10 Operations & Management
Pharmacy Practice News • October 2010
Practice Pearl
Comparing Pharmacists and Nurses in Med Reconciliation Kristi Hysan, PharmD
Diane Pepe, PharmD, BCPS
Table 2. Medication Errors Incurred During the Reconciliation Process
The Medical Center of Aurora Aurora, Colorado
M
edication reconciliation is a pressing issue in medication safety and has been the target of many national safety programs. For example, the Institute for Healthcare Improvement (IHI) implemented the 5 Million Lives Campaign, challenging hospitals to protect patients from 5 million incidents of medical harm during the 2006 to 2008 period.1 One of the 12 interventions the IHI recommended was to prevent adverse drug events by conducting medication reconciliation. The IHI has found that poor communication of medical information during the transition of care is responsible for as many as 50% of all medication errors that occur in the hospital and 20% of adverse drug events.2 For its part, the American Society of Health-System Pharmacists has devised a medication reconciliation toolkit in an attempt to improve this problem with transition of care.3 The American Medical Association addresses the issue by providing an “AMA My Medications” patient medication card for members to give to their patients.4 Additionally, since 2005, the Joint Commission has made medication reconciliation, specifically accurate and complete reconciliation of medications across the continuum of care, a National Patient Safety Goal.5 However, the Joint Commission has decided not to factor this goal into the accreditation process in 2010 because of the difficulties that the nation’s hospitals are experiencing with medication reconciliation. Although the Commission is holding off on implementing this goal until it is able to gather enough information to recom-
Table 1. Patient Demographics
a
Patient Population
N=100
Mean age, y
56.3
Male, %
44
Female, %
56
Mean LOS, d
3.89
Mean LOS in ICU, da
3.11
Mean time required to interview, min
15.61
English-speaking
97%
Mean LOS in the ICU is calculated only for patients who were admitted to the ICU during their hospital stay.
ICU, intensive care unit; LOS, length of stay
a
Error: Missing or Incorrect
ED Nurse
Floor Nurse
Pharmacist
Frequency
169
74
1
Dose
174
104
1
Administration
237
150
3
Incorrect medication
41
37
0
Omissions
376
296
15
Total points
2,665a
1,993a
80b
P=0.37
b
P<0.0001
ED, emergency department
An environment of open communication between patients, nurses, pharmacists, and physicians is ideal for medication reconciliation. mend opportunities for improvement, the Commission does recommend that on admission, transfer, and discharge, the patient’s medication history be reviewed and compared with the current regimen for omissions and discrepancies.
Evaluating Pharmacist-led Medication Reconciliation To compare the accuracy and completeness of medication reconciliation by a pharmacist with that of the nursing team, staff at The Medical Center of Aurora, in Colorado, conducted a prospective study of 100 patients aged 18 and older who were admitted to the level II trauma center and were able to respond to questioning (Table 1). The medication history was documented initially by the emergency department (ED) nurse, then by the ED pharmacist, and once the patient was brought to the floor, by the admitting floor nurse. The 3 histories were entered into a Microsoft Access Database and subsequently entered into NCSS Statistical & Power Analysis Software. The initial medication history was taken by the ED nurse and recorded in T-Systems (T-System Inc), a point-ofcare ED information system, to which admitting physicians had access. Once a physician decided to admit a patient, the patient was flagged in T-Systems, and the ED pharmacist was able to speak with patients awaiting beds about their home medications. A reference list of questions was asked of every patient to generate a second history. The pharmacist recorded the information obtained during the interview and entered it into the paper chart in the ED for reference by the admitting physician. Once the patient was brought to the
floor, this history was put into the chart under the “Home Medications” tab, and the floor nurse had immediate access to the information. The floor nurse then performed a third medication history of the patient and entered this information into MediTech (Medical Information Technology Inc.), the hospital-wide electronic medical record. The floor nurses had access to the pharmacist medication history, but only 14% of the nurses used this information. It is not known why only a small percentage of nurses accessed this information; however it may be due to the fact that they were not accustomed to having this pharmacistprovided medication list available. At this point in the process, the ED pharmacist compared all 3 medical records. If there were inconsistencies, the pharmacist would verify the information with the patient, the patient’s family, physician, the community pharmacy, or other sources, and record how the information was obtained. When discrepancies were identified, a point system was designed to place a value on each piece of missing information. The complete omission of a medication and the inclusion of an incorrect medication were each worth 5 points. The omission of a dose, frequency, or last time of administration, were each worth 1 point. A total of 763 medications were reconciled during the 3-month study period. The ED nurses documented an average of 3.87 medications per patient (P<0.0001), the floor nurses an average of 4.18 medications per patient (P<0.0001), and the pharmacist an average of 7.48 medications per patient, (P<0.0001). Omissions were the most common errors that occurred,
with vitamins and over-the-counter medications being omitted most frequently (Tables 2 and 3). The medication with the most total errors was multivitamins, with 48 errors, followed by aspirin with 40 errors, lisinopril with 35 errors, and ibuprofen with 34 errors. When the points were tallied, the ED nurses accrued 2,665 points, the floor nurses 1,993 points, and the pharmacist 80 points. The difference between the ED nurses and the floor nurses was not statistically significant (P=0.37), but the difference between the pharmacist and the ED and floor nurses was (P<0.0001). During the study, pharmacists were significantly more accurate and complete when taking a patient’s medication history. However, there are several factors that could contribute to the significant discrepancy between pharmacist and
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see RECONCILIATION, page 38
Table 3. Top Medication Classes Omitted During Reconciliation Medication
Omissions
Vitamins
155 a
a
OTC drugs
80
NSAIDs
71
Antihypertensives
36
Herbals
36
Inhalers
26
Minerals
18
Benzodiazepines
18
PPIs/H2RAs
15
Sleep aids
14
Antihyperglycemics and insulins
13
Antidepressants
13
Muscle relaxants
10
Antihyperlipidemics
9
All OTC agents except vitamins and minerals, herbal supplements, NSAIDs, and PPIs/H2RAs.
H2RAs, histamine-2 receptor antagonists; NSAIDs, nonsteroidal anti-inflammatory drugs; OTC, over-the-counter; PPIs, proton pump inhibitors