Evidence-Based Practice and the Procedural Education of Nurses
Medication reconciliation is a critical issue in healthcare reform. Today, improvement in this area of treatment could have a transformative effect on the current practices of nursing and medicine administration. The discussion, literature review and research tests that are conducted hereafter will outline the implications of medication reconciliation; justify the call for improvement in this treatment area; and offer support for the resultant recommendations using the Quality and Safety Education for Nurses (QSEN) template as a guide. The discussion will provide a background discussion on the three primary procedural steps by which medication reconciliation is defined: Verifying Medications by Collecting an Accurate Medication History; Clarifying Information by Ensuring Medications and Doses Are Appropriate, and; Reconciling and Documenting Change. Additionally, the discussion will offer a literature review as a means of providing some comprehensive knowledge of current practices in the field. Subsequently, a research observation conducted in the context of a specifically designated treatment facility will be assessed both in pre-test and post-test analyses. The pre-test analysis will demonstrate that evidence-based practice changes will be needed in order to transform the current educational and procedural standards within the designated facility. The post-test will indicate that creative teaching techniques (power-point, lecture, notes, lecture, feedback) are paramount to bridging the gap between current practice and proper medication reconciliation.
Medication error is among the leading causes of preventable illness, health crisis or fatality within the treatment context. Significant evidence is available to illustrate that the prevalence of medication errors relating to overlooked contraindications, dosage mistakes and a failure to document patient history can lead to tragic and costly healthcare incidences. This denotes a direct correlation between effective procedural control over the prescription, administration and monitoring of medication usage and the protection of a healthcare facility against preventable illness or fatality and the resulting legal consequences of these occurrences.
As this relates to the present study, this suggests the existing demand for improvements in the consistency and appropriateness of medication administration. This process is referred to as medication reconciliation, a concept which drives the discussion and research hereafter. Medication reconciliation is the process by which a patient's full medical and medication histories are evaluated at different points of transfer in the treatment sequence with the intent of eliminating possible medication errors that can lead to negative health consequences. Today, with the field's collective understanding of drug-treatment strategies always improving, there is a need to ensure that incoming generations of nursing professional are adequately educated in the area of medication reconciliation. Thus, a focus of the research hereafter will be the education of Associate and Bachelor Degree-holding nurses in the current best practices of medication reconciliation.
The discussion will examine this subject with an endorsement of improved focus on medication reconciliation, first providing an actionable definition of medication reconciliation based on the three primary steps to its effective implementation; second providing a comprehensive literature review on the subject; and third conducting an observational study of a selected healthcare facility, the Southeastern Acute Healthcare facility (SEAHC), as a way of evaluating the need for effectively streamlined medication reconciliation and consequently, as a blueprint for educating degree-holding nurses. Research imperatives are informed by the Quality and Safety Education for Nurses (QSEN) web portal, funded by the Robert Wood Johnson Foundation. Specifically, educational imperatives for incoming nursing professionals are informed by QSEN's Essentials of Baccalaureate Education for the Nurse Practice Education, which the American Academy of Nursing Practice (AANC, 2008, 2009) endorsed. The recommendations detail the quality and importance of patient safety outcomes. An additional source of importance will be Patient Safety and Quality: An Evidence-Based Handbook for Nurses (2008), which provides a delineation of optimal medication reconciliation in a nurse education context.
In 2011, after evaluating medication errors, The Southeastern Acute Healthcare facility identified reconciling medications as a pressing issue. According to (Hayes, Donovan, Smith, & Hartman (2007), approximately 60% of all medical errors occur as a result of inconsistencies either when patients are admitted, transferred between units for assigned for discharge. (p. 1,720). The Institute of Medicine (IOM) goes on to estimate that these inconsistencies are the cause of roughly 1.5 million preventable 'adverse drug effects (ADEs)' in the United States per annum." (Young, 2008, p. 332). This amounts to a troubling average of one medication error per every patient admitted in that same space of teime. The Joint Commission on National Patient Safety Goal is to precisely and absolutely reconcile (merge) how medications are dispensed across the continuum of care (Conley, Love, Kelly, & Bartko, 1999; Ptasinski, 2007; Thompson, 2005). The ultimate goal is to reduce the number of ADEs that occur when responsibility for a patient changes. The present study is intended to produce findings that can be used to improve education of associate and bachelor degree-holding nursing students in the area of medication reconciliation. The hope is that this would help to contribute to a reduction in the number of ADEs occurring among licensed nursing professionals.
The present study is further rationalized by evolving mandates relating to the need for improved medication reconciliation. To this end, the Joint Commission (JC) mandated medication reconciliation as an integral part of patient care in 2006. This is also consistent with the imperatives dictated by the QSEN/AACN doctrine, which among its Essentials of nursing education, indicates that the assurance of safety is of the utmost importance. Further, Essentials dictates the need for nursing professionals to be apprised during the process of their educational development of the complexity of modern healthcare systems with a specific focus on areas such as the transmission of data, the communication of treatment implications and modes of interaction with the populations, communities, families and patients treated. The QSEN/AACN doctrine therefore denotes that it is incumbent upon nurse educators to incorporate these imperatives into education on medication reconciliation. Further, this demonstrates the interconnectivity between education on medication reconciliation and the improvement of patient safety, suggesting that the aim of the present study -- to provide a research-basis for improved nursing education in this area -- could be successful in helping to reduce the frequency of ADEs in the general healthcare context.
Validation of this rationale will be sought through a case study involving the Southeastern Acute Healthcare facility (SEAHC). The purpose of this study is to introduce a quality improvement project to enhance medication reconciliation education among aspiring nursing professionals already holding associate or bachelor's degrees in nursing. The Southeastern Acute Healthcare facility has been selected because it is currently implementing a new power-chart for documenting all medication records. Medication reconciliation forms for each phase of transition have been developed at the state and federal level. To help the Southeastern Acute Healthcare facility (SEAHC) in developing and evaluating its new medication reconciliation education strategy, the discussion here will provide a literature review on medication reconciliation and, subsequently, a pre and post-test analysis of SEAHC's navigation of this important treatment area.
During the processes to uncover relevant articles on medication reconciliation, the researcher searched for articles relevant to the effects of medication discrepancies, reconciliation, adverse events, communication as a process, and patients' knowledge of their medications. The researcher used the MEDLINE (2005-2012), PubMed (2005-2012), and CINHL (2005-2012) to conduct the literature review. No language restrictions were applied. Search terms included medication reconciliation, medication errors, prescribing error, medication systems, adverse drug events, drug utilization review, medication list, medication record, and medications management.
Defining Medication Reconciliation:
Before proceeding to a more extensive literature review or a report on the observations made at SEAHC, it is appropriate to define Medication Reconciliation. The Institute for Healthcare Improvement, (IHI) (2006) defines medication reconciliation as a formal process of collecting and maintaining a complete and accurate list of a patient's current medications and comparing that list to the physician's orders at admission, transfer, or discharge. Vira, Colquhoun, and Etchells (2006) stated that while there are variances in pharmaceutical administration that are appropriate when guided by practitioners but that a great many variances are instead the result of poorly streamlined or regulated processes. These are considered medication errors and can have a range of serious consequences. (p. 122). And because hospitals so frequently must work to overcome poor nurse to patient ratios, problematic labor distribution and long working hours, medication error becomes a greater risk without medication reconciliation strategies in place.
For the purposes of the present research, the process of reconciliation (resolving issues related to medication lists and communication) involves a three-step process: (a) verifying medications by collecting an accurate medication history; (b) clarifying information by ensuring medications and doses are appropriate; and (c) reconciling and documenting every change (Institute for Healthcare Improvement 2006; Young, 2008). The three-step process is designed to avoid the most common types of errors, including inadvertently omitting home medications during hospital stay, failing to resume home medications at discharge, duplicating therapy, and inaccurate dosages. All such errors are known as a medication error event (Young, 2008; IHI, 2006). Fitzgerald (2009) classified medication errors…