R E V I E W S & A N A LY S E S Breakdowns in the Medication Reconciliation Process Tingting Gao, PharmD, BCPS INTRODUCTION Patient Safety Analyst Michael J. Gaunt, PharmD Medication reconciliation is a process of comparing the medications a patient is taking Senior Patient Safety Analyst and should be taking with newly ordered medications to identify and resolve discrepan- Pennsylvania Patient Safety Authority cies.1,2 In other words, the process involves collecting an accurate list of the patient’s medications, ensuring the medications collected and ordered are correct and appro- priate for the patient, and reviewing any changes in therapy with each change in level ABSTRACT of care. The goals of medication reconciliation are to obtain accurate and complete Pennsylvania Patient Safety Authority medication information for a patient and to use the information within and across the analysts identified 501 reports involving continuum of care to ensure safe and effective medication use.3 breakdowns in the medication reconcili- This process involves obtaining a detailed history of the medications that a patient was ation process with event dates between taking at home or during the previous level of care, including the drug name, strength, November 1, 2011, and November dose, route of administration, frequency, and the date and time when the last dose was 31, 2012. Analysts reviewed these taken. Having a complete and comprehensive medication history is critical and allows reports to classify the events by type clinicians to reconcile it against the patient’s current and newly ordered medications to of reconciliation, event type, and pos- identify discrepancies such as duplications, omissions, and interactions and minimize sible causes and contributing factors. potential adverse drug events. The majority of events occurred during admission medication reconciliation Medication errors are frequent during transitions of care due to inadequate communi- (69.3%, n = 347). Events most often cation and inadvertent omission of information.4 For example, medication errors can originated during prescribing (40.3%, occur while taking the medication history due to dependence on patient or caregiver n = 202) and transcribing (26.9%, n recall. This process is further complicated by reliance on healthcare providers who have = 135). Drug omission was the most other primary responsibilities. Lack of a complete and accurate medication history may frequently reported (26.7%, n = 134) compromise a provider’s ability to prescribe an effective medication management plan. event type overall. Other top event types With the majority of the patients taking more than one medication prior to hospital included wrong dose and additional admission, there is potential for providers to overlook at least one medication when drug or dose. Important risk reduction reconciling patients’ home medications upon admission.5,6 In addition, there is a posi- strategies include standardizing pro- tive correlation between the number of medications a patient is taking and the number cesses, clearly defining the roles and of medications missed during the process of taking the medication history.5 responsibilities of staff involved in the This analysis serves to uniquely review medication error events reported by Pennsylvania medication reconciliation process, using healthcare facilities to the Pennsylvania Patient Safety Authority in order to identify the a standardized medication reconciliation types of medication events associated with the medication reconciliation process, iden- form with a scripted list of questions or tify trends and factors contributing to the events, and provide risk reduction strategies prompts, and engaging patients when to prevent these events from occurring. obtaining their history and determining treatment. (Pa Patient Saf Advis 2013 METHODS Dec;10[4]:125-36.) While reviewing reports submitted to the Authority, analysts have the opportunity to Corresponding Author further classify reports using a “monitor code” for future querying opportunities. Ana- Michael J. Gaunt lysts queried the Authority’s Pennsylvania Patient Safety Reporting System database for reports assigned the monitor code “PI6,” representing reports identified as events involv- ing breakdowns during medication reconciliation. In addition, the event descriptions were queried for the phrases “reconcile” and “reconciliation” to identify reports that may involve medication reconciliation that were not assigned the “PI6” monitor code. The initial query yielded 4,965 reports submitted to the Authority from June 2004 through November 2012. Analysts narrowed the time period to focus only on reports with event dates from November 2011 through November 2012, which generated 681 reports. After eliminating reports that were not applicable (e.g., “during process of reconciling specimen with requisition, the lab technician noted patient’s specimen to be mislabeled”), 501 reports were analyzed in detail to identify trends and contribut- ing factors. Vol. 10, No. 4—December 2013 Pennsylvania Patient Safety Advisory Page 125 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S ANALYSIS Figure. Medication-Reconciliation-Related Events That Occurred from November 1, 2011, through November 31, 2012, by Node, as Reported to the Pennsylvania Despite the variety of ways in which Patient Safety Authority (N = 501) breakdowns occurred during medication reconciliation and the number of events that actually reached the patient, few resulted in patient harm. Categorization 45 Prescribing (9.0%) of the events by harm score, which is 62 Transcribing adapted from the National Coordinating (12.4%) Council for Medication Error Reporting 11 202 (2.2%) (40.3%) and Prevention harm index,7 shows that Dispensing 67.3% (n = 337) of the events reached the 46 patient (harm score = C to I), 17.4% (n = (9.2%) Administering 87) of the events reached the patient and required monitoring to confirm that it Other resulted in no harm to the patient and/ 135 or required intervention to preclude harm (26.9%) Unknown MS13581 (harm score = D), and 3.6% (n = 18) of the events resulted in patient harm (harm score = E to I). Likewise, analysts categorized the events transfer, discharge). Nearly 70% (n = 347) Discharge according to the node of the medication- occurred during medication reconciliation Patient was taking Altace® [ramipril] use process in which the event took place. upon admission, 10.0% (n = 50) during at home, which was therapeutically More (40.3%, n = 202) reported events medication reconciliation upon discharge, interchanged to lisinopril by phar- originated in the prescribing node than and 8.6% (n = 43) during medication rec- macy. Upon discharge, Altace was any other node. See the Figure for a com- onciliation upon transfer. Analysts were discontinued and lisinopril was listed plete breakdown of events by node. unable to determine the care transition in as a new medication. Patient went The care areas in which the events oc- 12.2% (n = 61) of the events because there home with new prescription for lisino- curred were distributed across many units. was insufficient information contained pril but already had Altace at home, The top five care areas were medical- within the event reports. leading to [therapeutic] duplication. surgical unit (21.2%, n = 106), emergency Examples for each care transition are as When analyzing the event description department (ED) (12.8%, n = 64), telem- follows: of each event report, analysts identified etry (7.2%, n = 36), medical unit (5.8%, Admission a broad spectrum of event types that n = 29), and pharmacy (4.6%, n = 23). As occurred during care transitions. The older patients often take more medica- Based on the medication history Table provides a breakdown of the top tions and access medical service more information from patient’s family, five event types by care transition. Overall frequently, it was not unexpected that atenolol 150 mg was prescribed. Phar- and for each care transition, drug omis- the majority of patients (55.7%, n = 279) macy caught the error, saying that the sion, wrong dose, additional drug or dose, involved in these events were age 65 or dose of atenolol was too high. After unknown, and wrong drug were the most older. Only 3.0% (n = 15) of patients were checking with patient’s outpatient common event types. Drug omission 18 or younger. More than 89.2% (n = 447) pharmacy, [it was learned that] the was the most frequently reported event of the reports were reported as medica- patient was actually taking Avapro® type overall and with each care transition tion errors, only one was reported as an [irbesartan] 150 mg. Patient did not except transfers. Insufficient information adverse drug reaction, and the remaining receive the wrong medication. was provided in 12.2% (n = 61) of the were submitted as other types of report- Transfer event reports to determine the type of able events. When the patient was transferred event that occurred. from the PACU [postanesthesia care Medication Reconciliation by unit] to the ICU [intensive care unit] Drug Omissions Care Transition to the floor, medication reconciliation An omitted or missed dose may contribute Authority analysts categorized the events was not conducted when the patient to therapeutic failure and deterioration according to care transition (i.e., admission, went from ICU to the floor. of the patient. Omissions, including dose Page 126 Pennsylvania Patient Safety Advisory Vol. 10, No. 4—December 2013 ©2013 Pennsylvania Patient Safety Authority Table. Top Five Event Types Associated with Medication-Reconciliation-Related Events That Occurred from November 1, 2011, through November 31, 2012, as Reported to the Pennsylvania Patient Safety Authority NO. OF EVENTS (%) BY CARE TRANSITION EVENT TYPE Overall Admission Transfer Discharge Unknown (N = 501) (N = 347) (N = 43) (N = 50) (N = 61) Drug omission 134 (26.7) 90 (25.9) 11 (25.6) 12 (24.0) 14 (23.0) Wrong dose 102 (20.4) 75 (21.6) 2 (4.7) 11 (22.0) 14 (23.0) Additional drug or dose 90 (18.0) 55 (15.9) 14 (32.6) 9 (18.0) 12 (19.7) Unknown 61 (12.2) 31 (8.9) 13 (30.2) 8 (16.0) 9 (14.8) Wrong drug 40 (8.0) 31 (8.9) 1 (2.3) 4 (8.0) 4 (6.6) or drug omissions, were the second most on-call doctor. The patient received home medications not being reordered common (26.7%, n = 134) type of event no meds until evening shift. on admission causing a delay in identified by analysts. The greatest number A lack of detail in the event reports discharge. This error was caused by of omission events occurred during the limited the analysts’ ability to identify the admission reconciliation form prescribing phase (35.1%, n = 47), while specific contributing factors to the drug not being completed and transcribed 17.2% (n = 23) occurred during the tran- or dose omission events. Analysts noted as an order form. The patient was scription phase. Examples are as follows: that in 20.9% (n = 28) of the events, the restarted on home medications and A patient was admitted for a surgical medication reconciliation form or docu- discharged a day later. procedure. Home medications were mentation was never communicated or A patient was discharged without not ordered. Patient’s seizure medica- transmitted (e.g., faxed) to the pharmacy Lopressor® [metoprolol] being ordered tion was not given. The patient had department or entered into the computer due to incomplete medication reconcil- a seizure. Physician contacted and system. The reason for this breakdown iation process. The patient went into ordered 2 mg Ativan® [LORazepam] in communication was not noted in the rapid atrial fibrillation, which neces- and now dose of 90 mg IV [intrave- reports. Nearly 19% (n = 25) of the event sitated readmission two days later. nous] push phenobarbital. reports simply described that the omission Pradaxa® [dabigatran etexilate] was The attending physician admitted a occurred when the drug or dose was omit- continued on medication reconcilia- patient and did not perform medi- ted from the medication reconciliation tion but not profiled. The error was cation reconciliation. The patient documentation. Medication reconcilia- detected during chart check after was admitted without medications tion was not completed for unspecified [two] doses were missed. Patient has prescribed. The patient was without a reasons in 13.4% (n = 18) of the events. a history of atrial fibrillation. The medication list and only remembered Roughly 18% (n = 24) of event reports attending physician was notified. Colace® [docusate sodium] stool soft- either did not provide a drug name or There were no adverse effects noted, ener as a medication. Two days later, indicated that a drug name was unknown, and the drug was started promptly. it was discovered that the medication not documented, or other. Multiple medi- reconciliation was not done [because] cations were involved in 8.2% (n = 11) Wrong Dose the attending thought the resident of the reports. Details as to the specific When breakdowns occur with the had completed the history and physi- medications involved were not provided medication order, patients are at risk of cal and medication reconciliation. in the reports. receiving an incorrect dose or medica- The patient was admitted at end Cardiovascular drugs (e.g., amLODIPine, tion. Analysts initially identified “wrong of the evening shift. Medications digoxin, diltiazem) were cited in 16.4% medication order” as the most frequently were not reconciled by doctor during (n = 22) of the events, and antiplatelet or reported (41.7%, n = 209) type of event overnight or day shifts, although the anticoagulant products were involved in associated with the medication reconcilia- overnight nurse was informed of the 9.0% (n = 12) of the events. Examples are tion process. When drilling down further patient’s diabetes, hypertension, and as follows: into these reports, nearly half (48.8%, past stroke history and told to call the n = 102) involved a wrong dose of medica- A patient’s blood pressure elevated on tion, which was the second most frequent the day of anticipated discharge due to Vol. 10, No. 4—December 2013 Pennsylvania Patient Safety Advisory Page 127 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S event type overall. Similar to previously was 85. The patient had no adverse A patient was on Levemir® [insulin mentioned drug omission events, the outcomes beyond measures to reverse detemir] 100 units/mL at home. majority of wrong-dose events originated hypoglycemia. When medication reconciliation was during the prescribing (49.0%, n = 50) Most often (65.7%, n = 67), wrong-dose completed, the physician called an and transcription (27.5%, n = 28) phases. events involved documentation errors order to substitute Lantus for Levemir, Examples are as follows: during the medication reconciliation but the dose was transcribed as The patient takes metoprolol tartrate process. For instance, 57.8% (n = 59) 100 [units] instead of 10 units. The 100 mg q am [every morning] and of wrong-dose events resulted from the patient received 100 units of Lantus 50 mg q pm [every evening]. [Medi- incorrect dose recorded by the practitio- insulin. The physician was notified. cation was] reconciled and ordered ner during medication reconciliation. The patient had a decrease in blood as [metoprolol tartrate] 150 mg q Breakdowns in the accuracy of the sugar that responded to dextrose. am. [Metoprolol tartrate] 150 mg patient’s recall of his or her medications Other medications involved in wrong- was given in morning. Patient was contributed to these documentation dose events include metoprolol tartrate then taken to cardiology, [where the errors. Another 18.6% (n = 19) of the and metoprolol succinate (6.9%, n = 7), patient] became severely symptomati- events resulted from an order entry error buPROPrion-containing products, includ- cally bradycardic and hypotensive. in a computerized prescriber order entry ing extended-release formulations (2.9%, Fluids were administered [as well system or pharmacy computer system. n = 3), and oral hypoglycemic agents (i.e., as] ondansetron for nausea. [Staff] Analysts found a variety of medications glipiZIDE, glyBURIDE, and glimepiride) discussed the discrepancy with cardiol- involved in the wrong-dose events. Insu- (2.9%, n = 3). ogy. Metoprolol held. lin products, a category of high-alert During previous hospital stay, a medications,8,9 were involved in 8.8% Additional Drug or Dose patient received Lantus® [insulin (n = 9) of the events. It should be noted Inadvertent prescribing or administering glargine] 6 units daily at bedtime. that 33.3% (n = 3) of the insulin reports of an additional or unnecessary drug can The discharge summary notes Lantus appear to involve the misinterpretation of pose a risk to patients. Analysts identi- 60 units daily at bedtime. Discharge the insulin concentration 100 unit/mL— fied that in roughly 18% (n = 90) of the instructions and discharge prescrip- as is often printed on hospital and long- events, patients nearly or actually received tion listed Lantus 6 units daily at term care discharge instructions as well an additional drug. Over 46% (n = 42) bedtime. The patient was admitted as outpatient prescription labels10—as the of these events originated in the prescrib- a month later, and ED personnel patient’s specific dose. Examples are ing node of the medication-use process, did not have Lantus listed as a home as follows: while 22.2% (n = 20) and 16.7% (n = 15) medication. History and physical originated in the transcription and dis- A patient was admitted to general notes Lantus 60 units daily at bed- pensing nodes, respectively. Examples are rehab. The admission orders included time, and Lantus 60 units daily at as follows: an order for Lantus 100 units daily bedtime was ordered. On day one, and 100 units at bedtime. During Upon retrospective review, it was the patient’s evening POC [point of acute care admission, the patient had noted that this patient was hyperkale- care] blood glucose level was 172; been receiving 35 units daily and mic upon admission, and kayexalate Lantus dose given. On day two, the 25 units at bedtime. I spoke with was prescribed and administered. patient’s evening POC blood glucose admitting resident to change [the Additionally, [the patient’s] potas- level was 161; Lantus dose given. On Lantus dose] back to previous dos- sium supplement was inappropriately day three, the patient’s morning POC ing. Per the admitting resident, the continued from the home medication blood glucose level was 59, and the patient’s discharge instructions stated list, [which] resulted in a refractory corresponding morning lab reported dose as 100 units. Upon review of hyperkalemia. The condition was tem- blood glucose level of 50. The patient the discharge instructions, the medica- porary, [and it was] treated with a was administered dextrose 15 g PO tion appears as follows: “Medication second dose of kayexalate. The potas- [by mouth]; repeat POC was 85. Name/Strength column: Insulin sium supplement was discontinued. Lantus dose was discontinued. The Glargine (Lantus) (Insulin Glargine patient’s evening blood glucose level Patient went to surgery, and after 100 units/mL Subcutaneous Solu- the procedure, the “OR/Transfer was 60. The patient was adminis- tion)” and the “How much do I tered dextrose 15 g PO; repeat POC Medication Reconciliation” was take?” field is blank. printed and signed by surgery. One Page 128 Pennsylvania Patient Safety Advisory Vol. 10, No. 4—December 2013 ©2013 Pennsylvania Patient Safety Authority minute later, the “Home Medica- A medication reconciliation form was was overlooked. The next day, the phy- tion Reconciliation” was printed completed in the ED and accepted as sician reviewed all records and, in the and signed by surgery, activating old admission medication orders. As per reconciliation process, realized that an medication orders that conflicted policy, the medication reconciliation error was made. Three medications with the post-op orders. This created form [was] reviewed with the patient were ordered in error. One of the meds numerous medication order problems and the family at the time of admis- was Opana® [oxymorphone], and one for nursing and pharmacy. The sion. The family stated that Remeron® dose was given to the patient before patient was on duplicate antisecre- [mirtazapine] and Zoloft® [sertraline] the error was discovered. The patient tory medications, as well as different had been discontinued in the skilled did not have any apparent ill effects doses of antidepressants. The orders facility. Transfer medication sheets from the medication. were evaluated by a hospitalist, and were reviewed, and both meds had In other events involving documentation medication order issues were resolved. been discontinued. The patient did errors, medications from lists belonging The patient, however, did experience not receive incorrect medications. to a different patient were ordered for a new onset confusion, agitation, and It was discovered by the medical patient (15.8%, n = 6). Most often, the bladder irritation [the day before the doctor that the patient had the lists were provided by patients or other hospitalist resolved the issue]. Per the following meds on [the medication facilities. Examples are as follows: physician, he cannot rule out that it administration record]: doxycycline, is medication-related. A patient presented at ED with metroNIDAZOLE, Pyridium® [the patient’s] son. The son gave the The patient was admitted for hyper- [phenazopyridine], and Bactrim® ED nurse the home medication list. tension, metoprolol was stopped, and [sulfamethoxazole and trimethopri- The list included both the patient’s labetalol was started. During the mon]. The physician realized that and patient’s spouse’s home medica- discharge medication reconciliation the patient should not be getting tions. The nurse transcribed both the process, the provider indicated that these meds, as the patient no longer patient’s and spouse’s medications the patient should start labetalol but needs these with no UTI [urinary when completing the patient’s medica- also ordered the home medication tract infection]. Apparently, the nurse tion reconciliation. The admitting of metoprolol. The patient required and psychiatrist both reconciled these physician used the medication recon- readmission for bradycardia. medications on admission, although ciliation list of home meds transcribed The most frequent breakdown that the patient has not needed them. The by the ED nurse to order medications occurred during these events were docu- patient was given these medications for the patient. The patient received mentation errors (42.2%, n = 38). One key in the morning, as they were on the the spouse’s medication twice in error. contributor involved the accuracy of the [medication administration record] The physician was notified. [There information practitioners accessed to deter- to give. The patient did not have any was] no apparent harm to the patient. mine the patient’s current medications. In sort of adverse reaction, and the medi- cations were discontinued. A patient [was transported] to ED 42.1% (n = 16) of the events, patients were from personal care facility (the ordered, and in some cases received, medi- When the patient was admitted, the patient was confused). Information cations documented in previous admis- nurse reviewed the records that came (medication lists) was sent on the sions, on home medication lists, or on lists with the patient to determine medica- patient and another facility patient. provided by other facilities when in fact the tions that the patient was receiving When medication reconciliation was patient was no longer taking that medica- upon discharge from the referring facil- completed, the two [patients’] medica- tion. Examples are as follows: ity. One record noted meds the patient tion lists were combined to compile Coumadin® [warfarin] was listed received the day of discharge from the a medication list for admission. The on the patient’s home medication transferring facility prior to admission physician reviewed the compiled list reconciliation sheet. These meds were to this facility. This list was reviewed and ordered medications based on the ordered by the ED physician. The with the physician, and verbal orders list. The patient received [multiple patient and [the patient’s adult child] were obtained from the physician for doses of] the following medications both stated that the patient no longer the medications reviewed. This list, from the other patient’s list: Ambien® takes Coumadin. The patient did not however, did not match the discharge [zolpidem], Seroquel® [QUEtiapine], receive any doses while in hospital. medication list record that was also in Celexa® [citalopram], Ventolin® the admission papers, and this record [albuterol] inhaler, Neurontin® Vol. 10, No. 4—December 2013 Pennsylvania Patient Safety Advisory Page 129 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S [gabapentin], OxyCONTIN® [oxy- multiple medications. Cardiovascular the patient was being transferred. In CODONE extended release], and drugs, primarily drugs used to treat hyper- another case, the wrong patient’s medica- Xanax® [ALPRAZolam]. During tension, were involved in 17.8% (n = 16) tion reconciliation form was placed on hospitalization, the patient was of all the additional drug or dose events. the patient’s chart and completed by the noted to be progressively lethargic. The next largest group of medications prescriber ordering medications. Exam- Rapid response was initiated, and noted in the event reports was anticoagu- ples are as follows: the patient was treated and remained lants and antiplatelets (14.4%, n = 13). A patient presented to the facility on the unit. Following a gastroin- with a medication list sent by a nurs- testinal procedure, the patient was Wrong Drug ing home. The patient was placed transferred to ICU due to inability to Wrong-drug events was the fifth most on NPO [nothing by mouth] status. fully wake up post sedation. Medica- frequently reported (8.0%, n = 40) event Medication reconciliation process tions were adjusted, with order to type overall. Similar to the other top event was performed based on medication hold for sedation. The remainder types, analysts identified that most events list sent from the nursing home. After of hospital course was uneventful. originated during the prescribing (37.5%, administration of eye drops only, Upon preparation for discharge, per- n = 15) and transcription (37.5%, n = 15) staff discovered that the med list sonal care facility [was] given report phases of the medication-use process. was that of another patient from the and medications [were] reviewed. Examples are as follows: nursing home. Facility questioned medications and indications. Medication errors were The patient was on HumuLIN® When admitting a patient, the wrong discovered at that time. Patient [was] 70/30 [insulin NPH and insulin patient medication reconciliation discharged back to facility in stable regular] 50 units BID [twice daily] at forms were placed on the patient’s condition. home. [On admission, the patient was] chart and were filled out by nurse ordered HumuLIN® N [insulin NPH] practitioners writing admission orders Prescribers indicated on medication rec- 35 units BID. The patient received (prescribing error). The error was onciliation forms or in orders to “hold” 1 dose of 35 units of HumuLIN N. discovered by the nurse before the list doses of medications in 16.7% (n = 15) [Staff] spoke with resident and the was scanned to pharmacy and pro- of event reports. However, either nursing patient’s nurse to verify and correct. filed. The physician was notified and or pharmacy staff missed the hold order. correct medications were ordered; no Similar to an article that appeared in the Medication was transcribed from patient list to reconciliation [form] harm to patient occurred. March 2006 Pennsylvania Patient Safety Advisory,11 anticoagulants were in nearly a by nurse as amiodarone instead of Another factor that contributed to wrong- third (n = 4) of these events. An example amLODIPine. Earlier today, PCP drug events was the use of inaccurate is as follows: [primary care physician] discussed this medication history information provided transcription error with nurse, and she by the patient or the patient’s family Coumadin was placed on hold on thought PCP had crossed it off. It later either on a printed list or verbally. This medication reconciliation sheet. became apparent that he had not. occurred in 7.5% (n = 3) of the wrong- Coumadin was dispensed to floor drug events. An example is as follows: with other medications. The nurse Nurse transcribed a medication by his- administered Coumadin, and when tory as isosorbide dinitrate 30 mg daily. The patient’s personal home list of heparin lock was discontinued, the Physician reconciled medication and medications lists tiazepam 15 mg patient was noted to have increased pharmacist verified order. Night shift PO daily as a home medication. bleeding time. The patient recalled pharmacist questioned order on cart Admitting nurse entered in computer that Coumadin was given night check. Physician contacted, and order as diazepam 15 mg daily. Pharmacy prior. The physician was notified. changed to isosorbide mononitrate. took order off as diazepam 15 mg No other adverse effects [were noted]. Patient received one incorrect dose. PO daily morning meds given. The Pharmacy [was made] aware, and Medication information from a different patient was unsure if she was on medication was profiled but was not patient was used to populate the medica- Valium® (diazepam) or not. Nurse placed on hold as per medication tion reconciliation documentation and double-checked home medication list reconciliation sheet. used to order and profile medications and confirmed as home medication. in 12.5% (n = 5) of the events. In some The patient’s friend gave home list Facilities indicated that 8.9% (n = 8) of of medications provided at time of additional drug or dose events involved cases, the wrong patient’s list was for- warded by an outside facility from which admission. Medication was listed as Page 130 Pennsylvania Patient Safety Advisory Vol. 10, No. 4—December 2013 ©2013 Pennsylvania Patient Safety Authority tiazepam. When asked if that was and accuracy of a patient’s current medi- Standardized Process for the correct medication, the patient cation history can reduce the risk of medi- Obtaining and Communicating stated it was her sleeping pill, cation errors, including those described Complete and Accurate Restoril® (temazepam). in this article. Consider the strategies Medication History Confused drug names, or drug names described in this section, which are based — The collection of a complete, accu- with look-alike or sound-alike similarities, on a review of events reported to the rate, single medication list, to be contributed to at least 35.0% (n = 14) of Authority, observations from the Institute shared and used by all disciplines, the events. It should be noted that while for Safe Medication Practices, and recom- at admission or at an initial point the event reports do not specifically cite mendations in the literature. Also, a num- of entry into the system is a corner- look-alike or sound-alike names as con- ber of organizations have made tools and stone of any successful reconciliation tributing factors, analysts identified that resources available to healthcare facilities process.13 Complete documentation some of the drug name pairs involved to aid in the successful implementation of all patient medications taken at have a long, documented history of confu- of medication reconciliation. A selec- the time of admission, including the sion and mix-ups.12 For example, insulin tion of these resources can be found in name of the drug, dose, frequency, products were involved in 42.9% (n = 6) “Resources to Aid in the Successful Imple- route, purpose of the medication, of these look-alike name errors. Specific mentation of Medication Reconciliation.” pairs involved in these events include HumuLIN 70/30 and HumuLIN N; HumaLOG Mix® 75/25 (insulin lispro RESOURCES TO AID IN THE SUCCESSFUL IMPLEMENTATION OF protamine and insulin lispro) and Humu- MEDICATION RECONCILIATION LIN 70/30; NovoLIN® N (insulin NPH) A key tenet in medication error preven- ISMP Canada provides information and NovoLOG® (insulin aspart); Huma- tion is to learn from other organizations and access to tools and resources LOG® (insulin lispro) and HumuLIN N; and facilities. Listed below are a num- for both healthcare facilities and HumuLIN 70/30 and HumaLOG; and ber of organizations that provide tools patients on their website at http:// Levemir and Lantus. Other examples of and resources to healthcare facilities to www.ismp-canada.org/medrec. drug name pairs involved in these events aid in the successful implementation of — Partnership for Patient Care. This include amitriptyline and nortriptyline; medication reconciliation. collaborative between the Health- isosorbide dinitrate and isosorbide mono- — Agency for Healthcare Research care Improvement Foundation, nitrate; NIFEedipine and niCARdipine; and Quality (AHRQ). AHRQ’s Independence Blue Cross, and and Zyrtec® (cetirizine) and Zyrtec-D® Clinical Handoffs (MATCH) Tool- ECRI Institute provides a report (cetirizine and pseudoephedrine). kit for Medication Reconciliation on the results and benefits of a provides a step-by-step guide to regional failure mode and effects improving the medication rec- analysis on medication reconcilia- RISK REDUCTION STRATEGIES onciliation process. See http:// tion. Access the report at https:// Medication reconciliation conducted at www.ahrq.gov/professionals/ www.ecri.org/Documents/Patient_ all care transitions, including temporary quality-patient-safety/patient- Safety_Center/PPC_Medication_ transfers to operating rooms or diagnostic safety-resources/resources/match/ Reconciliation.pdf. matchintro.html. testing areas, can improve patient safety. — World Health Organization Maintaining the most up-to-date patient — American Society of Health-System (WHO). WHO’s Assuring Medica- Pharmacists (ASHP). ASHP’s toolkit medication record remains a challenge, tion Accuracy at Transitions in Care includes examples of programs, Standard Operating Protocol, a particularly if an electronic patient medi- tools, and forms that have been cation record is not available. Healthcare component of the High 5s Project, implemented successfully in other facilities can strive to identify systems- provides information about medi- organizations. Access the tool cation reconciliation, including the based causes of the events associated with at http:// www.ashp.org/Import/ problem, strength of evidence that the medication reconciliation processes PRACTICEANDPOLICY/Practice supports the solution, and potential and implement effective risk reduction ResourceCenters/PatientSafety/ barriers and unintended conse- strategies to prevent harm to patients. ASHPMedicationReconciliation quences. See http://www.high5s. Toolkit_1.aspx. Standardizing the workflow processes org/bin/view/Main/WebHome. — Institute for Safe Medication Prac- involved in medication reconciliation and tices Canada (ISMP Canada). taking steps to improve the completeness Vol. 10, No. 4—December 2013 Pennsylvania Patient Safety Advisory Page 131 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S and last dose taken,14 is important including prescribers, nurses, and in the medication reconciliation for successful medication reconcilia- pharmacists, utilize and verify two process, as well as current workflow tion.15 To collect medication history, reliable patient identifiers to improve challenges. This can also assist in during the admission verification the accuracy of patient identification planning for changes in medication process, consider using a standard- during medication reconciliation.17 reconciliation procedures, especially ized form (either electronic or Verify the patient identity recorded the development of electronic pro- paper-based) that includes a scripted on documentation sent from outside cesses. Consider enlisting the support list of questions or prompts for the facilities is a correct match to the of the pharmacy and therapeutics patient or the caregiver. Include a patient being treated. committee and medical executive checklist on the form to ensure that — Consider minimizing, excluding committee in assisting prescribers the practitioner asks the patient emergent situations, the writing to accept their responsibility for the about prescription and over-the- or entry into electronic prescrib- performance of medication reconcili- counter medications, vitamins, and ing systems of admission orders by ation in all types of care areas. True dietary or herbal supplements that prescribers until a complete and reconciliation includes the prescriber the patient may be taking. Design accurate medication history has making a clinical judgment as to the checklist to remind the practi- been compiled. This can help limit whether all medications on the list tioner to also ask the patient about potential conflicts throughout the should be continued at the time of non-oral and non-parenteral medica- admission should the patient’s admission or change in level of care, tions, including patches, inhalers, home medication and dose be deter- held until further evaluation or for topical products, eye drops, ear mined to be different than what was diagnostic testing, or discontinued. drops, depot injections, and drug- ordered upon admission. — Both pharmacists and pharmacy eluting implantable devices that may — Orders to hold a medication can technicians can play important roles not be readily identified by patients lead to errors.11 For example, in medication reconciliation as well. as medications. Reviewing the labels indications to hold orders may be The pharmacy staff can participate in of any prescription containers a missed by nursing or pharmacy collecting and confirming essential patient brings and discussing how staff, resulting in medications being patient information (e.g., allergies the medications are currently being administered when not intended and reactions, complete medication used can help improve the accu- by the prescriber. A safer practice is history) with patients directly. Also, racy of the information collected. for prescribers to discontinue the pharmacy staff can provide a valuable Including the patient’s community medication and then order the medi- independent double check of the pharmacy contact information on cation when it is to be started. reconciliation of medication orders the medication reconciliation form conducted when the patient’s level will enable pharmacist clarification Define Roles and Responsibilities of care changes (e.g., upon transfer, when needed, keeping in mind that — Clearly define the roles and responsi- postoperatively, prior to discharge). a patient may use more than one bilities of staff, including prescribers, pharmacy.15,16 nurses, and pharmacists, involved Address Design of Electronic — Stress to all staff, including prescrib- in the medication reconciliation Health Record Systems ers, nurses, and pharmacists, the process.13,18 Take steps to foster team- — According to the Institute of Medi- importance of following the stan- work among the disciplines. cine,20 interoperable medication dardized process to reduce the risk of — Physician and prescriber engagement data and provision of such data medication errors and patient harm. with patients and other practitioners electronically can facilitate medica- — Work to eliminate documentation of is important in ensuring a successful tion reconciliation. For facilities medication reconciliation informa- medication reconciliation process.19 currently using a paper-based system tion on multiple assessment tools Medication reconciliation is the for medication reconciliation, or a (e.g., history and physical forms, responsibility of all physicians and combination of both electronic and anesthesiologist’s notes, preproce- prescribers, regardless of specialty.19 paper-based systems,21 consider tran- dural assessment sheets).13 To foster physician and prescriber sitioning to the use of a completely — Standardize patient identifica- engagement, obtain their feedback electronic reconciliation process tion processes such that all staff, regarding expected responsibilities through an electronic health record Page 132 Pennsylvania Patient Safety Advisory Vol. 10, No. 4—December 2013 ©2013 Pennsylvania Patient Safety Authority (EHR) system. Ensure that the reconciliation and the important Measure Medication process includes a single electronic role they play in the process.13 Reconciliation Processes listing for all practitioners to utilize — Collecting a medication history is — Ensuring that the medication rec- and eliminates documentation on often dependent on patient recall. onciliation process is successful multiple assessment tools.13 Include When a patient is on five or more and results in clinically meaningful all elements of a complete medica- medications, the likelihood of accu- outcomes requires the develop- tion order (e.g., drug, dose, strength, rate recall of a medication name, ment and use of specific metrics.18 frequency), and designate these as strength, dose, frequency, route of For example, facilities can develop mandatory data entry fields. Explore administration, and indication drops specific process measures (e.g., total options to provide physicians with significantly.5,23 Provide electronic number of admission reconciliations the ability to utilize an electronic list access to a blank copy of the medi- completed and documented within a of current medications for discharge cal center’s admission medication designated time frame over the total reconciliation procedures, as well as reconciliation form or a wallet number of admissions [new patients] the ability to automatically populate card to assist patients in provid- in 24 hours) to monitor the success a patient discharge instruction sheet ing a complete medication history. of medication reconciliation. It is once the reconciliation process is Alternatively, provide a link to the also important to identify any near- complete. Require periodic testing universal medication form avail- miss events (and actual events) from and assessment of the EHR system able from the Authority’s website at the voluntary reporting program or and medication reconciliation appli- http://patientsafetyauthority.org/ other sources that can be prevented cation to identify and address any NewsAndInformation/Brochures/ by an effective medication reconcili- performance or safety issues. Documents/Universal%20 ation process. Use this information — EHR systems that are integrated with Medication%20Form.pdf. to educate professional staff on the computer systems in outpatient clin- — Encourage practitioners to involve safety importance of implementing a ics and physician office practices can patients when prescribing new successful reconciliation program. provide prescribers and other health- medication orders and prior to care practitioners the opportunity medication administration. A simple CONCLUSION to view the medications a patient statement like “Mr. Jones, I am Completing accurate medication rec- was prescribed upon discharge. This going to give you your home blood onciliation is important to ensure safe can better enable the practitioner to pressure medications, lisinopril and and effective medication use. Having a perform medication reconciliation in Norvasc” or “Mrs. Jones, why do complete medication history allows clini- the outpatient setting by comparing you take lisinopril?” during admin- cians to compare it with the patient’s what the patient is taking at the time istration may help to identify any current and newly ordered medications of the office visit with what was pre- discrepancies that were missed and to identify discrepancies and minimize scribed upon discharge.20 minimize the potential for medica- potential adverse drug events. However, — Design discharge instructions to tion error. breakdowns in the admission, transfer, or clearly display the drug name, dose, — Involve patients by planning for and discharge medication reconciliation do and administration instructions.10 implementing an aggressive public occur and introduce potential risk to the For example, for insulin products, education campaign specifically patient. Implementing strategies to limit make sure the wording is congru- designed around medication safety these breakdowns and increase the accu- ent with how medications will be and medication reconciliation.18 racy of the medication histories obtained administered (e.g., 10 units) rather Healthcare facilities may consider and reconciled can help foster smooth than how they are supplied (e.g., advertising initiatives through and safe transitions from one level of care 100 units/mL).22 articles in the local newspaper, speak- to the next. ers at community forums, and the Encourage Patient and organization’s community outreach Caregiver Involvement programs. — Educate patients and their families or caregivers on medication Vol. 10, No. 4—December 2013 Pennsylvania Patient Safety Advisory Page 133 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S NOTES 1. The Joint Commission. Using http://www.ismp.org/Tools/ 17. Yang A, Grissinger M. Wrong-patient medication reconciliation to prevent institutionalhighAlert.asp medication errors: an analysis of event errors. Sentinel Event Alert 2006 Jan 23; 10. Medication errors with the dosing reports in Pennsylvania and strategies (35):1-4. of insulin: problems across the for prevention. Pa Patient Saf Advis 2. Institute for Safe Medication Practices. continuum. Pa Patient Saf Advis [online] 2013 Jun [cited 2013 Oct 23]. 2011 ISMP medication safety self [online] 2010 Mar [cited 2013 Nov 13]. http://patientsafetyauthority.org/ assessment® for hospitals [online]. 2011 http://www.patientsafetyauthority.org/ ADVISORIES/AdvisoryLibrary/2013/ [cited 2013 Sep 20]. http://www.ismp. ADVISORIES/AdvisoryLibrary/2010/ Jun;10(2)/Pages/41.aspx org/selfassessments/Hospital/2011 Mar7(1)/Pages/09.aspx 18. Greenwald JL, Halasyamani L, Greene 3. ASHP statement on the pharmacist’s 11. Hold on to these orders. PA PSRS J, et al. Making inpatient medication role in medication reconciliation. Patient Saf Advis [online] 2006 reconciliation patient centered, Am J Health Syst Pharm 2013 Mar 1; Mar [cited 2013 Jul 17]. http:// clinically relevant and implementable: a 70(5):453-6. patientsafetyauthority.org/ consensus statement on key principles 4. Kwan JL, Lo L, Sampson M, et al. ADVISORIES/AdvisoryLibrary/2006/ and necessary first steps. J Hosp Med Medication reconciliation during Mar3(1)/Pages/33.aspx 2010 Oct;5(8):477-85. transitions of care as a patient safety 12. Medication errors linked to drug name 19. Schwartzberg J, Sokol P, Toepp M. strategy: a systematic review. Ann Intern confusion. PA PSRS Patient Saf Advis The physician’s role in medication Med 2013 Mar 5;158(5 Pt 2):397-403. [online] 2004 Dec [cited 2013 Jul 18]. reconciliation: issues, strategies, and safety 5. Shepherd G, Schwartz RB. Frequency http://patientsafetyauthority.org/ principles. Chicago: American Medical of incomplete medication histories ADVISORIES/AdvisoryLibrary/2004/ Association; 2007. obtained at triage. Am J Health Syst dec1(4)/Pages/07.aspx 20. Institute of Medicine. Preventing Pharm 2009 Jan 1;66(1):65-9. 13. Agency for Healthcare Research and medication errors: quality chasm series. 6. Rogers S, Wilson D, Wan S, et al. Quality. Medications at transitions and Washington (DC): National Academy Medication-related admissions in older clinical handoffs (MATCH) toolkit Press; 2006. people: a cross-sectional, observational for medication reconciliation [online]. 21. Sparnon E. Spotlight on electronic study. Drugs Aging 2009;26(11):951-61. 2012 Aug [cited 2013 Sep 20]. http:// health record errors: paper or electronic 7. National Coordinating Council for www.ahrq.gov/professionals/quality- hybrid workflows. Pa Patient Saf Advis Medication Error Reporting and patient-safety/patient-safety-resources/ [online] 2013 Jun [cited 2013 Nov 20]. Prevention. NCC MERP index for resources/match/matchintro.html http://patientsafetyauthority.org/ categorizing medication errors [online]. 14. Cohen MR. Preventing prescribing ADVISORIES/AdvisoryLibrary/2013/ 2001 Feb [cited 2013 Jun 10]. http:// errors. Chapter 9. In Cohen MR, ed. Jun;10(2)/Pages/55.aspx www.nccmerp.org/medErrorCatIndex. Medication Errors. 2nd ed. Washington 22. Institute for Safe Medication Practices. html (DC): American Pharmacists Insulin concentrations rarely needed 8. Institute for Safe Medication Practices. Association; 2007:186. on orders. ISMP Med Saf Alert Acute Results of the ISMP survey on high- 15. Gleason KM, Groszek JM, Sullivan C, Care 2012 Nov 29;18(24):1-2. alert medications: differences between et al. Reconciliation of discrepancies 23. Vilke GM, Marino A, Iskander J, nursing, pharmacy, and risk/quality/ in medication histories and admission et al. Emergency department patient safety perspectives [online]. ISMP Med orders of newly hospitalized patients. knowledge of medications. J Emerg Med Saf Alert Acute Care 2012 Feb 9 [cited Am J Health Syst Pharm 2004 Aug 2000 Nov;19(4):327-30. 2013 Jul 15]. http://www.ismp.org/ 15;61(16):1689-95. Newsletters/acutecare/showarticle. 16. Horn D, Gaunt MJ, Vaida AJ. asp?id=15 Medication reconciliation: a survey of 9. Institute for Safe Medication Practices. community pharmacies and emergency ISMP’s list of high-alert medications departments. Patient Saf Qual Healthc [online]. 2012 [cited 2013 Jul 15]. 2010 May-Jun;7(3):18-23. Page 134 Pennsylvania Patient Safety Advisory Vol. 10, No. 4—December 2013 ©2013 Pennsylvania Patient Safety Authority LEARNING OBJECTIVES SELF-ASSESSMENT QUESTIONS — Recognize the most frequently The following questions about this article may be useful for internal education and reported event types involved in assessment. You may use the following examples or come up with your own questions. breakdowns of the medication recon- 1. Which of the following was the most frequently reported type of event associated ciliation process. with breakdowns in the medication reconciliation process? — Identify causes and factors contribut- a. Additional drug or dose ing to breakdowns of the medication b. Drug omission reconciliation process. c. Wrong dose — Distinguish between effective and d. Wrong drug ineffective strategies to reduce the e. Wrong patient risk of errors occurring during the 2. An omitted or missed dose may contribute to therapeutic failure and deterioration medication reconciliation process. of the patient’s condition. Which of the following was a leading factor in drug omissions related to medication reconciliation? a. The medication reconciliation documentation was not communicated or transmitted to the pharmacy department. b. Breakdowns occurred when patients were transferred between units within a hospital. c. Prescribers indicated on medication reconciliation forms to “hold” doses of medications. d. A medication list for a different patient was used during medication reconciliation. e. The accuracy of information used during medication reconciliation was questionable. 3. Strategies to standardize the workflow processes involved in medication reconcilia- tion and improve the completeness and accuracy of a patient’s medication history include all of the following except: a. Design the checklist to remind the practitioner to also ask the patient about non-oral and non-parenteral medications. b. Assign responsibility to nursing and pharmacy for the medication reconcilia- tion process. c. Standardize patient identification processes such that all staff, including prescribers, nurses, and pharmacists, use and verify two reliable patient identifiers. d. Enlist the support of the pharmacy and therapeutics committee and medical executive committee in assisting prescribers to accept their responsibility for the performance of medication reconciliation in all types of care areas. e. Work to eliminate documentation of medication reconciliation information on multiple assessment tools. Question 4 refers to the following case: A patient with confusion was transported to the emergency department from a personal care facil- ity. Two medication lists were sent with the patient—one for the patient and one for a different patient at the facility. When medication reconciliation was completed, the two patients’ medica- tion lists were combined to compile a single medication list for admission. The physician reviewed the compiled list and ordered medications based on the list. As a result, the patient received multiple doses of the following medications from the other patient’s list during the admission: zolpidem, QUEtiapine, citalopram, gabapentin, oxyCODONE, and ALPRAZolam. During the admission, the patient was noted to be progressively more lethargic. The rapid response team was called. The patient was treated and remained on the unit. Later in the admission, following Vol. 10, No. 4—December 2013 Pennsylvania Patient Safety Advisory Page 135 ©2013 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S SELF-ASSESSMENT QUESTIONS (CONTINUED) a procedure, the patient was transferred to the intensive care unit due to inability to fully wake up following sedation. Medications were adjusted. The remainder of the hospital course was uneventful. Upon preparation for discharge, information about the patient’s hospital stay and medications was communicated to the personal care facility. The facility questioned some of the medications and indications, revealing the medication errors that occurred upon admission. The patient was discharged back to facility in stable condition. 4. Which of the following is the appropriate strategy that would most directly prevent this event from reoccurring? a. Clearly define the roles and responsibilities of staff involved in the medication reconciliation process. b. Request pharmacy to confirm and verify essential patient information with the patient directly. c. Instruct nurses collecting medication history information during medication reconciliation to adhere to the “five rights.” d. Standardize the verification of the patient identity recorded on documentation sent from outside facilities in the medication reconciliation process. e. Stress to all staff, including prescribers, nurses, and pharmacists, the impor- tance of following the standardized process to reduce the risk of medication errors and patient harm. Question 5 refers to the following case: A patient was admitted to the general rehabilitation unit. The admission orders included an order for Lantus® (insulin glargine) 100 units daily and 100 units at bedtime. During acute care admission, the patient had been receiving 35 units daily and 25 units at bedtime. I spoke with admitting resident to change the Lantus dose back to previous dosing. Per the admitting resident, the patient’s discharge instructions stated dose as 100 units. Upon review of the discharge instruc- tions, the medication appears as follows: “Medication Name/Strength column: Insulin Glargine (Lantus) (Insulin Glargine 100 units/mL Subcutaneous Solution)” and the “How much do I take?” field is blank. 5. Which of the following strategies would be most effective in reducing the risk of this wrong-dose event? a. Design discharge instructions to clearly display the dose such that the wording is congruent with how the medication is to be administered rather than how it is supplied. b. Encourage practitioners to involve patients when prescribing new medication orders and prior to medication administration. c. Differentiate the names and package designs of insulin products to reduce look-alike and sound-alike confusion. d. Identify near-miss and actual events, and use them to educate staff on the importance of following the standardized medication reconciliation process. e. Develop standardized clinical guidelines on how to prescribe insulin. Page 136 Pennsylvania Patient Safety Advisory Vol. 10, No. 4—December 2013 ©2013 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 10, No. 4—December 2013. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2013 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (Mcare) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s An Independent Agency of the Commonwealth of Pennsylvania website at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for more than 40 years, ECRI Institute marries experience and indepen- dence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions. Scan this code with your mobile device’s QR reader to subscribe to receive the Advisory for free.