By Kurt A. Patton, RPh

IN 2005, THE JOINT COMMISSION PUBLISHED A NEW NATIONAL PATIENT Safety Goal requiring accredited health care organizations to plan the implementation of a medication reconciliation process. In 2006, the Joint Commission expected to see full implementation. Some pharmacists have asked exactly what the term “medication reconciliation” means. Reconciliation is the process of identifying a patient’s current list of medications, doses, frequencies, and routes of administration, so that caregivers can decide what must be continued and discontinued given the clinical situation, what poses a problem given a planned procedure, and what must be altered. Rather than establishing a medication history of all past and present medications, the starting point in this process is to interview the patient in order to obtain a list of current medications. The second step is the caregiver’s analysis of the list, with the goal of deciding what to administer in the new health care setting.

What Information Should Be Gathered?
In gathering the list, there are multiple questions to ask and multiple pieces of information to collect about the patient’s medications, including the name, dose, frequency, the date and time last taken, and the indications for each drug. Knowing the indication can help you discern between any lookalike/sound-alike drugs your patient may be taking. Knowing when the last dose was taken can help you decide when the next dose may be needed.

When Should Reconciliation Be Performed?
The Joint Commission has specified the particular clinical situations in which you should perform reconciliation. Conduct the reconciliation interview at the start of inpatient admission. In addition, you should collect a reconciliation list in any ambulatory settings in which you will administer medications to provide patients with an up-to-date reconciliation list each time changes are made to it – not just upon discharge from care. In other words, if you change the patient’s medication regimen, update the list and provide a copy to the patient.

What Does Medication Reconciliation Accomplish?
Some have asked what we are trying to accomplish with reconciliation. We are trying to prevent errors of omission, in which a long-term medication is missed or forgotten upon admission, and errors of commission, in which we start a new medication that is contraindicated given the patient’s current medication profile. We can also prevent errors in dose, frequency, and form by diligently performing the reconciliation interview. Most importantly we can also prevent errors of duplication, in which a patient resumes taking home medications that are duplicated by medications initiated in the hospital.

The ISMP’s Medication Safety Alert of April 21, 2005, provided us with a series of vignettes that detail the value of a thorough reconciliation process. The alert listed the following errors as a result of incomplete reconciliation:

• A patient transfers from one hospital to a second hospital, and receives a morning dose of insulin at each hospital.
• A patient taking Desogen, (handwritten list) was prescribed digoxin 0.25 mg daily, but not asked, “Why are you taking digoxin?”
• Pamelor was prescribed for a newly admitted patient, who was later discovered to have been taking Panlor (acetominophen, caffeine, and dihydrocodeine).
• A patient transferred from extended care to acute care in the same hospital received repeat doses of all morning meds: warfarin, levothyroxine, metoprolol, amlodipine, and sertraline.
• ED administers heparin bolus before infusion, ICU repeats bolus, and a cardiac catheterization procedure has to be postponed.

Each of these examples identifies an opportunity to prevent errors through thorough medication reconciliation. The Joint Commission presentations on sentinel events also describe a very dangerous example of a failure to reconcile: A patient on a respirator in the ICU is extubated and transferred to a general medical surgical unit. In this tragic scenario, the patient’s medications are not reconciled and the skeletal muscle blocker that paralyzed the diaphragm while the patient was on a respirator is restarted after transfer, but the patient is no longer on mechanical ventilation.

When considering the relative value of reconciliation, think of your elderly relatives and the struggles they have with medications. I think of my father-inlaw, who passed away last year at age 84, while taking 13 different medications. He received some from his local VA hospital, some from the VA mailorder system, some from a local hospital, and some from community pharmacies close to his home. Each hospital and each pharmacy used different generic and therapeutic-equivalent products, and his ability to reconcile what to take was limited. Fortunately, my wife and I are both pharmacists and we were able to help him after each discharge from inpatient care. For my live presentations, I have retained a copy of the discharge instructions he received from one hospital – an NCR copy scrib-
bled with Latin abbreviations. No senior should have to sort through that themselves.

Resources
If you are looking to either start or refine your medication reconciliation process, there are many very good resources available on the Web. The Massachusetts Coalition (www.macoalition.org) has some great articles, slide shows, and forms to help get you started. The Institute for Health Care Improvement (www.ihi.com) has a great downloadable tool kit. If you work in an accredited organization, it is also very important to download the Joint Commission’s “Frequently Asked Questions” (www.jointcommission.org). There are 17 pages that deal just with the and can help explain the finer points of the expectation.

When it comes to implementing or refining reconciliation in your own hospital, many software vendors can help by tweaking the hospital information system and its reports to facilitate transfer and discharge reconciliation. The admission reconciliation still requires an oral interview, but once the results are data entered, that information can be retrieved for decision making at future transition points.

Pitfalls to Avoid
Many hospitals have encountered problems during a Joint Commission survey because they falsely believed some part of their hospital was exempt from the reconciliation process. The best way to determine the parts of the hospital that have to perform reconciliation is to ask: Do you administer or plan to administer medications? If you do, then you have to perform admission reconciliation. Identifying discharge reconciliation responsibilities is a little more complex. You have to perform discharge reconciliation if you have administered medications that have a lasting effect on the patient, requiring them to alter their medication regimen when they leave your care, or if you have prescribed medications that should be taken at home.

Another very common pitfall is a failure to eliminate redundant medication lists. Too often you see a redundant list on a medical history and physical, a nursing assessment, or an ambulatory problem summary list. These redundant lists often identify different medications, which then identify a failure to actually reconcile and identify one valid listing of medications. You have not truly reconciled if the ED nurse thinks the patient is on one list, the physician a second, and the unit nurse a third. When patients report variations in their list of medications, validate what is being reported and put the correct information in one place for all to see and act upon it.

Conclusion
Probably the most important thing to remember is that the medication reconciliation process is not about lists; it is about patient care. Too often we focus on the requirement of the regulatory or accrediting body, and lose sight of the basic value of the initiative. Medication reconciliation is a process that will
help our patients and help us provide better patient care.

Now the owner of Patton Healthcare Consulting, LLC, Kurt A. Patton, RPh, served as executive director of accreditation services at the Joint Commission for
over seven years, until his retirement in December 2005. Before joining the Joint Commission, Patton was the deputy director for the Division of Strategic Initiatives and Managed Care in the New York State Office of Mental Health. Previously, he served as the administrator for a stateoperated behavioral health managed care program and as the director of the Bureau of Health Services. Patton earned his bachelor’s degree in pharmacy and his master’s degree in institutional administration from St. John’s University.