Medication reconciliation, pharmacist involvement vital to reducing medication errors, study finds


Northwestern Memorial Hospital study demonstrates way to reduce medication errors

CHICAGO Obtaining complete and accurate medication histories of patients and instituting a medication reconciliation program are vital to reducing medication errors, a new study conducted at Northwestern Memorial Hospital has shown. The study demonstrated that when hospital pharmacists perform medication reconciliation, taking steps to ensure patients receive the correct medication and accurate dosage, the number of medication errors dropped and with them the potential for patient injury.

"A medication error, once in a patient's medical record, can carry-over from admission through discharge unless medication reconciliation is performed," says Kristine Gleason, who is on the hospital's Patient Safety Team and is the lead author of the study, Reconciliation of Discrepancies in Medication Histories and Admission Orders of Newly Hospitalized Patients. "Doctors, nurses, pharmacists and patients often just assume medical histories are accurate, and that's not always the case."

The study findings, published this week in the American Journal of Health-System Pharmacy, are particularly significant in light of the recent announcement by the Joint Commission on Accreditation of Healthcare Organizations that medication reconciliation for all hospital patients is one of its 2005 National Patient Safety Goals. That means medication reconciliation programs are a requirement for accreditation.

Northwestern Memorial is working toward that goal, implementing a computerized prescriber order entry (CPOE) system as part of its patient safety initiative. A previous study at Northwestern Memorial found that a combination of pharmacist involvement and a CPOE system with significant clinical decision support will likely provide the best approach to improve medication safety among patients.

Data collected by Northwestern Memorial researchers for the new study showed that in the absence of a pharmacist intervention, 22 percent of medication discrepancies may have resulted in patient harm during hospitalization and 60 percent may have resulted in patient harm if continued beyond discharge. The most common discrepancy was complete omission of a medication that the patient reported taking prior to hospitalization. The next most frequent discrepancy was a different dose, route or frequency of medication ordered compared to what the patient was taking prior to admission. Gleason says such discrepancies occur most often during patient transfers, when a patient is discharged or moved to another hospital, nursing home or even another floor within the same facility.

The reconciliation process consisted of comparing the patient's medications listed in the admission orders to the medication information documented in: 1) the physician's history and physical; 2) the patient's admission profile, a form completed collaboratively by the nurse and patient (or patient's advocate); and 3) information obtained during the pharmacist-conducted interview. A discrepancy was defined as any inconsistency or difference in the medication regimen noted during this manual comparison process.

The study found that pharmacists are in the best position to perform medication reconciliation.

"We believe that pharmacists are especially suited to obtain medication histories and perform reconciliation based on their education, experience, medication knowledge and patient counseling skills," says Gleason. "Pharmacists can recognize sound-alike and look-alike medications or omissions that others may miss, or dosages that don't seem right."

"The project clearly demonstrated that pharmacists play an integral role in this," adds Gary Noskin, M.D., a study author, the medical director of Healthcare Epidemiology and Quality at Northwestern Memorial and professor at Northwestern's Feinberg School of Medicine. "And what this paper demonstrates is that medication reconciliation is an effective method to prevent medication errors."

A previous study conducted at Northwestern Memorial found that while CPOE systems reduce medication errors, they may have limited impact on actual patient harm. The study concluded that the involvement of physicians and pharmacists is critical to safe care.

Healthcare professionals should educate patients on the importance of maintaining an updated medication list, keeping it on a card that they carry all the time, and reconciling this information during every healthcare encounter, the latest study recommended.

"We always have to engage the patients in this conversation and get them involved," Gleason says. "This has to be a collaborative effort."

The Northwestern Memorial study found that medication reconciliation not only increased patient safety but was also cost-effective. The time, and therefore cost, required to perform reconciliation was more than offset by the savings from fewer possible patient injuries.

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Last reviewed: By John M. Grohol, Psy.D. on 21 Feb 2009
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