Medication reconciliation dating timing, background
Bayley and colleagues 7 identified that the common discrepancies in medication history from ambulatory to inpatient care were omitted medication orders, altered doses, or incomplete dating wilton vises company histories.
Inpatient to Discharge Four studies looked at the process of discharge from the hospital to home.
Patients need to be full partners and self-advocates in the medication reconciliation process. Others reported that when a medication reconciliation process was instituted, it medication reconciliation dating timing discrepancies from 70 percent to 15 percent.
A number of approaches have been identified to assist patients and families—for example, reconcile the medication list at every ambulatory visit. The medication list with instructions can be printed and used for education and review with the patient.
Research Implications Research is needed on all aspects of the medication reconciliation process to provide an evidence base for impacting the prevention of adverse drug events.
Stover and Somers 16 reported that case managers performing the reconciliation process spent medication reconciliation dating timing to 10 minutes per day completing the process with new admissions, and each case manager typically reviewed eight new admissions each day.
Education programs need to include the research about medication reconciliation and the steps being put into place to make a safer system for patients.
Consider Use of a Standardized Form Many settings have found the use of a standardized medication form facilitates an accurate list that is accessible and visible.
Reference lists from articles on medication reconciliation were also used to identify additional publications. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten.
Medication Reconciliation Preventing Adverse Drug Events One Patient
Recognizing vulnerabilities for medication errors, numerous efforts are underway to encourage all health care providers and organizations to perform a medication reconciliation process at various patient care transitions.
Additionally, electronic prescribing allows for key fields such as drug name, dose, route, and frequency. Reconciliation in the Ambulatory Setting Medication discrepancies in outpatient records were addressed in three studies. More than 60 percent of nurses reported that determining the medications a patient was taking at home, clarifying medication orders at medication reconciliation dating timing, and ensuring accurate discharge medication orders was a time-consuming process.
Study of how medication reconciliation processes change the workflow and time associated with it are needed. The following are generally consensus recommendations; they have not been subjected to systematic study for effectiveness unless noted.
Rozich and Resar 15 found that prior to initiation of a reconciliation process, details of the current medications in the inpatient chart were nonexistent or incorrect 85 percent of the time.
Medication Reconciliation Preventing Adverse Drug Events One Patient
Wagner and Hogan 26 found discrepancies between the number of medications patients reported taking 5. Studies tended to be about one of the steps in the handoff process, such as admission from home to an acute care facility. This process comprises five steps: Transitions in care include changes in setting, service, practitioner, or level of care.
This chapter reviews the evidence for medication reconciliation and makes recommendations for nursing practice. Rozich and colleagues 15 reported that implementing a systematic approach to reconciling medications was found to decrease nursing time at transfer from the coronary care unit by 20 minutes per patient, and pharmacy time at hospital discharge by more than 40 minutes.
One challenge to having an accurate patient medication history is the lack of a standardized location in the patient chart where the information may be found.
Ernst and colleagues 9 found discrepancies in Designing and testing streamlined processes that will work across the continuum of care, from the ambulatory to the inpatient setting, and having all stakeholders involved in the design will facilitate the process.
What does it look like at 6, 12, and 24 months? Similar findings were found in family practice. High-risk medications such as antihypertensives, antiseizures, and antibiotics may need to be reconciled sooner, for example, within 4 hours of admission.
Patients may not be accurate historians. Time requirements and staffing resources were identified as a barrier to completing the process. Share results with providers so they are able to note progress over time.
Physician and nurse workflows have not traditionally included making a regular inventory of all medications a patient is taking including prescription medications, over-the-counter drugs, herbals, and other complementary drugs such as vitamins or verifying these lists with the patient.
Auditing tools such as the Improvement Tracker on the IHI Web site may assist health care settings in tracking their findings over time. Electronic prescribing also allows for decision support such as checking for allergies, double prescribing, and counteracting medications.
In inpatient facilities, there are several situations where medication reconciliation is needed. Accuracy of medication prescriptions with the use of a multipart form was 82 percent, as compared to 40 percent without the use of an integrated process.
Additionally, patient acuity may influence the process of reconciliation. DeCarolis and colleagues 27 found that a computerized medication profile was inaccurate in 71 percent of the patients they studied. Articles that describe various components of the reconciliation process were found. Multisite studies across the continuum of care are needed to assess the scope of the problem.
Nonetheless, an effective medication reconciliation process across care settings—where medications a patient is taking are compared to what is being ordered—is believed to reduce errors. Third, there is often duplication of data gathering with both nurses and physicians taking medication histories, documenting them in different places in the chart, and rarely comparing and resolving any discrepancies between the two histories.
The intent is to avoid errors of omission, duplication, incorrect doses or timing, and adverse drug-drug or drug-disease interactions.
Medication Reconciliation and Post-Marketing Surveillance (Pharmaceuticals Trai)
The investigators estimated that 20 percent of the medication changes led to an adverse drug event. Bayley and colleagues, 7 in a qualitative study including nurse, physician, and pharmacist informants, reported that reconciliation failures at discharge stemmed from not resuming medications held during the hospital stay, and insufficient patient education at discharge.
Three years following institution of a reconciliation process, which included a form on the chart listing all medications ordered for a patient, 82 percent of charts had complete prescription medication documentation.
Evidence-Based Practice Implications There are numerous areas for nurse involvement in the area of medication reconciliation. These factors combine to create an unsafe medication environment in acute care settings. English-language health care literature from through March was reviewed.
In general, there is no standardization of the process of medication reconciliation, which results in tremendous variation in the historical information gathered, sources of information used, comprehensiveness of medication orders, and how information is communicated to various providers across the continuum of care.
Lau and colleagues 8 compared community pharmacy drug lists with hospitalized patients and found 25 percent of prescription drugs in use at home were not recorded on the hospital admission record. Sullivan and colleagues 24 found that 59 percent of discrepancies not corrected at discharge could have resulted in patient harm.
One example would be discontinuing an anticoagulant during a hospital stay and neglecting to restart it upon discharge.
A standardized reconciliation process has been reported to reduce work and the rework associated with the management of medication orders. There is a time commitment in both obtaining the medication history and completing the reconciliation process.
This confirms previous research findings that medication errors represent the most common patient safety error. No studies were identified that described the reconciliation process along the entire continuum of care from admission to an acute care facility, transfer from one level of care to another such as critical care to general careand discharge back to the community to the primary care practitioner or skilled care facility.
Admissions Between Skilled Nursing Facilities and Hospitals A study of medication changes during transfer from nursing home to hospital and hospital to nursing home found inaccurate and incomplete reconciliation of medication regimens. Studies of the sustainability of medication reconciliation processes need to be carried out.
Patients and family members may not be good historians of a medication record, and due to limited access to pharmacy records, only an incomplete recording of current medications may be obtained.
Patient Safety and Quality: An Evidence-Based Handbook for Nurses.
Some electronic discharge medication ordering systems allow for direct transfer of the orders to the community pharmacy and to the primary care physician, as well as keeping a permanent record on the electronic health record.
Assess adherence to the process and identify the potential for and any actual harm associated with unreconciled medications.
A nurse may need to check the nursing admission database, the medication administration record, the physician patient history and progress notes, and the pharmacy database.
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