list of the most recent fills
Patient’s demeanor/unwillingness to help
(Won’t answer your open-ended questions, merely nodding or saying yes to your narrowed questioning)
Bedside manner is key. Sometimes explaining to the patient why this is so important will help open their eyes; or simply asking how they are doing and letting them talk to you for a bit (we’re pharmacists, this is the norm anyways) before poking and prodding over their meds. Do your best to empathize and be sincere with your concerns - we want the best for our patients, don’t forget to show it. BUT always keep in mind, not everyone will be willing to talk or help, don’t take it personally, find other sources for your information.
If English is not a first language for the patient, almost all facilities have translation services to effectively communicate. It may sound crude, but pen and paper can be effective.
Time available to do a proper reconciliation
Make the most of the down-time on rounds; frequently there are “lulls” during rounds or times where little is going on and you can sneak away to interview the patient or family members. Set aside time every day new patients come on service to discuss their medications with them. Be prepared with all the tools you will need.
Patient interview doesn’t match a comparator (recent fills from pharmacy, list they hand you or you receive from the PCP)
Patients may be confused - large pill burden can be a daunting task to handle at home. Pile on a hospital visit, a potentially overwhelming environment and you have the recipe for mistakes when they are listing off their meds to you. Any discrepancies you can not reasonably answer, you should go back to discuss with the patient again - mention your concerns, and go from there. Maybe ask them to have a family member bring in the actual bottles. If the patient truly has been taking a medication differently than listed or filled for, document the discrepancy for all providers to be easily aware of.
I hope this will serve as a succinct guide for many, it is something we see a lot of and practice frequently in school, but may seem more daunting when in the moment. Do not lose sight of the significance an incorrect med rec can have on a patient’s health, and the potentially costly mistakes that may follow. Feel free to leave your recommendations and comments below, any opinions on areas I'm missing or could improve on will be greatly appreciated!
As promised here are the resources that helped bring together the system above!
- Edson BS, Federico F, Jackson E, et al. Medication Safety Reconciliation Tool Kit. Institute for Healthcare Improvement. Published on September 2006.
- Institute for Healthcare Improvement. How‐to guide: Prevent adverse drug events by implementing medication reconciliation. Cambridge, MA: Institute for Healthcare Improvement; 2011.