Pharmacist Kristine M. Gleason, RPh, got the chance to personally test her ability to help ED providers with medication reconciliation—known by most in healthcare as “med rec”—when she broke her leg a couple of years ago. No problem, she thought: “I’ve been involved in med-rec efforts for eight-plus years.”
But when asked to provide her current medications, Gleason, who is the clinical quality leader in the department of clinical quality and analytics at Northwestern Memorial Hospital in Chicago, says she was in pain and overwhelmed. “I couldn’t even remember my children’s names, let alone the names and dosages of my aspirin and my thyroid medication,” she says. Moreover, she didn’t carry a list in her wallet because “I’m a pharmacist and I do med rec,” she says.
Gleason’s experience highlights why, six years after The Joint Commission introduced medication reconciliation as National Patient Safety Goal (NPSG) No. 8, hospitals and providers still struggle with the process.1 As a younger patient, Gleason took few medications. But for the majority of elderly inpatients with comorbid conditions, just establishing the patient’s medication list can bring the whole process to a halt; without that foundational list, reconciling other medications becomes problematic.
Although the commission has taken the goals under review and has, since July 1, required compliance with the revised NPSG 03.06.01 (see “Additional Resources,”), hospitalization-associated adverse drug events continue to mount. A recent Canadian study caused a ripple this summer with its findings that patients discharged from acute-care hospitals were at higher risk for unintentional discontinuation of their medications prescribed for chronic diseases than control groups, and those who had an ICU stay are at even higher risk.2
There’s been no shortage of med-rec initiatives in recent years. Medication reconciliation was at the top of the list for ways to prevent errors when the Institute for Healthcare Improvement launched its “5 Million Lives Campaign” in December 2006. SHM weighed in on the issue in 2010 with a consensus statement on key principles and necessary first steps in med rec.3
“This isn’t a new problem,” Gleason says. “Med rec has become more heightened because we have many more medications and complex therapies, more care providers, more specialists—more players, if you will.”
The March launch of the Hospital Readmissions Reduction Program, part of the Centers for Medicaid & Medicare Services’ (CMS) Inpatient Prospective Payment System, will again shine the spotlight on med rec’s role in the prevention of 30-day readmissions. The Hospitalist talked with researchers, pharmacists, and hospitalists about the reasons behind medication discrepancies, and their strategies for addressing mismatches.
Why So Difficult?
The goal of medication reconciliation is to generate and maintain an accurate and coherent record of patients’ medications across all transitions of care, which sounds straightforward enough. But the process involves much more than just checking items off a list, says Jeffrey Schnipper, MD, MPH, FHM, currently the principal investigator for the $1.5 million study funded by the Agency for Healthcare Research and Quality (AHRQ) to research and implement best practices in med rec, dubbed MARQUIS (Multicenter Medication Reconciliation Quality Improvement Study). Those immersed in med rec know that it’s nonlinear, multilayered, and surprisingly complex, requiring partnerships among diverse providers across many domains of care.
“Medication reconciliation gets right at all the weaknesses of our healthcare system,” says Dr. Schnipper, a hospitalist and director of clinical research for the HM service at Brigham and Women’s Hospital (BWH) and assistant professor of medicine at Harvard Medical School, both in Boston. “We have an excellent healthcare system in so many ways, but what we do not do such a good job of is coordination of care across settings, easy transfer of information, and having one person who is responsible for the accuracy of a patient’s health information.”