AN ACCURATE MEDICATION HISTORY IS NECESSARY to prevent medical errors and improve patient care. If an incomplete or inaccurate medication history is obtained, drug therapy may be interrupted or inappropriate medications may be ordered during hospitalization. The University of Utah Health Sciences Center (UUHSC) is a 384-bed teaching hospital, employing 53 inpatient pharmacists. Prior to January 2004, medication histories were not consistently taken by clinical pharmacists on the medical-surgical unit. However, we felt that consistently using a pharmacist to obtain medication histories upon patients’ admission could help to decrease the number of errors and unclear orders regarding home medications.

This quality improvement project was designed to investigate the accuracy of the medication reconciliation process on admission, and to assess the role of the pharmacist in this process. We specifically assessed the accuracy of medication histories taken by a pharmacist in comparison to the current standard of care. We also assessed the types of errors that occurred when a patient’s medication history was taken according to standard procedures, and the number and types of pharmacy interventions made regarding orders for home medications.

Methods
Patients who met at least one of the following inclusion criteria were eligible to participate in the study: 65 years old or older; four or more home medications; more than two chronic disease states; home medication requiring close monitoring; request by a physician or nurse for a pharmacist to conduct a medication history; or admission due to an adverse drug reaction.

Eligible patients were alternately assigned to two groups. The medication history group’s medication histories were taken by the investigating pharmacist at admission, and the standard care group’s histories were taken in accordance with standard procedures. Patients in the standard care group then had their medication history taken by the investigating pharmacist at discharge to determine if discrepancies occurred with the ordering of patients’ home medications during hospitalization. If the patient could not provide an accurate medication history, the investigating pharmacist contacted the patient’s community pharmacy.

Results
Of the 49 patients included in the study, 27 were assigned to the medication history group and 22 to the standard care group. The majority of patients took at least four home medications (93.8%) and had at least two chronic disease states (79.6%). Approximately 57% of patients were 65 or older, and 16% were, prior to admission, taking a medication that required monitoring, including warfarin, digoxin, tacrolimus, and carbamazepine.

Both groups had similar demographic characteristics, including age, gender, admitting service, number of chronic disease states, and number of home medications. The average number of home medications was 8.9 in the medication history group and 8.7 in the standard care group. On average, patients in the medication history group reported using 6.7 scheduled medications, three over-the-counter medications, and 2.1 PRN medications. Patients in the standard care group reported using an average of 7 scheduled medications, 2.5 over-the-counter medications, and 2.5 PRN medications.

The medication orders written within 24 hours of admission were compared to the medication list obtained by the investigating pharmacist to determine if home medications were ordered correctly. Home medication orders were considered incorrect if a medication was omitted or if the order was written for the incorrect dose, schedule, or formulation. The orders were not considered incorrect if an appropriate alternative medication was ordered during hospitalization or if a home medication was contraindicated— for example, if the patient was hypotensive during hospitalization and an antihypertensive medication was not ordered.
An average 2.7 medications were ordered incorrectly per patient in the medication history group, versus 2.8 in the standard care group. The majority of incorrect orders were due to omitted home medications (95% in the medication history group and 75% in the standard care group). Other types of incorrect orders included incorrect dose, incorrect schedule, and incorrect formulation. The majority of omitted orders were for OTC medications followed by medications for pain, gastrointestinal disorders, and psychiatric disorders.

The investigating pharmacist made interventions to reconcile home medications for medication history group patients after taking the admission medication history. The staff pharmacists made interventions regarding home medications as part of their daily patient monitoring activities. The investigating pharmacist made an average of 2.5 interventions per patient in the medication history group, compared to 0.9 interventions made by the staff pharmacist for patients in the standard care group.

On average, 11.8 minutes was spent per patient reconciling home medications. This included approximately 8.5 minutes conducting the medication history and 3.3 minutes making interventions. Interventions were typically made by paging the physician or leaving a note in the chart.

Conclusions
Pharmacists play an integral role in ensuring that patients’ home medications are ordered correctly. The investigating pharmacist made interventions to correct 93% of errors that occurred in the medication history group, compared to 28% made by the staff pharmacists for patients in the standard care group.

Since the conclusion of this study, we have seen benefits as our clinical pharmacists have placed a higher priority on obtaining medication histories upon admission. We have also extended pharmacy services to include the availability of a pharmacist on the medical-surgical floor during swing shifts, to help obtain medication histories and clarify orders for home medications. Because of the clear reduction in the number of necessary interventions with pharmacist-driven medication histories, a medication reconciliation program is currently planned for all medical, surgical, intensive care, and medical specialty units at University Hospital. A centralized electronic list of each patient’s home medications will be entered by a pharmacist, nurse, or physician after a medication history is collected. Within 24 hours of admission, a pharmacist will review the home medication list and reconcile it with medications ordered at admission. Documentation of this reconciliation step will also be entered in the patient’s record. The goal is to complete medication reconciliation for 100% of inpatients by 2006, as prescribed by JCAHO.

Authors:
Kristen Jefferies, PharmD, Clinical Pharmacist Shantel Mullin, PharmD, Clinical Pharmacist University of Utah Hospitals and Clinics