Accreditation Resource Services Newsletter
September 2020

CIHQ-ARS Article

Making the Case for Medication Reconciliation

By: Gina Miller
What is the worth of an accurate medication list? Let us look at the data: In a recent study of patients aged 65 and over taking 5 or more medications, only 5.3% of patients had an accurate medication history at admission. One-third of inpatient medication orders had errors and 85% of those originated from an incorrect medication history. Unfortunately, errors and adverse drug events are one of the top three causes of hospital-associated events and are responsible for extended hospitalizations and millions of dollars in care. Furthermore, errors on discharge medication lists are a causative factor in hospital readmissions.
Consider this example – a patient admitted to the hospital has brought his mediations along. In the bag is warfarin, 5mg tablets. The nurse asks the patient if Coumadin is taken every day and receives an affirmative answer. Because the tablets are 5 mg, the nurse records Coumadin 5mg daily on the medication list; hence this is ordered by the hospitalist. However, with further questioning, it may have been discovered that the patient is taking 2.5 mg on Monday, Wednesday and Friday, and 5 mg the remainder of the days. Several days later, the patient’s INR is elevated, requiring treatment and an additional day in the hospital.
It Is obvious that collection of an accurate list is important for safe care, both on admission and at discharge. CMS, however, has very little to say regarding medication reconciliation. In fact, CMS’ Conditions of Participation only mention medication reconciliation as an element of discharge planning and states the list provided on discharge must be a “legible, complete, reconciled medication list that highlights changes from the post hospital regimen” and that medication “changes to the patient’s pre-hospital medication regimen” must be provided to the post-discharge care provider. Why then is an admission list required? Guidance at CMS 482.25 and 482.43 provide the basis for this discussion.
Optimizing medication therapy is a collaborative effort between pharmacists, pharmacy technicians, providers, and nursing staff. Hospitals are required to develop and implement policies and procedures for admissions, discharges, and transfers so that patients’ medication therapy is well managed regardless of patient transitions across care settings. This includes transitions between home and the hospital, between units within the hospital, and during discharge or transfer to another facility. A complete list including dose and frequency is required for all inpatient admissions. For PRN medications, the indication for use should also be obtained.
How the hospital decides to collect the list is left up to the organization. Hospitals are expected to make reasonable efforts to collect an up-to-date accurate list, including herbals, dietary supplements, and over-the-counter medications. This may include information from the patient and caretakers, the electronic record, as well as information from other databases (retail pharmacies, physician offices). Polypharmacy, multiple medical conditions and/or medical specialists make this process particularly difficult. Involving a pharmacist or pharmacy technician in the medication list process has been shown to decrease errors but is not a requirement. Records (electronic and paper) should be constructed so the medication history is available to all health professionals caring for the patient. If an accurate list is unable to be collected, attempts made and the reasons for the inability to collect the information should be clearly documented.
In the outpatient setting, a list of current medications is also required. For diagnostic or procedural settings, the list need only include those medications pertinent and relevant to the safe rendering of care. The organization’s policy may define the extent of the list. For recurrent settings such as outpatient offices, the list is to be collected on the initial visit and updated anytime a medication is changed. This would require a review of the list at each visit.
Hospitals are also expected to reconcile medications when transferring patients within the facility to a higher or lower level of care. The specifics of how this is done may be defined by the organization’s policy, however evidence of performance of the reconciliation is required.
At discharge or transfer of the patient, all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and a complete list of medications the patient is to be taking must be delivered to the appropriate post-acute care service provider, facility, agency, and other outpatient service practitioners responsible for the patient’s follow-up or ancillary care. This means the hospital is responsible for communicating the course of treatment along with an accurate list of medications the patient should be taking to each of the agencies or practitioners that will be providing post-acute care. This may be accomplished by transmission through the electronic health record (EHR), however if the post-acute provider does not have access to the EHR, the hospital is expected to either send the information with the patient for delivery to the provider or securely fax or transmit the information to the follow-up office within 7 days of discharge. If the patient is being transferred to a facility, the information is required to be provided at the time of transfer.
The requirements are clear. Make the case for prioritizing medication reconciliation as a patient safety program at your organization. How do you design a process? Here are several evidence-based practice implications for medication reconciliation:

Define the Steps in the Reconciliation Process

  1. Verify current medications by collecting the list of medications, herbals, supplements, and OTC drugs. Use all available resources (EHR list, patient list or bottles, pharmacy, MD/DO office).
  2. Clarify that the medications and dosages are appropriate.
  3. Assure all medications are addressed (ordered or discontinued) on admission.
  4. Review current medications at change in level of care or when ordering additional medications; resolve conflicts, duplicates, or omissions.
  5. On discharge, review and update all medications the patient was taking from the home medication list, incorporating new prescriptions, and clearly noting discontinuation or recommended changes on the discharge list.
  6. Assure the patient and/or caregiver has a clear understanding of the list, especially changes to medication or doses prior to discharge.

Clearly Identify the Responsibilities for the Process

Evaluate the current process and identify current deficiencies within the organization or practice setting. Define who is ultimately responsible for obtaining the medication history and identify the standard location in the chart where the medication history is kept. Define the responsible staff for completion of the discharge reconciliation.

Have an Explicit Timeframe for Completion

Best practice calls for reviewing high-risk medications within 4 hours of admission, however the full reconciliation should be completed at least within 24 hours of admission or at the initial primary care visit and each visit thereafter. Build time into the admission process for medication reconciliation.

Design Education Programs for Health Care Professionals

Medication reconciliation, done appropriately, is a complex process. Education needs to include the specific steps put into place to obtain the medication history, definition of roles, and expectations for completion.

Design and Implement a Monitoring Process

Implement concurrent and closed record review for compliance. Address adherence to the process and identify the potential for and any actual harm associated with unreconciled medications. Auditing tools are available on the IHI website. Share results with providers and pharmacists, and staff.

Educate Patients and Family Members to Serve as Advocates

Patient education needs to be a major focus in medication reconciliation. Design processes that encourage patients to provide an accurate list or bring their medications to healthcare visits.