A review of medication reconciliation issues and experiences with clinical staff and information systems

Abstract

Medication reconciliation was developed to reduce medical mistakes and injuries through a process of creating and comparing a current medication list from independent patient information sources, and resolving discrepancies. The structure and clinician assignments of medication reconciliation varies between institutions, but usually includes physicians, nurses and pharmacists. The Joint Commission has recognized the value of medication reconciliation and mandated implementation in 2006; however, a variety of issues have prevented simple, easy, and universal implementation. This review references issues related to the development and the implementation of medication reconciliation including: - the need of a system or standard for accurate drug identification to create a definitive 'gold standard' patient medication list, - identifying stakeholders of medication reconciliation within the institution and contrasting staff interest and participation with institutional resources, - observations and opportunities of integrating medication reconciliation with the electronic patient health record, and - summarizing a series of institutions experiences developing and implementing medication reconciliation. Last, as medication reconciliation becomes a regular process within medical centers, key concepts for effective implementation are discussed.

Keywords: Medication reconciliation; drug errors; medical errors; medical informatics; patient safety; pharmaceuticals.

Fig. 1

Current Medication Information Distribution Problems. Sources of medication misidentification or administration miscommunication, leading to medical error and patient injury emerge at several points along the health care process. As noted along the top row there are numerous methods and classification systems to ‘name’ medications, but without a single recognized system, multiple incommunicable systems emerge containing nontransferable information. The middle row of topics recognizes the variable quality of drug information available on the Web, inconsistent name use for similar medications, and underuse of reviewed high-quality information Web-based resources. The bottom row identifies common administrative, technical and educational information hurdles encountered with many medical center electronic health information systems.

Fig. 2

Naming and concept relationships in UMLS. This graphic steps through the commercial name of the drug sold as Zyrtec in 5 mg tablets, continues to the chemical form of the drug, cetirizine HCl supplied as an oral tablet, to the active drug ingredient and dose, cetirizine @ 5 mg, and finally to the basic active ingredient, cetirizine [28]. This format utilizes standard nomenclature on several levels, allowing identification and integration of medications with information systems that use different criteria to specify medications: trade and generic names, generic names and dose, salt form of the drug, and active ingredient.

Fig. 3

Sample Longitudinal Medication List. Bails et al. [53] created an electronic outpatient medication list as the first step of medication reconciliation. The list included the drug name, dose and frequency, the number of pills in the prescription and refills, specific administration instructions or comments, and dates of initial prescribing, and latest activity. Modification of the list identified medications as new or renewal medications and identified the information source for the drug. The list included prescription medications, but also over-the-counter medications and herbal or dietary supplements. This medication list could be populated from the electronic health record, but also from pharmacy records and the patients verbal history.

Fig. 4

Physician Compliance Before and After Mandatory Participation. Agrawal et al. [54] measured physician compliance with medication reconciliation before and after institution of soft stop warnings with a hard stop workflow interruption. During the process of creating electronic daily progress notes for patients with incomplete medication reconciliation, physicians initially were warned using a soft stop reminder alert. After 24 hours, a hard stop technique required medication reconciliation completion prior to creating the progress note. Physician compliance rose following initial rollout, which was not unusual, but then declined to the 25-35% range. Compliance rose to over 95% within two months of initiating mandatory medication reconciliation completion using the hard stop technique.