Medication reconciliation is a formal process of obtaining a complete and accurate list of every patient's current home medications and comparing the prescriber's admission, transfer, and/or discharge orders to that list. Prescribers are alerted to any discrepancies, and, if necessary, orders are changed and documented. The process involves verification (collection of medication history), clarification (confirmation of appropriate medications and doses), and reconciliation (documentation of order changes).
Using a model for improvements
The Institute for Healthcare Improvement (IHI) recommends using the Model for Improvement, a tool developed by Associates in Process Improvement for accelerating improvement that's used successfully by hundreds of healthcare organizations to improve various processes and outcomes. The model has two parts:
1. Three fundamental questions that guide improvement teams to set clear aims, establish measures that will tell if changes are leading to improvement, and identify changes that are likely to lead to improvement.
2. The Plan-Do-Study-Act (PDSA) cycle to conduct small-scale tests of change in real work settings by planning a test, observing the results, and acting on what's learned.
After testing change on a small scale, learning from each test, and refining change through several PDSA cycles, your team can implement changes on a broader scale. After successful implementation for a pilot population or entire unit, the team can spread the changes to other parts of the facility or to other organizations.
Setting aims, involving patients
Improvement requires setting aims. These aims should be time-specific and measurable, and define the particular patient population that's affected. As teams work on different steps in the reconciliation process, the aims should be tailored to that portion of the project.
Medication reconciliation is a multi-disciplinary team effort, including, at a minimum, a nurse, pharmacist, and physician. Patients can also play a vital role in this process by carrying a list of the medications they're taking. Having this information readily available helps make reconciliation more efficient and effective.
Conducting reviews
Once the pilot unit has been selected, develop a simple process flow diagram and collect some baseline data to determine the effectiveness of your current process. IHI recommends the use of a data collection form to assist with medication history data collection and to facilitate reconciliation. A medication reconciliation review consists of the following three steps:
1. Obtain a set of 20 closed patient records, using a random selection process.
2. Identify a multidisciplinary team to review the patient records, counting errors from unreconciled medications.
3. Tally errors from unreconciled medications. (Count each medicine once, not each dose that's due). Identify unreconciled medications on admission using the following steps:
-Compare all medications ordered on admission with all medications the patient was taking prior to admission. Each medication that's not ordered or commented on should be counted as an error (unreconciled).
-If staff is unable to determine whether a medicine has been intentionally omitted, it's unreconciled.
-Look for any adverse drug events (ADEs) that might be indicated in the charts or discharge summaries. If the ADE resulted from an inadvertent discontinuation of a medication or an order missed at a point of transition, count this as an error.
Consider the following tips for data collection:
[white diamond suit] Divide the process into steps and share responsibilities.
[white diamond suit] Involve administrative support to identify/pull charts.
[white diamond suit] Develop a quick audit tool, asking nurses, prescribers, and pharmacists from the implementing unit to pull necessary data from the subset of charts each one reviews.
[white diamond suit] Assign to one person the role of aggregating data and developing charts to display on units and include in reports to administrators.
[white diamond suit] Engage clinicians for their feedback regarding definition measurement.
[white diamond suit] Consider using experienced pharmacy technicians to collect medication histories.
[white diamond suit] Incorporate the reconciliation review into an existing data collection program.
[white diamond suit] Focus only on the parts of the chart that relate directly to your work; you should only need to review the reconciling form and the admit orders; limit your review to 15-20 minutes per chart.
[white diamond suit] Each month, list your sample 20 charts on the unit where you're testing the process.
To enlist support and engage staff, share baseline data on how reliable the existing process is in reconciling medication. Tracking two key measures-percent of unreconciled medications and unreconciled medications per 100 admissions-will also help you evaluate, over time, the effectiveness of the medication reconciliation process.
About the IHI
Founded in 1991 and based in Cambridge, Mass., the Institute for Healthcare Improvement (IHI) is a not-for-profit organization, cultivating innovative concepts for improving patient care and implementing programs for putting these ideas into action. The 100,000 Lives Campaign is a nationwide initiative of the IHI to radically reduce morbidity and mortality in American healthcare. Building on the successful work of healthcare providers all over the world, the Institute introduced proven best practices across the country to extend or save as many as 100,000 lives. The IHI and its partners in this work believe it's possible to achieve this goal by June 2006. To learn more about this effort, contact the IHI at 1-866-787-0831 or http://www.ihi.org.