During 2005, healthcare organizations were to develop a process for obtaining and documenting a complete list of patients' current medication upon admission. However, in discussing this National Patient Safety Goal (NPSG) during periodic performance review conference calls, it's apparent that medication reconciliation continues to be a challenge for many healthcare organizations.
NPSG 8 was formed to accurately and completely reconcile medications across the continuum of care. Part of this goal, specifically 8A, affirms that there's a process for comparing the patient's current medications with those ordered for the patient while under the care of the organization. The other part, 8B, states 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. The complete list of medications is also provided to the patient upon discharge from the facility.
Four-step process
The medication reconciliation process includes four steps:
1. Verify (collect a current medication list)
2. Clarify (make sure the medications and doses are appropriate)
3. Reconcile (compare new medications with the list and document changes in the orders)
4. Transmit (communicate the updated and verified list to the appropriate caregivers).
Development of a medication reconciliation form to be used as a template for gathering information about current medications can be used to standardize care and prevent errors. In the inpatient setting, many organizations utilize the patient's medication administration record as their medication reconciliation form. This NPSG only requires a medication list on entry/admission into the organization. Once the medication list is obtained, the organization needs to make sure its process is in place.
At a minimum, the reconciliation must occur any time the organization requires that orders be rewritten and any time the patient changes service, setting, provider, or level of care and new medications orders are written. For transitions not involving new medications or rewriting of orders, the organization should determine whether reconciliation must occur. This goal applies across the continuum of care.
Q Will The Joint Commission (formerly JCAHO) expect to see a specific form or document in the chart?
A No. On admission/entry to a care setting, the expectation is that the patient's current medication list is documented in some identifiable fashion as part of the patient's record. The organization should specifically define the expected time frame for that to occur. A surveyor may review a patient's chart to see if the medications on admission/entry were noted. If this information is only available electronically, the surveyor may ask the organization to demonstrate how information about medications upon admission/entry is obtained and made available to appropriate staff.
Q Is documentation of the reconciliation required, and if yes, what type?
A The only required documentation is the list itself. It's up to each individual organization to determine how it will monitor its compliance with the medication reconciliation requirements. This may or may not be supported by documentation that the organization requires for its own purposes.