The Medication Reconciliation Review tool provides step-by-step instructions for conducting a review of closed patient records to identify errors related to unreconciled medications. Organizations that are considering creating a medication reconciliation process can use this tool to establish a baseline of errors from unreconciled medications and to build a case for the importance of having a reconciliation process in place This tool contains: Overview Instructions Data Collection Form: Errors from Unreconciled Medications Roger Resar, MD Luther Midelfort Mayo Health System Eau Claire, Wisconsin, USA 1 Institute for Healthcare Improvement Boston, Massachusetts, USA
Overview Reconciliation is a process of identifying the most accurate list of all medications a patient is taking including name, dosage, frequency, and route and using this list to provide correct medications for patients anywhere within the health care system. Reconciliation involves comparing the patient s current list of medications against the physician s admission, transfer, and/or discharge orders. Experience from hundreds of organizations has shown that poor communication of medical information at transition points is responsible for as many as 50 percent of all medication errors and up to 20 percent of adverse drug events (ADEs) in the hospital. Each time a patient moves from one setting to another, clinicians should review previous medication orders alongside new orders and plans for care and reconcile any differences. If this process does not occur in a standardized manner designed to ensure complete reconciliation, medication errors may lead to adverse events and harm. Tallying the number of errors related to unreconciled medications establishes a baseline that tells hospitals how much harm is caused to patients because of poor or nonexistent processes for reconciling medications. Establishing a baseline can help organizations make the case for improving or establishing such processes; tracking this measure over time can help organizations to see if changes they make are leading to improvement. 2
Instructions 1. Identify a multidisciplinary team consisting of, at a minimum, a nurse, a pharmacist, and a physician. 2. Obtain a set of approximately 20 to 30 closed patient records (each with a minimum stay of 3 days), using as random a selection process as possible. 3. Have each team member review one-third of the patient records, counting errors due to unreconciled medications. Tips for Finding Errors Due to Unreconciled Medications a. Look for discrepancies in medication orders between outpatient and inpatient settings, pre- and post-intra-hospital transfers, and discharge documents, using the following steps: b. Compare all medications ordered upon admission with any available information about medications the patient was taking prior to admission. Each medication that is not ordered or commented on represents a discrepancy and should be counted as an error. Exclude the obvious. (Example: Patient admitted for bleed due to warfarin; warfarin not continued would be obvious. Since the medication was intentionally discontinued, this is not an error.) c. Look for any other evidence of medication errors resulting from a medication that was not continued inadvertently on the medication administration record (MAR), incident reports, or nursing or physician notes. d. Look for any adverse drug events that might be in the charts or discharge summaries. Then review the details to see if the ADE was the result of the inadvertent discontinuation of a medication or an order that was missed at a point of transition (at admission, transfer to another patient care unit, post-procedure, or discharge). If you find this, it counts as an error, as well as being an ADE. In U.S. hospitals only, also review the list of diagnosis codes that have been assigned to the case by medical staff and see if any of the codes start with the letter e ; these are complication codes and the complication may be the result of an ADE. e. Look for any discrepancies between the discharge medications and the medications that were on the MAR. Any medication discrepancies not accounted for are considered errors. f. On the transfer from one patient care unit to another, look for medications that are still on the MAR that cannot be used in the receiving unit. Those are errors. 4. Tally errors from unreconciled medications. 3
After the records have been reviewed, add up all the errors from unreconciled medications and note the number of patient records reviewed. Report data as a monthly number of errors per 100 admissions. On average, two to three errors are noted per 100 admissions. Then look at these errors and find out how many occur due to the handoffs of care at admission, transfer, or discharge. On average, about 50 percent usually occur in this area. Note: If you find very few errors, suspect the quality of the review; don t assume the reconciliation process is already very good. Medication reconciliation is a process that has a well-established set of standardized methods to ensure that the right medication is given. The baseline measurements above should serve only to support the case for improvement. As improvements to the medication review process are tested and implemented, most organizations conduct retrospective reviews of patient records from only those patients who have been through a medication reconciliation process. This allows the organization to measure the success of the changes. If subsequent reviews are conducted in this manner, the results should not be compared to the baseline data. Generally, changes to the admission medication reconciliation process have the greatest effect on prescribing and ordering errors, and changes to the discharge medication reconciliation process have the greatest effect on adverse drug events. Once an organization has reconciliation processes in place throughout the entire organization, it may conduct another review using the same method to obtain another baseline and the data may then be compared. 4
Medication Reconciliation Data Collection Form: Errors from Unreconciled Medications Patient Record Review Date Errors at Admission Errors during Transfer Errors at Discharge Total Errors Number of Records 1 2 3 4 5 Etc. Total Errors from Records Total Records 5