A Journey of Challenges with Medication Reconciliation

Saturday, 7 November 2015

Julie Vinod, MS, BSN, RN, ANP-C
Department of Cardiology, Stonybrook University, Stonybrook, NY, USA


 Background: Unintentional medication errors are a significant problem in healthcare in terms of morbidity, mortality and cost. Hospitalized patients are at particular risk for unintentional medication errors. At least 1.5 million Americans are injured every year by medication errors (IOM, 2006). On average, every hospital patient is likely subjected to at least one medication error per day, leading to approximately 98,000 annual deaths. Furthermore, the cost of medication errors is high in terms of negative patient outcomes and litigation. Over 3 billion dollars are spent annually towards treating the consequences of medication errors. Medication reconciliation is one of several strategies used to reduce medication errors. Medication reconciliation is the process of comparing a patient’s medication regimen across the continuum by reviewing, analyzing and resolving any discrepancies.

Purpose: To examine the accuracy of electronic medication reconciliation upon admission compared to discharge.

Theoretical Framework: One strategy to improve quality and prevent medication errors is to properly conduct medication reconciliation. Proper medication reconciliation is collection of a detailed medication history with open-ended questions, accurate documentation of medication reconciliation, and congruence with electronic technology. Changing processes supporting medication reconciliation is a challenge for healthcare systems. Rogers’ theory of Diffusion of Innovations informs the process of change and adoption of improved medication reconciliation systems.

Review of Literature: Medication reconciliation emphasizes evaluating and improving medication regimen throughout the continuum to reduce patient harm. Few investigators have studied medication discrepancies on admission to discharge using electronic medication reconciliation. Patient safety is a challenge pertaining to preventing unintentional medication errors. Recent studies demonstrated that pharmacist- enhanced medication reconciliation improved patient outcomes, safety and reduced healthcare costs. Evidence supports using medication reconciliation processes to prevent medication errors. When nurses identified discrepancies, physicians changed the discharge orders of 94% of patients (Barnsteiner, 2005). Using electronic technology for medication reconciliation may generate a false sense of accuracy and security.

Method: A retrospective electronic chart review (n=200) was conducted at a tertiary care safety-net hospital, between July 2014 and December 2014 using a data extraction tool created for the study. Medication reconciliation conducted at admission and discharge was examined for medication discrepancies for patients admitted from the emergency department to cardiology and medical surgical units. Non-modifiable predisposing factors for medication reconciliation examined included age, gender, marital status, ethnicity, and comorbidities. Modifiable precipitating factors examined were medication discrepancies, change in medication regimen on discharge, polypharmacy, critical lab values and combination drugs. Variables were analyzed using descriptive statistics.

Results: The sample of 140 patients (mean age 58.8 years, SD 9.4) had more males than females and was predominately white. Preliminary results suggest that the prevalence of medication discrepancies were detected and corrected in greater than 50% of discharge medication reconciliations. More than 80% of patients were discharged home with a change in medication regime compared to their home regimen. Approximately 71% of patients reported to be on at least five medications or more. Most patients had comorbid illnesses; 86% had a history of hypertension; 67% had history of hyperlipidemia; 60% had a history of coronary artery disease.

Implications: Discharge Medication Reconciliation is costly in terms of nursing workload. Discrepancies detected during discharge medication reconciliation took approximately 30 minutes to correct. Delay in discharge to correct medication discrepancies may have a negative impact on patient satisfaction and financial management of the institution.  Identification of risk factors for medication reconciliation serves as the potential targets of intervention. Outcomes rely on the health care provider’s ability to identify risk factors and enter complete and accurate information in the electronic medical record.