Making inpatient medication reconciliation patient centered, clinically relevant and implementable: A consensus statement on key principles and necessary first steps

Authors


  • This article is also being published by The Joint Commission Journal on Quality and Patient Safety [Greenwald JL, Halasyamani L, Greene J, LaCivita C, Stucky E, Benjamin B, Reid W, Griffin F.A., Vaida A.J., Williams M.V. Making Inpatient Medication Reconciliation Patient Centered, Clinically Relevant and Implementable: A Consensus Statement on Key Principles and Necessary First Steps. Jt Comm J Qual Patient Saf 2010 Nov;36(11)(in press)].

    Disclosure: The medication reconciliation conference held on March 6, 2009, was supported by the Agency for Healthcare Research and Quality through grant 1R13HS017520-01 and by the Society of Hospital Medicine. Jeffrey L. Greenwald: Dr. Greenwald received a stipend and conference travel expenses from the AHRQ grant for serving as the co-principal investigator for the grant. Lakshmi Halasyamani: Dr. Halasyamani received a stipend and conference travel expenses from the AHRQ grant for serving as the co-principal investigator for the grant. Dr. Halasyamani is also on the Board of the Society of Hospital Medicine. Jan Greene: Ms. Greene received payment from the AHRQ grant as a medical writer to work on this manuscript. Cynthia LaCivita: Dr. LaCivita received a stipend and conference travel expenses from the AHRQ grant for serving as the conference committee for the grant and an honorarium from the Society of Hospital Medicine which was donated to the ASHP Foundation. Erin Stucky: Dr. Stucky received conference travel expenses from the AHRQ grant for serving on the conference committee for the grant. Bona Benjamin: Nothing to declare. William Reid: Mr. Reid is an employee of Microsoft Corporation and holds stock therein. Frances A. Griffin: Dr. Griffin received travel reimbursement from the Institute for Healthcare Improvement. Allen J. Vaida: Dr. Vaida received conference travel expenses from the Society of Hospital Medicine and the AHRQ grant for serving on the conference committee for the grant. Mark V. Williams: Dr. Williams is the Editor-in-Chief of the Journal of Hospital Medicine.

Abstract

Executive Summary:

Medication errors and adverse events caused by them are common during and after a hospitalization. The impact of these events on patient welfare and the financial burden, both to the patient and the healthcare system, are significant. In 2005, The Joint Commission put forth medication reconciliation as National Patient Safety Goal (NPSG) No. 8 in an effort to minimize adverse events caused during these types of care transitions. However, the meaningful and systematic implementation of medication reconciliation, as expressed through NPSG No. 8, proved to be extraordinarily difficult for healthcare institutions around the country.

Given the importance of accurate and complete medication reconciliation for patient safety occurring across the continuum of care, the Society of Hospital Medicine convened a stakeholder conference in 2009 to begin to identify and address: (1) barriers to implementation; (2) opportunities to identify best practices surrounding medication reconciliation; (3) the role of partnerships among traditional healthcare sites and nonclinical and other community-based organizations; and (4) metrics for measuring the processes involved in medication reconciliation and their impact on preventing harm to patients. The focus of the conference was oriented toward medication reconciliation for a hospitalized patient population; however, many of the themes and concepts derived would also apply to other care settings. This paper highlights the key domains needing to be addressed and suggests first steps toward doing so.

An overarching principle derived at the conference is that medication reconciliation should not be viewed as an accreditation function. It must, first and foremost, be recognized as an important element of patient safety. From this principle, the participants identified ten key areas requiring further attention in order to move medication reconciliation toward this focus.

  • 1There is need for a uniformly acceptable and accepted definition of what constitutes a medication and what processes are encompassed by reconciliation. Clarifying these terms is critical to ensuring more uniform impact of medication reconciliation.
  • 2The varying roles of the multidisciplinary participants in the reconciliation process must be clearly defined. These role definitions should include those of the patient and family/caregiver and must occur locally, taking into account the need for flexibility in design given the varying structures and resources at healthcare sites.
  • 3Measures of the reconciliation processes must be clinically meaningful (i.e., of defined benefit to the patient) and derived through consultation with stakeholder groups. Those measures to be reported for national benchmarking and accreditation should be limited in number and clinically meaningful.
  • 4While a comprehensive reconciliation system is needed across the continuum of care, a phased approach to implementation, allowing it to start slowly and be tailored to local organizational structures and work flows, will increase the chances of successful organizational uptake.
  • 5Developing mechanisms for prospectively and proactively identifying patients at risk for medication-related adverse events and failed reconciliation is needed. Such an alert system would help maintain vigilance toward these patient safety issues and help focus additional resources on high risk patients.
  • 6Given the diversity in medication reconciliation practices, research aimed at identifying effective processes is important and should be funded with national resources. Funding should include varying sites of care (e.g., urban and rural, academic and nonacademic, etc.).
  • 7Strategies for medication reconciliation—both successes and key lessons learned from unsuccessful efforts—should be widely disseminated.
  • 8A personal health record that is integrated and easily transferable between sites of care is needed to facilitate successful medication reconciliation.
  • 9Partnerships between healthcare organizations and community-based organizations create opportunities to reinforce medication safety principles outside the traditional clinician-patient relationship. Leveraging the influence of these organizations and other social networking platforms may augment population-based understanding of their importance and role in medication safety.
  • 10Aligning healthcare payment structures with medication safety goals is critical to ensure allocation of adequate resources to design and implement effective medication reconciliation processes.

Medication reconciliation is complex and made more complicated by the disjointed nature of the American healthcare system. Addressing these ten points with an overarching goal of focusing on patient safety rather than accreditation should result in improvements in medication reconciliation and the health of patients. Journal of Hospital Medicine 2010. © 2010 Society of Hospital Medicine.

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