Medication reconciliation: what every nurse needs to know

AORN Journal, Jan, 2007 by Suzanne C. Beyea

An important National Patient Safety Goal, as stipulated by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), relates to medication reconciliation across the continuum of care. The JCAHO requirements for this National Patient Safety Goal specify that health care organizations should develop a process for comparing each patient's current medications with those ordered for the patient while he or she is under an organization's care. This goal is applicable to office-based surgery, ambulatory care, critical access hospitals, and hospitals. (1,2) Medication reconciliation ensures that

   a complete list of the patient's medications
   is communicated to the
   next provider of service when a
   patient is referred or transferred to
   another setting, service, practitioner,
   or level of care within or outside
   the organization. (1)

For 2007, JCAHO also emphasizes the importance of providing the patient with a complete list of medications at the time of his or her discharge from a health care facility.

Implementation guidelines require that the organization, in cooperation with the patient, document a complete list of the patient's medications at the time of the patient's admission or entry into the health care setting and that a patient's admission medication list be compared to medications ordered for the patient during an episode of care. The purpose of this comparison is to identify any differences such as omissions, duplications, and possible interactions and to resolve any of these issues. (1)

MEDICATION RECONCILIATION RATIONALE

The rationale for establishing medication reconciliation as a National Patient Safety Goal relates to the risks that exist at the time of hand offs across settings, services, providers, or levels of care. Maintaining an accurate medication list throughout the continuum of care is one step toward increasing the reliability of care by reducing the risks of transition-related adverse drug events. The potential for serious adverse events led JCAHO to release a Sentinel Event Alert in January 2006 to address this significant concern. (3) In this publication, JCAHO reported that 63% of 350 sentinel events related to medications were attributed to communication issues, and half of the errors would have been avoided through an effective process of medication reconciliation. (3) The Joint Commission also reported that both the Institute for Safe Medication Practices and the United States Pharmacopeia (USP) had received reports of medication reconciliation errors. The types of errors reported through USP's MEDMARX program include improper dose or quantity, omission errors, and prescribing errors. (3)

Another organization concerned with medication reconciliation is the Institute for Healthcare Improvement (IHI), which has identified medication reconciliation as a key initiative of the 100,000 Lives Campaign. (4) The IHI reports that poor communication is a factor in 50% of all medication errors and 20% of adverse drug events in hospitals. (5) The IHI describes the medication reconciliation process as one that involves three steps:

* verification (ie, obtaining a patient's medication history);

* clarification (ie, verifying that the medications and doses are appropriate); and

* reconciliation (ie, documenting any changes in orders). (6)

Additional resources related to medication reconciliation are available online from IHI at http://www.ihi.org/IHI/Programs /Campaign/Campaign.htm?tabld= 2#PreventAdverseDrugEvents.

NURSES' ROLES IN MEDICATION SAFETY

Medication reconciliation requirements and initiatives at first may appear to be a burden to nurses; however, perioperative nurses can play an instrumental role in reducing a patient's risk of adverse medication reactions. Imagine the negative outcomes that could occur if a surgeon is unaware that a patient routinely takes an anticoagulant or if a patient's antiarrhythmic medication is not continued after surgery. Imagine caring for a patient whose regular intake of herbal medications was not revealed during the admission process and then having that patient bleed excessively during a procedure as a result of the herbal medications' side effects. Each of these examples of potential errors or adverse events could be averted by a careful and effective medication reconciliation process.

For these reasons, every perioperative nurse needs to understand what his or her health care organization is doing to address the JCAHO requirements. Even if a facility does not seek JCAHO accreditation, medication reconciliation should still occur.

The fast-paced nature of most perioperative settings makes it crucial for perioperative nurses to actively participate in multidisciplinary teams that address medication reconciliation. The nuances of the preadmission process and multiple hand offs of patients make it imperative that health care facilities develop systems that address the needs of patients and involve at least one other individual (eg, a family member, significant other, surrogate decision-maker) when appropriate. (3) Designing an effective process by which a reliable medication list is documented and then accessed by caregivers will help ensure each patient's safety. Obtaining accurate and complete information, however, may present some challenges for clinicians.