Abstract

Keywords: Medication reconciliation, medication errors, Joint Commission, participatory medicine.
Citation: Greene A, Greene J. Medication errors result from current medication reconciliation practices: it’s time to adopt participatory reconciliation. J Participat Med. 2012 May 7; 4:e11.
Published: May 7, 2012.
Competing Interests: The authors have declared that no competing interests exist.
 

This editorial was prompted by the recent hospitalization of one of the authors for major surgery. For the most part he received superlative care by a capable team working in an outstanding institution following state-of-the-art practices. Nevertheless, the medication reconciliation procedures, though consistent with the Joint Commission recommendations, created an alarming systemic failure to recognize and prevent medication errors.

Medication errors are perhaps the most common patient safety errors.[1]

The problem is widespread during and after hospitalization. The Institute of Medicine found that the average patient is subject to at least one medication error per day while in the hospital.[2] With about 190 million inpatient days in acute care hospitals per year in the US,[3] the financial and health toll of inpatient medication errors and the adverse events caused by them is considerable.

The Joint Commission chose medication reconciliation as a key National Patient Safety Goal to ameliorate this problem:[4]

Medication reconciliation is the process of comparing a patient’s medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions in care include changes in setting, service, practitioner, or level of care. This process comprises five steps: (1) develop a list of current medications; (2) develop a list of medications to be prescribed; (3) compare the medications on the two lists; (4) make clinical decisions based on the comparison; and (5) communicate the new list to appropriate caregivers and to the patient.[5]

When coming to the hospital for his recent surgery, the author brought a list of the medicines he had been taking at home, their dosing, and the bottles themselves. In the post-operative period, when the nurses administered medications they were quick to explain what medicines he was getting at any point in time, but neither the nurses nor the parade of providers who came through could answer why the doses he was getting seemed different than his home doses. Were they switched because of the surgery? Or was this an error?

More worrying, as the days of recovery progressed, the patient began to sense that something was missing from his complex medication regimen. He asked to see a list of all his medications, but at first was only given the names of medications administered as they were being given. The authors did obtain a current medication list, but no longer had the original list for comparison. Eventually, the patient noticed what was missing: an important cardiac medication he had been taking for years had failed to make it into the new orders.

Medication Reconciliation was part of the Institute for Healthcare Improvement’s 5 Million Lives Campaign to save lives and prevent medical harm.[6] But there is a temptation for rushed physicians to click a medication reconciliation button on an electronic medical record without adequate thought. Patients and their family members or support network are motivated to reconcile past and current medications and have ample time for the task. Let patients help save time and improve accuracy.

For medication reconciliation to become more than paperwork (or pixelwork), all it takes is adding six words to the Joint Commission’s five-step process:

(3) compare medications on the two lists with the patient and/or caregiver.

Participatory reconciliation goes well beyond “patient-centered medication reconciliation,[7]” an idea that has gained in popularity – but patient-centered in this context means only that the measures have defined benefits for the patients (not just for accreditation) and that additional resources are focused on high-risk patients. In other words, patient-centered is about patients and their safety, but doesn’t imply with patients participating fully in the critical comparison step. The author’s perilous reconciliation was patient-centered, but not participatory.

Patients and caregivers are in a special position to spot discrepancies, much as people notice their own face first in a group snapshot. But to do this, they need to see the snapshot — they need to see and have copies of both lists. More than 40 percent of medication errors are thought to occur from inadequate reconciliation at care handoffs.[8] Participatory reconciliation has the potential to prevent many of these costly, or even lethal, errors.

Beyond this, inviting the patient and appropriate caregiver to participate in medication reconciliation turns this chore into a therapeutic opportunity.

Participatory medicine is better medicine.

References

1. Bates DW, Spell N, Cullen DJ, et al. The costs of adverse drug events in hospitalized patients. JAMA. 1997;277:307–11. ↩
2. Institute of Medicine. Preventing medication errors. Washington, DC: National Academies Press; 2006. ↩
3. Agency for Healthcare Research and Quality. Hospitalization in the United States, 2002. Available at: http://archive.ahrq.gov/data/hcup/factbk6/factbk6a.htm. Accessed May 2, 2012. ↩
4. Joint Commission on Accreditation of Healthcare Organizations. National Patient Safety Goals. 2012. Available at: http://www.jointcommission.org/assets/1/6/NPSG_Chapter_Jan2012_HAP.pdf. Accessed May 2, 2012. ↩
5. The Joint Commission on Accreditation of Healthcare Organizations. Sentinel Event Alert, Issue 35: Using Medication Reconciliation to Prevent Errors. 2006. Available at: http://www.jointcommission.org/sentinel_event_alert_issue_35_using_medication_reconciliation_to_prevent_errors/. Accessed May 2, 2012. ↩
6. Institute for Healthcare Improvement. Protecting 5 Million Lives from Harm. Available at: http://www.ihi.org/offerings/Initiatives/PastStrategicInitiatives/5MillionLivesCampaign/Pages/default.aspx. Accessed May 2, 2012. ↩
7. Greenwald JL, Halasyamani LK, Greene J, et al. Making inpatient medication reconciliation patient centered, clinically relevant, and implementable: a consensus statement on key principles and necessary first steps. Jt Comm J Qual Patient Saf. 2010:36(11):504-513. ↩
8. Rozich JD, Howard RJ, Justeson JM, et al. Patient safety standardization as a mechanism to improve safety in health care. Jt Comm J Qual Saf. 2004;30(1):5–14. ↩

Copyright: © 2012 Alan Greene and John Greene. Published here under license by The Journal of Participatory Medicine. Copyright for this article is retained by the authors, with first publication rights granted to the Journal of Participatory Medicine. All journal content, except where otherwise noted, is licensed under a Creative Commons Attribution 3.0 License. By virtue of their appearance in this open-access journal, articles are free to use, with proper attribution, in educational and other non-commercial settings.