Introduction

The latest version of the National Safety and Quality Health Service (NSQHS) Standards includes criterion regarding the reconciliation of medication on admission, transfer within the organisation and discharge to other healthcare settings. In particular, medication reconciliation (in conjunction with other policies, procedures and protocols) is critical for the following standards:

Regarding documentation of patient information, the NSQHS Standards specify:

“4.8 The Clinical Workforce reviewing the patient’s current medication orders against their medication history and prescriber’s plan, and reconciling any discrepancies.

4.8.1 Current medicines are documented and reconciled at admission and transfer of care between healthcare settings.”

They go on to establish continuity of medication management by:

“4.12 Ensuring a current comprehensive list of medicines, and the reason(s) for any change, is provided to the receiving clinician and the patient during clinical handovers.

4.12.1 A system is in use that generates and distributes a current and comprehensive list of medicines and explanation of changes in medicines.”

It is therefore imperative that hospitals have a plan for medication reconciliation moving forward.

What is medication reconciliation?

Medication reconciliation is defined by the Australian Commission on Safety and Quality in Health Care (ACSQHC) as “a formal process of obtaining and verifying a complete and accurate list of each patient’s current medicines”. Practically, this means comparing the medications patients are actually supplied to those which should be prescribed. Any identified discrepancies should have the reason for change documented, or be discussed with the prescriber.

This usually takes place when care is transferred so that a complete, current, and accurate list of medications is provided to those taking over the patient’s care.

Medication reconciliation varies from a standard medication history, as it consists of a systematic interview process with the patient or family, and a review with at least one other source of information.

There are a number of tools available to aid in this process, most notably the national Medication Management Plan, however ultimately what is essential is that the process is followed as outlined by the ACSQHC:

  • Obtain a Best Possible Medication History (BPMH);
  • Confirm the accuracy of the history with a second source;
  • Reconcile the history with prescribed medicines; and
  • Ensure accurate medicines information during transfer of care.

When completed appropriately, medication reconciliation is “a conscientious, patient-centred, inter-professional process that supports optimal medication management”.

Benefits of medication reconciliation

The medication reconciliation process has numerous positive outcomes, some of which are:

  • Reduced medication errors;
    • Medication discrepancies occur in up to 70% of patient admissions/discharges, with approximately 30% of these having the potential to harm the patient.
  • Reduced adverse drug reactions;
    • Potential reduction of 28% compared to usual care without medication reconciliation.
  • Increased medication compliance;
    • Help patients maintain and understand medication lists, and gives the patient and their family the chance to speak up if they believe an error may have occurred.
  • Potential to save time at discharge;
    • The process with discharge medication orders becomes more clear, accurate and efficient if a BPMH has been recorded early during admission.
  • Achieve compliance with NSQHS.

These outcomes benefit patients upon admission into hospital, when discharged home, or when transferred to another facility.

When should medication reconciliation occur?

There is some conjecture over whether hospitals should target admission, discharge, or internal transfer events, as these are times which have been shown to increase the risk of medication discrepancies.

Practically though, medication reconciliation is usually best served within 24-48 hours of admission, so as to identify any potential medication errors early, and also to serve as a reference point for use at the time of discharge.

There is also an emerging trend towards more proactive medication reconciliation to be performed at pre-admission clinics prior to surgical admissions. The benefits of this model is that it reduces discrepancies prior to arrival at hospital, saves time during admission, and can also provide information to patients and prescribers regarding medications that may need to be withheld during the perioperative period.

Which patients should medication reconciliation be completed for?

Hospitals have limited resources, so it seems logical to target only those patients who would benefit most from medication reconciliation (i.e. high-risk patients). There is uncertainty however, regarding the criteria which define high-risk status, and furthermore this status may change during the hospital admission due to changes throughout hospitalisation which would elevate their risk status.

It is therefore suggested that all patients should have medication reconciliation completed; this eliminates the need for risk stratification and the potential to overlook high-risk patients. More importantly still, the NSQHS Standard 4.8 makes no mention of risk level, signifying that all patients must have reconciliation completed to meet the standard.

Who should complete medication reconciliation?

A systematic review of hospital-based medication reconciliation processes found the best evidence for successful interventions was in the use of pharmacy staff, particularly when targeting higher risk patients. There is also evidence to suggest that pharmacist-led medication reconciliation is the most cost-effective system.

Although the most proven professionals to carry out medication reconciliation, this can be an issue for wards without pharmacy services or limited pharmacy resources. Pharmacy involvement should also be careful not to overshadow the broader inter-professional approach to gathering a complete medication history.

Irrespective of who is carrying out the reconciliation, it is vital that the person has received formal training on how to complete the process, especially with regards to taking a BPMH. Pharmacists are ideally situated to lead the practice due to their specialised training, whether this is active involvement or education of other health professionals.

Implementing medication reconciliation

Many facilities will have some form of medication reconciliation already taking place, be that completed by doctors, nurses or pharmacists. The challenge for the future, and for accreditation purposes, is to have a meaningful, systematic and documented medication reconciliation process. Completing the minimum necessary requirements will do little to prevent serious adverse medication events occurring. Hospitals should invest adequate time, funds, and effort into developing robust and effective strategies.

Barriers to effective implementation include:

  • Significant underestimation of time and resources required to implement medication reconciliation;
  • Opposition from front-line staff due to effects on workload and work flow;
  • A shortage of implementation/change management knowledge;
  • Resource limits for ongoing education and support to maintain the implementation; and
  • Implementing too quickly in order to meet accreditation timelines, causing a poorly designed process.

Support from senior management is crucial in ensuring a successful implementation. A collaborative approach between different health professionals and other health facilities is also of great help. Ultimately, careful organisational planning and change leadership is required for a successful implementation, and maintenance of effective medication reconciliation processes.

Conclusion

Medication reconciliation is now a key part of achieving NSQHS accreditation for all hospitals. There are significant benefits associated with effective medication reconciliation, which have benefits for both patients and service providers. Effective medication reconciliation can save time at admission or discharge, and can prevent medication errors. Implementing an effective process requires a coordinated approach and a substantial investment in time and resources. Pharmacy departments are ideally placed to assist in this process and have been proven to be effective and to offer best value.

References:

  1. Australian Commission on Safety and Quality in Health Care (ACSQHC). National Safety and Quality Health Service Standards, Sydney: ACSQHC; 2011.
  2. Australian Commission on Safety and Quality in Health Care (ACSQHC). Medication Reconciliation. Sydney: ACSQHC; 2013.
  3. Australian Commission on Safety and Quality in Health Care (ACSQHC). Match up medicines instructions. Sydney: ACSQHC; 2012.
  4. Bedford G, Stark H, & Duguid M. Partnering with patients to reduce medication errors and adverse drug events at transitions of care. Sydney: Australian Commission on Safety and Quality in Health Care; 2012.
  5. Fernandes O, Shojania K. Medication Reconciliation in the Hospital: What, Why, Where, When, Who and How? Healthcare Quart 2012; 15: 42-49.
  6. Gleason KM, Groszek JM, Sullivan C, Rooney D, Barnard C, and Noskin GA. Reconciliation of Discrepancies in Medication Histories and Admission Orders of Newly Hospitalized Patients. Am J Health-Syst Ph 2004; 61(16): 1689–95.
  7. Kwan Y, Fernandes OA, Nagge JJ, Wong GG, Huh J, Hurn DA, et al. Pharmacist Medication Assessments in a Surgical Preadmission Clinic. Arch Intern Med 2007; 167: 1034–40.
  8. Mueller S, Sponsler K, Kripalani S, & Schnipper JL. Hospital-Based Medication Reconciliation Practices: A Systematic Review. Arch Intern Med 2012; 172(14): 1057-1069.

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