The highly complex medication-use process introduces numerous opportunities for error, including drug omission and duplication errors. It is well documented that a robust medication reconciliation process can significantly reduce the incidence of medication errors that can result from an incomplete or inaccurate medication history. 

Although the Joint Commission added medication reconciliation as a NPSG in 2005, improving medication reconciliation rates remained a challenge for many facilities. It was not until 2 years later that APhA and ASHP collaborated to develop a working definition of medication reconciliation (see SIDEBAR), which notes that omissions, duplications, dosing errors, and drug interactions all are errors that can be reduced by ensuring the accuracy of medication orders. For that reason, the Joint Commission NPSG.03.06.01, implemented July 1, 2011, states that accredited organizations must maintain and communicate accurate patient medication information, as medication discrepancies clearly affect patient outcomes.¹ Since that time, many US hospitals have made it a priority to develop and implement effective medication reconciliation strategies. 

Defining Medication Reconciliation Goals
Accredited by the Joint Commission, Children’s Mercy Hospitals and Clinics (CMH&C) comprises two main hospitals, three urgent care centers, and two freestanding outpatient clinics in the Kansas City, Missouri area. The inpatient pharmacists service almost 14,000 annual patient admissions with an average daily census of 221 (on the combined main and south campuses). Round-the-clock pharmacy services are provided at both of the inpatient campuses and outpatient pharmacy services are available from 8:00 AM to 5:30 PM.

Our goal at CMH&C is to complete the medication reconciliation process for 90% of patients within 24 hours of hospital admission. When we began the project to improve our admission medication reconciliation rates in September 2012, just 47% of patients in the main hospital and 10% of patients in the south hospital had medication reconciliation completed within 24 hours of admission. Because an accurate medication history is critical to properly completing admission medication reconciliation, CMH&C focused on improving this process by correctly recording medication name, medication strength, medication directions, and compliance/adherence. 

Evolution of a New Medication Reconciliation Process 
A key component to ensuring that frontline staff is able to adequately perform these new duties is identifying modalities that allow for the incorporation of medication reconciliation activities into the workflow without hindering current processes. Thus, when evaluating how to improve our medication reconciliation rates at CMH&C, one of our goals was to incorporate effective changes with minimal workflow disruption.

Physician-Driven Medication History Model
Our previous medication reconciliation method centered on the physician compiling a patient’s medication history during the physical examination, but this approach was fraught with challenges, including the following concerns:

• Time Commitment. The process for physicians to collect, record, and analyze a medically complex pediatric patient’s medication list was time-prohibitive. Previously, we did not use electronic prescribing, so identifying which prescriptions had been filled by the patient or caregiver could be determined only by contacting the patient’s retail pharmacy. 
• Medication History Inaccuracies. The medication histories collected by the physicians were sometimes inaccurate and did not match the information in the medication reconciliation tool in our electronic health record (EHR) for various reasons (eg, medication not in database, non-formulary medication, different formulations for outpatient versus inpatient, etc). As a result, the admitting physician often was not confident that the medication history was accurately entered into the EHR, and thus would add each inpatient medication individually, which led to transcription errors, including omission and duplication of the patient’s home medications. 
• Nonstandard Prescribing. Pediatric medications are rarely prescribed in a standard manner (eg, one tablet twice daily, two capsules every morning, etc); rather, they typically are written as weight-based and change as the child grows. 
• Reconciling Amounts. To aid caregivers in administering medication, instructions most often are given in units of volume rather than in absolute amount (eg, 5.5 mL twice daily versus 55 mg twice daily). Because retail pharmacies deliver medications in absolute amount, it can be difficult to reconcile absolute amount and units of volume. 
• Physician Knowledge of Available Concentrations. Physicians often were unaware as to which concentrations were stocked in the inpatient pharmacy; this could lead to dosing errors if exact concentrations were unavailable.

Medication Reconciliation Steering Committee
To develop a strategy to improve the medication reconciliation process and identify opportunities for resource redistribution, we formed a multidisciplinary medication reconciliation steering committee. The committee reviewed inpatient and ambulatory care medication reconciliation practices, including barriers to the process, information services (IS) issues, and workflow concerns and identified key stakeholders to address specific medication reconciliation issues. For example, an electronic alert was added that fires if a provider enters a discharge order without completing the discharge medication reconciliation tool. The IS department plays a significant role in the committee, as ensuring accuracy of the EHR is central to an effective medication reconciliation process. 

Upon review of the challenges faced by physicians compiling medication lists, the steering committee determined that because nurses have the most interaction with patients’ families, nursing should assume this responsibility. Therefore, nurses were educated on how to collect and enter a medication history, which allowed the provider to use the medication history in conjunction with the medication reconciliation tool in the EHR to place inpatient orders. 

Incorporating PPMI Recommendations
In February 2012, the pharmacy department utilized the ASHP Pharmacy Practice Model Initiative (PPMI) recommendations to implement a practice model change designed to place pharmacists closer to the patients for whom they provide care. This change reduced the number of pharmacists in the central pharmacy to one and created a total of 14 areas where decentralized pharmacists provided patient care. After relocating these pharmacists to be closer to patients and more involved in the multidisciplinary health care team, further integration of pharmacy in the medication reconciliation process was the next logical step.

In 2010, an EHR enhancement allowed for the utilization of an electronic admission medication reconciliation application at CMH&C. With this application, the provider could convert medication histories to inpatient medication orders. Pharmacy became more involved in the medication reconciliation process in September 2012, working on medical resident-covered inpatient teams to compile electronic home medication lists. The goal of this effort was to simplify the process by enabling the provider to use this list to convert to inpatient orders. In addition, PPMI recommendation B25k states that providing medication reconciliation in the emergency department (ED) should be considered essential to pharmacist-provided drug-therapy management in optimal pharmacy practice models.² Therefore, a pharmacy technician was placed in the ED to obtain medication histories of patients presenting there. 

While utilization of a pharmacy technician to gather the medication lists was effective, no technician FTE had been allocated for this role in the budget. However, a pharmacist FTE had been allocated in the ED 24 hours a day, so the responsibility for obtaining medication histories on patients being admitted from the ED was shifted from the technician to the pharmacist. Because most patients being admitted spend a few hours in the ED awaiting their inpatient bed assignment, there was sufficient time for the pharmacist to obtain medication histories while simultaneously performing other ED duties. 

The medication reconciliation process varies slightly depending on where the patient is admitted (see FIGURE 1). A medication history is obtained and documented in the EHR by either the pharmacist (if the patient is admitted through the ED) or a nurse. The provider then uses this medication history to determine which medications will be continued during the inpatient stay or held until discharge. (See

ONLINE-ONLY SAMPLE P&P: Electronic Medication Information Management at CMH&C)

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Automating the Medication Reconciliation Process
All Joint Commission-accredited institutions are working toward achieving compliance with NPSG.03.06.01, with the ultimate goal of improving patient care. Some organizations have attempted to achieve this by adding human resources (technicians, pharmacists, etc), which often can be scarce in today’s cost-conscious hospital environment. Instead of adding staff, CMH&C chose to improve medication reconciliation by automating the process and optimizing available resources. 

The PPMI recommendations also advocate incorporating technology to improve patient care. The medication reconciliation tool in our EHR enables physicians to access home medication lists and current electronic prescriptions to inform inpatient ordering and ensure a seamless medication reconciliation process. In addition, some areas of the hospital use a software performance management tool to retrieve, organize, and display information from the EHR. Such data can be customized, converted into an email, and sent to the pharmacists working in a specific hospital area so they can complete the required action. A report is automatically generated every 12 hours listing inpatient and ICU patients that have been admitted within 24 hours; this report is then automatically emailed to the inpatient and the ICU pharmacists so they can easily identify patients requiring medication reconciliation. 

Results
Maximizing automation has dramatically improved accuracy and reduced the time required to determine which patients require medication reconciliation. Prior to utilizing this method, pharmacists had to go through each individual chart to verify that medication reconciliation had been performed. Because an automated report is now issued every 12 hours, we are better able to organize our work priorities and communicate with the rest of the medical team.

In addition, shifting responsibility for compiling medication lists from physicians to pharmacists and nurses has significantly improved the medication reconciliation process. CMH&C has dramatically increased the 24-hour medication reconciliation completion rate for admitted patients (see FIGURE 2). Prior to our medication reconciliation initiative, less than half of patients admitted to our main campus received this service within 24 hours; as of August 2014, 82% received timely medication reconciliation. Results in our south campus are even more impressive, improving from a 10% compliance rate to an 87% compliance rate, and we are closing in on our goal of 90%.

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One unanticipated benefit of the medication reconciliation improvement initiative has been the change in culture that we have experienced within the hospital. While medication reconciliation was previously viewed as a burden or a chore, hospital staff has now embraced the practice as an essential safety component of the medication-use process. 

Future Goals
Because our focus has been on admission and discharge medication reconciliation, medication reconciliation at transitions of care has yet to be addressed on an organizational level. Currently, our multidisciplinary quality improvement task force is identifying high-risk patient populations that would benefit from increased attention on transition of care medication reconciliation. In addition, we are focusing on the challenge of providing timely medication reconciliation for post-operative patients who are under observation or are inpatients for fewer than 24 hours.

References

1. The Joint Commission. National Patient Safety Goals Effective January 1, 2014.http://www.jointcommission.org/assets/1/6/HAP_NPSG_Chapter_2014.pdf.Accessed October 2, 2014.
2. Pharmacy Practice Model Initiative. Summit Recommendations. February 1, 2011. http://www.aacp.org/resources/education/cape/Documents/Other%20Pharmacy%20Association%20Related%20Documents/Pharmacy%20Practice%20Model%20Intiative%20Summit-Recommendations.pdf. Accessed October 3, 2014.

Wendy Hoebing, RPh, is the director of medication information management at Children’s Mercy Hospital in Kansas City, Missouri. She provides direction for the institution’s pharmacy informatics team, electronic medication processes, and medication reconciliation programs. Wendy graduated from the University of Missouri-Kansas City School of Pharmacy.

Richard K. Ogden, PharmD, BCPS, is the assistant director of pharmacy at Children’s Mercy Hospital. His responsibilities include pharmacy clinical services, the pediatric intensive care unit, emergency department, and intensive care nursery. Richard graduated from the University of Missouri-Kansas City School of Pharmacy. 

SIDEBAR
APhA-ASHP Definition of Medication Reconciliation* 
The comprehensive evaluation of a patient’s medication regimen any time there is a change in therapy in an effort to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions, as well as to observe compliance and adherence patterns. This process should include a comparison of the existing and previous medication regimens and should occur at every transition of care in which new medications are ordered, existing orders are rewritten or adjusted, or if the patient has added nonprescription medications to [his or her] self-care.

*Chen D, Burns A. Summary and Recommendations of ASHP-APhA Medication Reconciliation Initiative Workgroup Meeting, February 12, 2007. http://www.ashp.org/s_ashp/docs/files/MedRec_ASHP_APhA_Wkgrp_MtgSummary.pdf. Accessed September 24, 2014.