Medication History Part I

Building a Firm Foundation for Medication Reconciliation

by Molly Procuniar, BSN-RN, BA, FF-P

“A 68-year-old man with a history of diabetes and atrial fibrillation maintained on warfarin presented to the emergency department (ED) with fever and mental status change.  Lumbar puncture was attempted three times without success; empiric treatment for meningitis was started. Further examination revealed an area of cellulitis, and intravenous antibiotic therapy was changed accordingly. At the time of admission, the patient was unable to recite his medication history, and his wife was unclear about the doses.  However, the EMS run-sheet had a list of the patient’s medications and doses. The patient was started on the medication regimen per the EMS report.” ¹

For clinicians, this is not an unfamiliar scenario. In emergencies, they frequently find themselves working with questionable information and no means of verification.  Non-emergency situations present challenges of their own. There’s the woman with the weekly pill organizer who doesn’t know the names of the tablets and capsules inside. There’s the man with the grocery bag who grabbed every pill bottle off the medicine shelf - including duplicates, expired bottles and prescriptions for other family members.  There’s the elderly patient whose handwritten list is worn and too illegible to read, and there are a host of memory-impaired patients who simply can’t provide an accurate list of medications. So it falls to the clinician to call the patient’s primary care provider or pharmacy to obtain a current list of what the patient takes at home.

A Two-Part Challenge
Medication reconciliation – what a challenge! It has been one of the Joint Commission’s National Patient Safety Goals (NPSG) since 2005, and clinicians, physicians and pharmacists in hospitals, ambulatory care, assisted living, behavioral health, home care, and long-term care settings² have struggled with it. The requirement is to accurately and completely reconcile medications across the continuum of care.³

There are two parts to Goal 8. The first part requires taking an accurate history of what medications the patient had been taking at home and comparing them to the new orders that are being issued during the patient’s stay. The second part requires that the patient and the patient’s care providers receive an accurate list of current medications upon discharge.

The Breakdown
“After 3 days, the patient was transitioned to Augmentin. While in hospital, the patient had been receiving 5mg of warfarin at bedtime, which, according to the EMS intake sheet, was his usual outpatient dose. The team did not confirm this dose with the patient’s family, primary physician or pharmacy. At the time of discharge, his INR was noted to be 4. Realizing the warfarin dose was too high, the team instructed the patient to decrease his dose to 3mg at bedtime and to have his INR rechecked in 3 days. After 3 days, his INR was 10. He was treated with vitamin K. Two days later, the patient returned to the ED with back pain, lower extremity weakness and incontinence. He was found to have an epidural hematoma, which was emergently evacuated. One week post-operatively, the patient still had neurological deficit.”

Unfortunately, the medication reconciliation process today is error-prone, mostly due to failures in communication, particularly at points of transfer.  One study indicates that up to 70 percent of potential errors and 15 percent of all adverse drug events could be prevented through a standardized medication reconciliation process. In fact, 77 percent of all patients may be discharged with inadequate medication instructions.⁴ Another study, which focused specifically on medication history, showed that during the admission process, errors occurred 22 percent of the time.⁴

Building a Rock-Solid Foundation
When errors result in patient harm or threats to patient safety – the price is simply too high, regardless of how labor-intensive the process.  What hospitals and their clinicians need is a standardized approach for gathering medication history that can be adopted throughout their health systems.  Only then will they stand a better chance of enhancing accuracy and patient safety.

To create a better history-gathering process, three specific practices need to be in place. First, retrieve prescription information directly from the “gatekeepers.”  In this case, the gatekeepers are retail pharmacies, pharmacy benefit managers and the Centers for Medicare and Medicaid Services’ (CMS) database for Medicare Part D. In querying these databases, hospitals can give clinicians an effective starting point for building an accurate medication history. In other words, hospitals can provide a foundational list that clinicians can use to validate and verify, adding pertinent information as they go.

Second, retrieve existing medication history from within HIS. If the last time the patient was seen in the facility was recent enough to matter medically, perhaps it’s worth considering what information was captured during the last interview process. Most clinicians work exceptionally hard to retrieve all items that Joint Commission regards as “medications,” including over the counter medications, vitamin supplements, samples, herbal remedies, nutriceuticals, etc.  If this information was painstakingly documented previously, why disregard it?

Third, automate these medication history queries as part of the registration/admission process. Done silently, behind-the-scenes with all appropriate business logic applied, the process can be invisible to the frontline registration staff.  Yet, it will enable hospitals to capture medication history for a wider group of patients throughout the continuum of care.  Choosing whether to keep the information retrieved in an electronic state or printed as part of the registration process is a hospital decision. Either way, the final step in the process is to have the information verified with the help of an appropriate clinician.

A Transformation in Patient Care
The advantages of using a standardized, automated medication history process are substantial in terms of enhanced patient safety, improved clinician workflow and compliance with accreditation standards. If the clinicians in our opening scenario had the opportunity to retrieve prescription history for the patient through the pharmacy and other relevant prescription gatekeepers and verify it with family members – perhaps the patient could have been saved much distress. 

Hospitals have a significant opportunity to improve patient outcomes, given better tools for medication reconciliation.  In the next issue of Insights, we’ll provide you with an up-close look at a new automated solution for capturing Rx history that will lay the foundation for more accurate medication reconciliation and improved clinical efficiency.  

However, if you prefer not to wait, contact us now and we can begin a one-to-one discussion about transforming your approach to Rx history capture.