The Importance of Effective Medication Reconciliation
Failure in medication reconciliation can be demonstrated in a real-life story of a young man who was admitted to a California hospital with complications of HIV disease while visiting from New York. The patient was admitted to the hospital on combination HIV medications, the protocol he took at home. Since the hospital did not stock the combination pills, the patient was given multiple single pills while in the hospital. On discharge, the patient's medication was not correctly reconciled and he continued to take both the combination pills and the single pills, which led to double dosing of the HIV medications. When he returned to New York, the patient was admitted to his home hospital in complete liver failure, which ultimately led to his death.
As simple and unimportant as medication reconciliation may sound on the surface, it has important implications to those patients who are affected by reconciliation errors. Medication reconciliation is the process of identifying the most accurate list of all medications the patient is taking, including name, dosage, frequency and route, and comparing the medical record to an external list of medications obtained from the patient, hospital or other provider.
According to the Joint Commission, from September 2004 to July 2005, the MEDMARX® reporting program captured medication reconciliation failures leading to 2,022 medication errors. On January 25, 2006, the Joint Commission issued a Sentinel Event Alert related to medication reconciliation in an attempt to bring awareness to health care organizations.
Physicians play a vital role in reviewing patients' medications and reconciling the list to assure that all medications continue to be appropriate and if not, discontinuing or changing the prescribed medications. Although here at Stanford Health Care, the medication reconciliation process is multidisciplinary, physicians are held responsible for all medications prescribed and are ultimately accountable for any medication incorrectly reconciled. Based on the findings by the Joint Commission and the Sentinel Event Alert, the types of medication reconciliation errors involved improper dose/quantity, followed by omission error, prescribing error, wrong drug, wrong time, extra dose, wrong patient, mislabeling, wrong administration technique and wrong dosage form. The causes of medication reconciliation errors included performance deficit, transcription error, documentation, communication lapses and workflow disruption.
Here at Stanford Health Care we have ongoing efforts in improving medication safety, and medication reconciliation is on top of the list. This process is reviewed tri-annually by both the Joint Commission and the California Department of Public Health as part of the Medication Error Reduction Program (MERP). Continued vigilance and improvement processes help keep our patients safe and medication reconciliation plays a large role in preventing patient harm.