Medication reconciliation: A hospital visit is a time to do it right


Patricia Kienle, RPh, MPA, FASHP

Accreditation and Medication Safety
Innovative Delivery Solutions
Cardinal Health

What medications is the patient taking?

Every experienced health professional knows two things about this question: (1) it's one of the most essential things to know, and (2) we have the wrong answer a shocking amount of the time. There are all-too-often discrepancies between the medications the medical practitioner intended the patient to take and what medications a person actually takes. The reasons are varied. Maybe a medicine is too expensive, too unpleasant or too hard to take on schedule. Maybe the patient has contraindicated prescriptions from several doctors who aren't aware other physicians are involved in care. Maybe the patient is taking herbal supplements, over-the-counter medicines or illegal drugs.

No matter the reason, an inaccurate medication list can and should be fixed when a patient enters the hospital, whether for emergency care or a scheduled admission. Medication reconciliation is a formal process of creating a comprehensive and accurate list of all medications that a patient is taking.

The Joint Commission for hospital accreditation raised our awareness about the seriousness of the problem when it added reconciliation as a national patient safety goal. The commission issued a Sentential Event Alert in January 2006.

Nurses, pharmacists and pharmacy technicians usually speak to the patient directly to assemble the medication list. Sometimes a prescriber or another clinician, such as a radiology technologist, will obtain the patient's list, depending on the situation and the department. Pharmacy's involvement makes sense because pharmacists are best educated to handle the specifics of a wide range of medicines.

Many hospitals contact patients in advance and ask them to create a "home medication list" prior to coming into the hospital. This may be a good starting point, but what we've learned is that the pharmacist or other medical professional must ask very specific and pointed questions. "Do you take anything for headaches?" "Do you take anything from a nutrition store?"

Hospital pharmacists are crucial at the next step of medication reconciliation, especially if the preliminary list has been assembled by another competent professional. The hospital pharmacist may need to check the list by calling the patient's community pharmacy - or, in some cases, pharmacies. The hospital pharmacist will confirm what's accurate, including brand, dosage, directions, and refill history.

Physicians and nurses are an obvious audience for an accurate medication list. The doctor can use the list to refine the patient's overall medication strategy, even for conditions that may not be directly related to the hospital visit.

The patient is also a crucial audience. Each patient needs to leave the hospital with an accurate medication list. Encourage them to keep it up-to-date after the hospital visit is over. Encourage the patient to share it with his or her community pharmacist. Make sure the patient understands the list is a very important and on-going diary to keep. Suggest the patient keep the list in his or her wallet.

A hospital pharmacist possesses wisdom gained from experience. Use that wisdom when patients are discharged to give advice that can help in their everyday lives. For example, many errors are associated with two commonly used high-alert drugs: insulin for diabetes and anticoagulants for heart problems and blood clots. Make it a point to talk to patients and families about these high-alert drugs. Impress upon them that these are potentially very dangerous drugs. Tell those on warfarin that their INR (international normalized ratio) is a number they should know and follow.

Asking patients questions - even when you know the answer - is a great way to educate patients. "What did the doctor tell you that you're using this medicine for?" "Did the doctor tell you what you should look for in side effects?"

It's unfortunate that electronic health records don't yet provide patients, doctors and pharmacists access to a master medication list. Privacy concerns are one roadblock. The patient must hand-write information to keep a medication list up-to-date after leaving the hospital. The best thing a patient can do is go to a single pharmacy so records are stored on one computer. In reality, a one-pharmacy approach often doesn't work for a patient. Shopping around for price or getting prescriptions filled while visiting other states are common occurrences.

Medication reconciliation has improved dramatically since The Joint Commission issued its wake-up call and other accreditation organizations followed. Technology is better than it used to be. Many hospitals have a polypharmacy cutoff - say 8 or 10 medicines - that triggers a holistic overview of medications.

Think of a hospital stay as two opportunities for reconciliation. A hospital admission is the perfect time for medical providers to solve a vexing mystery: what medications is a patient really taking? A hospital discharge is another opportunity: to send a patient back into the real world with accurate information and helpful guidance.

"Reconciliation" is a word that has many meanings. I think of it this way: How can we make sure everyone is singing out of the same songbook? That's a concept that works in both medicine and a patient's everyday life.