BEFORE HER transfer from a long-term-care facility to a hospital, a patient with diabetes receives a scheduled dose of insulin. On her arrival at the hospital, she's given a duplicate dose in error. A nurse discovers the mistake when the patient's medication history catches up with her an hour later.
According to the Institute for Healthcare Improvement (IHI), poorly communicated medical information at admission and other health care transition points is responsible for as many as 50% of all medication errors in hospitals. Transition points include facility admission, transfers within the facility, transfers between facilities or agencies, and discharge.
To prevent errors and adverse drug events (ADEs) stemming from oversights, duplication, and other discrepancies in a patient's medication record, the IHI has made medication reconciliation a key strategy in its 100,000 Lives Campaign. (See Learning more about the IHI's 100,000 Lives Campaign.) The IHI defines medication reconciliation as "the process of creating the most accurate list possible of all medications a patient is taking-including drug name, dosage, frequency, and route-and comparing that list against the physician's admission, transfer, and/or discharge orders, with the goal of providing correct medications to the patient at all transition points within the hospital." Determining the timing of a drug's last dose is a critical part of the process, as the opening scenario illustrates.
Medication reconciliation is also one of the 2006 National Patient Safety Goals set by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). As of January 2006, all JCAHO-accredited facilities must have protocols in place for documenting and reconciling medications across the continuum of care.
Medication reconciliation is a three-step process:
* verification (collecting the patient's medication history and other medication information)
* clarification (ensuring that medications and dosages are appropriate for the patient)
* reconciliation (resolving any discrepancies and documenting communications and changes in orders).
Here's how it works. On admission, a list of the patient's home medications is compiled and compared with the initial primary health care provider's orders. At the time of transfer to another unit, all the medications she's taking are compared with the orders in the new unit. At discharge, medications she's taking in the hospital are compared with the primary health care provider's discharge medication orders.
When a discrepancy is detected between any of these lists, the nurse, pharmacist, or health care provider must reconcile or correct the discrepancy and document the action. An independent check performed by a nurse or pharmacist provides an extra safety net to screen for potential ADEs before they occur.
Communication and clarification of information should involve the patient and others as appropriate; for example, family members who help care for her at home, other health care providers who care for her, and the pharmacist who fills her prescriptions at home.
The IHI provides a starter kit to help health care professionals set up protocols and develop documentation tools to facilitate medication reconciliation. (See Selected Web sites below.) Make sure you know and follow your facility's protocol.
When interviewing a patient about her medications, use these tips to compile an accurate and complete list:
* Ask open-ended questions starting with what, why, and when, and balance them with yes-no questions.
* Ask simple questions and don't use medical jargon. Avoid leading questions that might elicit inaccurate information.
* Prompt the patient to try to remember all medication products she uses, including patches, creams, eyedrops or eardrops, inhalers, sample medications, "shots," herbal or mineral supplements, and vitamins.
* Pursue unclear information until it's clarified. For example, check previous medical records, ask a family member to bring in the patient's medications, or call her home pharmacy for a list of prescriptions she's been filling.
* Encourage her to get all her medications from the same pharmacy.
* When questioning her about ADEs, educate her about the difference between an expected adverse effect and a true allergy and make sure she knows which signs and symptoms require immediate attention.
* Ask her to describe how and when she takes her medications, which may help you determine if she's adhering to the prescribed regimen.
* Advise her to keep a medication wallet card and to bring her medications or a list of her medications to the hospital and appointments with health care providers.
Learning more about the IHI's 100,000 Lives Campaign
About the IHI
Founded in 1991 and based in Cambridge, Mass., the Institute for Healthcare Improvement (IHI) is a not-for-profit organization cultivating innovative concepts for improving patient care and implementing programs for putting these ideas into action. The 100,000 Lives Campaign is a nationwide initiative of the IHI to radically reduce morbidity and mortality in American health care. Building on the successful work of health care providers all over the world, the Institute introduced proven best practices across the country to extend or save as many as 100,000 lives. The IHI and its partners in this work believe that achieving this goal by June 2006 is possible. To learn more, contact the IHI at 1-866-787-0831 or http://www.ihi.org.
About this series
This article is the third in a series that examines the IHI's suggested 100,000 Lives Campaign interventions from a staff nurse's perspective. Each article in the series focuses on one of six key strategies that have been proven to prevent avoidable deaths:
* deploying rapid response teams
* preventing ventilator-associated pneumonia
* preventing adverse drug events with medication reconciliation
* delivering evidence-based care to treat acute myocardial infarction
* preventing central line infections
* preventing surgical-site infections.
We discussed deploying rapid response teams in January and preventing ventilator-associated pneumonia in February. We'll explore the remaining strategies in future issues of Nursing2006. For an examination of the IHI's 100,000 Lives Campaign from a managerial perspective, see the "Best-practice protocols" series in Nursing Management, June to December 2005.
Martin S. Manno is a clinical nurse specialist, division of cardiology and critical care nursing, at Penn Presbyterian Medical Center/University of Pennsylvania Health System in Philadelphia, Pa. Denise D. Hayes is senior clinical editor for Nursing2006 in Ambler, Pa.
SELECTED WEB SITES
Institute for Healthcare Improvement: http://www.ihi.org
Joint Commission on Accreditation of Healthcare Organizations: http://www.jcaho.org
Last accessed on February 1, 2006.