Ms. Jones is 72 years old. She was admitted for new onset atrial fibrillation. When her rhythm and rate were controlled, workup for underlying causes revealed critical coronary artery disease, which was successfully stented. Per discharge protocol, she was sent home on ramipril, an ace inhibitor, among other medications. Two days later, Ms. Jones was readmitted for syncope. Her blood pressure on admission was 70/40 and she was again in atrial fibrillation. Her second admitting physician team performed medication reconciliation and discovered that she had been taking both the ramipril prescribed at the first discharge and enalapril prescribed by her primary care physician, resulting in the hypotension and syncope. This simple double medication administration cost several thousand dollars. It also threatened Ms. Jones’ life and safety. Had medication reconciliation been done at her first admission, her second admission could have been prevented.
What is medication reconciliation? Physicians practicing in a hospital setting may already be familiar with the term, but basically it is the review and comparison of patient medication lists to ensure that the lists are complete, up-to-date and accurate. This becomes especially important when patients are moving from one location of care to another, such as from a hospital admission or discharge to the outpatient setting. Thousands of medication errors occur every year because the patient changes care venues. Having a sound process in place to avoid such errors is an important patient safety measure. The Institute for Healthcare Improvement offers a Medicare-sponsored medication reconciliation online tool, and the American Medical Association offers a monograph on the topic.
While TransforMED's National Demonstration Project (NDP) did not deal with patient safety per se, the concept was embedded in every aspect of the study. Our practice found that it is just as important to have a medication reconciliation process in place in the outpatient setting as the inpatient. Our electronic health record (EHR) has an embedded medication list where all physicians enter medication changes, which helps keep us on the same page. When patients are cared for by physicians who do not use our EHR, staff members update the patient's medication list in our EHR according to those physicians’ paper records. We catch duplicate and/or obsolete medications very often. The reconciliation process also gives providers an opportunity to teach patients about their medications and what they do for them.
Medication reconciliation takes time. However, as any safety officer (and lawyer) knows, time spent preventing mistakes is better than time spent correcting mistakes. The team concept utilized in the TransforMed study can help you put a process in place in your practice:
- The front office prints the patient’s last medication list when the patient checks in.
- The patient (who is asked to bring a current medication list to the appointment during the pre-visit reminder call) then reconciles both lists.
- The nurse reviews, updates and educates the patient from the reconciled list.
- The physician makes final adjustments and leaves time for patient education and questions.
A process like the above ensures safety, involves all members of the office and allows the patient and physician to spend time on other issues during the visit.
–Melissa Gerdes, MD