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Tuesday, January 7, 2014

Medication reconciliation demands a 'no ifs, ands or buts' list

There’s a universal problem that is plaguing hospitals across the nation. In the midst of all the other challenges in health care, it is a surprisingly under talked about issue. Medication reconciliation. For anyone non-medical reading this, in a nut-shell medication reconciliation is all about clarifying the patient’s home medications when they are admitted to hospital, and then confirming them again—with any changes—upon discharge. According to JCAHO (Joint Commission on Accreditation of Healthcare Organizations) the definition is “the process of comparing a patient’s medication orders to all of the medications that the patient has been taking.” Sounds simple enough? If only that was the case. I’ve found this to be an elusive goal in every single hospital I’ve ever worked in, all the way from rural hospitals to major academic teaching centers. I’m yet to see this seemingly simple process fully mastered.

It all essentially boils down to these questions: How can we best confirm what a patient’s exact home medications are when they are admitted to hospital? And how can we ensure that this list is again clarified during any in-hospital transfers and upon discharge?

Here’s the process that currently occurs. When a patient is admitted to hospital, the doctor takes a complete history and performs a physical examination (hopefully by then we are confident of the diagnosis). Part of the history taking is to obtain the patient’s full home medication list. Some reasons why this is so difficult and haphazard include:
• Physicians are typically only able to dedicate a handful of minutes to this task, since it forms only a relatively small part of the history and physical;
• The patient is not sure about exactly what medicines they take. This is an extremely common scenario, and it can understandably get very confusing for some elderly patients who are on a dozen or more medications;
• No easy access to the patient’s regular medication list from external sources. Lack of a universal computer system which is connected to the patient’s primary care doctor or pharmacy. After hours (the majority of the time when people are admitted to hospital), the admitting doctor will find it difficult to contact these other places;
• Different medication lists. Often 3 or more different ones from the primary care physician, prior hospital records, and the patient themselves;
• The patient doesn’t actually take the medications that have been prescribed to them; and
• Upon discharge, after some of the medications have been changed, the new list is not properly reconciled with the original one on admission.

I’ve lost count of the number of times an anxious relative feels the need to clarify their loved ones’ medications after they’ve already been admitted to hospital. I always feel very bad when this happens, because it shouldn’t fall on their shoulders to be left telling us. We may not be able to account for patients who are not taking what they should be, but we should at least be able to say with certainty exactly what they are supposed to be taking. Neither should the solution rest with relying on patients to give us a complete medication list; that isn’t likely to work any more than a car service center expecting a customer to know all the details of their last repair work.

Getting this right is important for a number of reasons. First and foremost, it’s a huge patient safety issue. Medication errors were first brought into the national spotlight in 1999, with the Institute of Medicine’s landmark report, To Err is Human: Building a Safer Health System. At that time, it was estimated that about 100,000 deaths per year were because of hospital errors. Latest statistics suggest that this figure may be even higher, as much as a staggering 400,000 per year according to a recent study in the Journal of Patient Safety. This would make them the third leading cause of death in the US.

While these statistics include all hospital errors, medication errors are top of the list. The Institute of Medicine estimates that the average hospitalized patient is subject to at least one medication error per day, of which more than 40% are thought to be the result of poor reconciliation. Alarmingly, 1 in 5 of these will cause harm to the patient. It is therefore very dangerous to have any confusion surrounding the patient’s medications.

New technology has the potential to greatly help solve this problem, especially if medication lists are clarified within one central computer system. The federal government’s Meaningful Use policy adds extra incentives to do this. Unfortunately, because hospitals have rushed to comply, not enough thought has been put into the underlying processes. Simply putting everything on the computer doesn’t automatically make everything okay if it’s the wrong list in the first place! It isn’t all about just complying with Meaningful Use. Computerized medication reconciliation is a classic example of a great idea, which simply takes too long on our currently available cumbersome computer systems. Far more accurate right now would be to have a laminated list of the correct medications that was kept in a secure part of the chart.

Many studies have looked into who the right person is to perform the reconciliation task. Is it always the doctor? In some hospitals, it’s even the ER nurse that is given the responsibility. Several studies have in fact shown that pharmacists are the professionals best equipped to do this, since their whole expertise and focus is on reviewing medicines. In my experience, this is very true, and I’ve been fortunate enough to work with some great pharmacists in my time as a hospital medicine doctor. It’s typically the pharmacy that acts as a backup anyway for physicians when they write any medication orders. Frontline doctors are well used to communicating with pharmacists on a daily basis (usually after receiving an informational message on their pager). Some ways that hospitals can successfully utilize pharmacists in the medication reconciliation process are as follows:
• Have a pharmacist stationed in the ER dedicated to documenting a complete and thorough medication list for every patient admitted to hospital (there may need to be more than one pharmacist for busier EDs). If the cost of employing these extra pharmacists is a problem for hospitals, think of the patient safety and saved “doctor time;”
• This pharmacy-generated list should be made part of the computerized record, and instantly available to the admitting doctor; and
• The pharmacist should again review the medications and go over any changes with the patient upon discharge. This can be targeted to more complex patients if staffing is an issue.

Many hospitals are finally realizing the importance of medication reconciliation and putting significant resources into solving the problem. Doctors, pharmacists and administrators have to work closely together to drive this quality improvement. The first goal should be to have a definite process in place whereby the accurate list is known on admission—to put it bluntly, a “no ifs, ands, or buts” medication list. By doing this seemingly simple thing, we will be taking a huge leap forward into the new health care era.

Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care. This post originally appeared at his blog.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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