Medication Reconciliation Evidence-Based Practice and the Procedural

Medication Reconciliation

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.

Introduction:

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.

Rationale:

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.

Literature Review:

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 as "omission errors (drugs missed from the history), commission errors (drugs added to the history), frequency errors, and dose errors" (p. 672).

Verifying Medications by Collecting an Accurate Medication History:

As the subsequent discussion will demonstrate, a great many medication errors can be eliminated at the outset by taking the proper steps to gather information at the time of admission. It is at this first step in the healthcare process that the absence of a streamlined and consistent medication reconciliation process can result in errors that may follow the patient problematically throughout his or her treatment experience. Accordingly, time and labor limitations in emergency room and other clinical contexts can lead to errors resulting from inaccurately gathered drug histories, deficits in communication between medical professionals, illegible handwriting, and lack of access to prior medical histories. FitzGerald (2009) identified that the simplicity of using terminology of "medicines or medications rather that drugs, which may be mistaken for drugs of abuse" (2009, p. 672) might have a bearing on the elicited response from the patient. FitzGerald (2009) stated that the way a patient is asked about medications will affect his or her response. For example, an 85-year-old woman may not respond with full understanding to inquiries regarding "drugs," but may be more informative when asked about prescribed "medications." In keeping with such terminology, it is necessary to ask what herbal remedies, over-the-counter medications, vitamins, and ointments the patient uses at home, and whether he or she uses any custom remedies. Kripalani, LeFevre, Phillips, Williams, Basaviah, and Baker (2007) found that deficits in communication between the hospital and the physician often lead to medication information not reaching the primary care setting.

Therefore, researchers find that this first step of admission should include an extensive consultation of existing records and of the patient's firsthand account where possible. This process is not inherently a straightforward one however, with the Evidence-Based Handbook For Nurses (2008) indicating that a number of inherent complexities must be navigated in order to create a gathered patient medication history that is effective, usable and optimized to maintain accuracy as it moves through the healthcare system. Accordingly, the handbook reports that a wide range of variables will enter into the process of gathering this medication history and that, consequently, there is a great need for comprehensive education among nurses on how to control these variables. (Barnsteiner, p. 1)

The Handbook goes on to observe that the three intersecting disciplines of medicine, pharmacy and nursing will have their own specific procedural ways of handling medication reconciliation. As a result, it is also incumbent upon the field of nurse education to provide nurses not just with a full undertanding of the procedures and roles fulfilled by registered nurses where medication reconciliation is concerned but also with an understanding of how to navigating the sometimes divergent or inconsistent procedures and roles fulfilled by pharmaceutical and medical counterparts. (Barnsteiner, p. 1) Also of consequence during this first step is a fuller understanding among nurse professionals of how to navigate and eliminate the duplication of data. Because physicians, pharmacists and nurses will often interact with the patient using their respective procedural orientations, it is possible to multiple patient histories may emerge and, with them, discrepancies in medication history. These discrepancies can in turn lead to uncertainty and drug-treatment errors. (Barnsteiner, p. 1)

This denotes that in the education of prospective nurses holding associate or bachelor's degrees, proper instruction must be given on how to conduct evidence-based gathering of data and cross-comparison with the data of colleagues.

Clarifying Information by Ensuring Medications and Doses Are Appropriate

In an effective medication reconciliation context, it is important not simply to gather data on a patient's medication history but also to evaluate it with nuance and care. The second step that is emphasized here is that of information clarification, wherein nurses encountering patient medical histories and records must subject them to assessment relative to the patient's current condition. Here, communication between parties involved in patient care becomes the most critical necessity and one which must drive nursing education on medication reconciliation. Particularly, effective communication between parties offers practitioners the opportunity to collaborate when reflecting on dosage, administration schedule and medication type.

Accordingly, Wortman (2008) noted, "Effective communication tools are essential components of the medication reconciliation process" (p. 2,047); so indeed, communication plays a broad role in numerous healthcare professions. When we consider the range of sensitive and demanding professions in the medical field, the importance of effective communication amplifies, because medical professionals are dealing with far more complex and sensitive aspects within the human domain of life than many other professions. Communication among medical professionals (e.g., doctors, nurse practitioners, nurses, and auxiliary staff) and patients is vital at every point of transition during the healthcare treatment process, from admission to triage to examination to treatment and ultimately to discharge. (Daugherty, et. al. 2008, p. 489; Walraven, et. al, 2004, p. 628-629).

These points of transition are particularly of concern as these are often the sites of garbled communications and transmitted errors. Accordingly, Bayoumi, Howard, Holbrook, and Schabort's (2009) study aimed to review all primary care intervention studies intended to implement medication reconciliation. Their aim was to define a way to reduce "inaccurate medication profiles" (p. 1,667). In searching for studies to include in their review, the authors applied no language restrictions. Search terms included medication reconciliation, medication errors, prescribing error, medication systems, adverse drug events, drug utilization review, medication list, medication record, and medications management.

During the interventions to improve medication reconciliation in primary care, the author searched for articles relevant to the effects on medication discrepancies, clinical outcomes, and patient knowledge of their medications. Randomized controlled trials or before-and-after studies that examined the effect of various interventions on medication discrepancies in either ambulatory settings or at hospital discharge among community-dwelling adults were included. Four trials met the criteria to be included. The two before-and-after studies (n = 275) in ambulatory care that examined systematic medication reconciliation at each visit produced conflicting results. One study showed a reduced the proportion of medication discrepancies from 88.5% to 49.1% (OR 0.13; 95% CI 0.07 to 0.21), whereas the other showed no benefit. In addition, one randomized controlled trial and one before-and-after study (n = 202) evaluated pharmacists' medication reviews at hospital discharge; unfortunately, neither study showed any benefit. Heterogeneity precluded pooling the studies, and all studies had significant design flaws.

Two reviewers independently assessed studies to determine whether the studies should be included. The level of agreement between the reviewers was good, with an unweighted Cohen's kappa of 0.71. Two of three independent reviewers abstracted data and evaluated validity from included studies, and consensus was used to resolve disagreements between the reviewers. According to the authors' conclusions, "[t]he best possible medication profile in both studies was the medication list obtained from patients by study personnel who contacted the patient after the appointment (by phone in Nassaralla et al. And either by phone (14.4%), email (57.7%), or direct review of medication bottles [27.9%] in Varkey et al.)" (p. 1,670). Bayoumi et al. (2009) concluded that the…improved accuracy of medication lists alone are unlikely to reduce medication-related adverse events or to improve the patient's clinical status, without a process of expert review of the patient's medication profile, undertaken in a critical evidence-based fashion, with the discontinuation of potentially harmful and unnecessary therapies and addition of potentially beneficial medications (p. 1,673).

It is this expert review of the patient's medication profile which must be instructed in the nurse education context with foci on: improving the base knowledge required to conduct this expert review; communicating effectively with other parties such as physicians and pharmacists who will also participate in an expert review at some point in the process; and perhaps most importantly, communicating effectively with patients in order to clarify and confirm information as well as to consult on whether certain historical medication decisions might be subject to alteration or reversal in light of expert review findings. As this relates to the list of priorities identified in the QSEN/AACN document, Essentials, two major imperatives of the nursing baccalaureate program are invoked. The present section on clarifying the patient's medication history echoes the communication imperative cited by the AACN, which calls for nurses to extend communication efforts to all members of a healthcare team both within the provider community and in the patient's personal support system. (p. 32) Likewise, the present section echoes the call for nurses to use evidence-based interventions as a way of pursuing positive long-term health outcomes and lengthening the life span for patients. (p. 32) In both regards, the imperatives identified by the AACN in conjunction with QSEN serve to reinforce the stated imperative to employ such strategies in implementing medication reconciliation. This, in turn, underscores the areas of emphasis required for the education of degree-holding nurses in order to effectively serve this step in the medication reconciliation process.

Reconciling and Documenting Change:

Beyond arming nursing students with the ability to navigate the processes of patient transition through clarification, communication and expert review, it is also incumbent upon an effective nurse education curriculum to arm nursing students with the instruments and knowledge to reconcile and document changes in the medication approach and treatment strategy. Here, an emphasis on the patient's experience upon discharge becomes critical, with the importance of self-administration of medication following treatment and of maintenance of records within the healthcare facility for future visits both requiring a final reconciliation and documentation of any changes made during the patient's stay. It is thus that the following section contains a review of literature on the strategies for medication reconciliation upon patient discharge.

Within this context, researchers note, at the time of discharge, the medication list is reviewed with the patient. Notably, doctors and paramedic staff in many contexts seem well versed with the responsibilities of communicating proper discharge medication information to the patient (Walraven, et. al, 2004, p. 627). Debate has emerged, however, regarding the discharge process and the role played by nurses there within. Doctors discharge patients from hospitals, but it is the discharging nurse that provides the patient with reams of documentation that may or may not include a medication list with the patient's name, all the medications' names (trade and generic), correct doses, administration route, time to be taken, and instructions for future medical appointments (Georgia Board of Nursing, 2011). Ideally, such a list should include the five "rights of medication," which the electronic medical record, (EMR) has the capacity to develop, that will provide the patient with the necessary information he or she needs when discharged from a facility.

It is particularly important at this juncture that proper and consistent information has not only been provided to the patient but that recognition of any changes in self-administered healthcare strategy have also been delineated. This is because the discharging patient carries the sole responsibility of administering medications to him- or herself without the guidance of a trained medical professional. Without properly learning the five rights of medications, however, patients are at risk of medication errors, which can worsen their condition, lead to hospital recidivism, and can be fatal at times (Vira, Colquhoun, & Etchells, 2006). Therefore, it is imperative to provide complete and accurate instructions about each medication to the patient at the time of discharge, and it is equally imperative to provide this medication list to the next care provider with all changes during the most recent treatment encounter being fully and clearly documented for review.

This is a particularly important area in which to improve the assumption of responsibilities amongst nursing professionals at the time of discharge. By using the channels of nursing education to foster the prioritization of this final documentation of change in conjunction with the provision of discharge instructions, literature suggests the opportunity to yield future nurses with a far greater appreciation for the role of medication reconciliation especially for those leaving inpatient care settings. To the point, the obstacle of communicating effectively with the discharging patient is often related to the absence of a clear or streamlined medication reconciliation process. For instance, the failure to list all pharmaceuticals that are prescribed and those purchased over-the-counter creates the potential for an adverse drug-to-drug interaction. Even topical ointments, vitamins, herbal remedies, custom regiments, and as-needed medications should be listed on the discharge medication form (Greenwald, et al., 2010; Thompson, 2005; Young, 2008). The patient should receive both verbal and written instructions to provide the medication list to all healthcare providers.

According to the Joint Commission, discharge summaries are mandated, but such summaries may lay dormant for 30 days until they are completed. Another shortcoming is missing data on discharge summaries, a patient not knowing when and where to follow up on diagnostic testing, and the legibility of patient instructions (Kripalani, et al., 2007). This demonstrates that there is a clear connection between the patient's need for effective instruction upon discharge and the proficiency with which final documentation and reconciliation of medication and/or treatment changes occurs. Education for nurses holding associates or bachelor degrees should accordingly emphasize the role that better coordination between these two priorities can play in reducing ADEs, particularly by easing the process of initiation in the next instance that a patient is admitted for medical care.

This also echoes the call, in the QSEN/AACN document, for a more comprehensive and holistic approach to patient treatment. The baccalaureate program imperatives call for a treatment strategy that recognizes the healthcare continuum. (p. 32) This continuum notes that every nurse has a responsibility to a patient not just within the contextualizing healthcare facility but, beyond this, within the whole healthcare system. The information that is reconciled and documented, as well as the information that is provided to the patient at discharge, will be employed by subsequent healthcare providers all assisting toward the same goal of optimizing the patient's life-span.

Pre-Test Analysis:

The literature review above provides a strong endorsement for the use of medication reconciliation in this three step process as a way of improving the health outcomes at a selected healthcare facility. The Southeastern Acute Healthcare facility (SEAHC) will serve in this capacity. The present study compares and evaluates three recommended patient medication discharge forms used in southeastern states to the Department of Health and Human Services Food and Drug Administration Form 3664 (FDA Form 3664). The intent is to develop suggestions on developing a patient-centered medication list, which the patient receives at the time of discharge. Consequently, these suggestions will inform curriculum for incoming nursing education students.

The focus on the process of discharging, largely outlined in the third step of medication reconciliation delineated in the literature review, is intended to narrow the focus of the present study as a way of controlling variables. All data from FDA Form 3664 will be compared to the other accepted patient-centered discharge medication lists used in southeastern region. The states recognized as "southeastern" include Alabama, Georgia, Florida, Mississippi, North Carolina, South Carolina, and Tennessee. Of these, Alabama, South Carolina, and Tennessee have adopted the "Universal Medication Form." Identifying the variations and similarities between FDA Form 3664 and three southeastern accepted patient-centered discharge medication list will provide a template to survey the local Advance Register Nurse Associations, as well as the nurses employed by the SEAHC in the assigned region. This effort will help validate the pertinent information that should potentially be included as the SEAHC facilities are planned and as the discharge medication list is developed. This effort will provide evidence of the importance of effective communication as an ultimate parameter that bolsters patient safety and satisfaction.

Therefore, the chosen methodology for examination of this facility is a case study informed by the evidence-based and Plan Do Study Act conceptual models of medication reconciliation.

The idea of using a conceptual model for medical reconciliation provides a logical, cohesive, and systematic way to envision related procedures relevant to the art of nursing science (Fawcett, 2005). Two views of quality in the healthcare sector have emerged: One view purports that quality has a negative relationship with efficiency, whereas the other claims just the opposite -- similar to the competing traditional view and Deming's (year) view. For example, zero defects and the safety of various processes are highly sought after in the healthcare sector; indeed, much like any other business, firm quality is an important concern. Such quality attains even more importance because a human being is directly part of the procedure (Thompson, 2005). An evidence-based conceptual model called Plan Do Study Act developed by W. Edwards Deming, provides a framework for developing a new practice policy in implementing a new medication discharge form.

The phenomenon being investigated, medication reconciliation across the three phases delineated by the literature review, provides the first structure for the present research in the planning phase. The planning phase provides for the progress and analysis of interventions. The Plan Do Study Act conceptual model allows modifications for either improving or maintaining productivity. It also reveals shortcomings and considers costs and potential side effects and identifies areas of resistance.

Phase one of Plan Do Study Act, the Deaming model (year), is to establish an objective (Moen & Norman, 2010). This includes questioning current processes and making predictions. Then, the next step is to develop a plan to carry out the remainder of the four-step cycle.

During the planning phase, a preliminary observation of the current medication reconciliation process at the SEAHC facility was conducted to understand the process. Twenty-five observations were made during the admission, transition, discharge, and initial follow-up appointment.

In this phase, the assessment encompasses an evaluation of the current recommended FDA Form 3664 to the other three southeastern state medication discharge forms. Phase two of the Plan Do Study Act is the "doing" phase (Moen & Norman, 2010). During this phase, is the active process of carrying research plan. Problems encountered will be documented and unexpected observations or findings will be noted. As the final activity of the "do" stage, analysis of the data will begin. The "do" phase will test the importance of the items listed on the FDA Form 3446 to the other southeastern state medication discharge forms to develop a process improvement survey tool. This tool will be used to identify the level of importance of the various items listed on the FDA Form 3664 and on the 3 other southeastern state medication discharge forms.