Researchers at Brigham and Women's Hospital (BWH) and Massachusetts General Hospital (MGH) in Boston have found that the use of a better-integrated computer system and process redesign could reduce the number of potential medication errors present in the medication reconciliation process.
The study, published in the April 27 Archives of Internal Medicine, took place during May and June 2006, and focused on using existing technology to compare patients' medication lists to prevent adverse events.
"We know that good medication reconciliation is not occurring," says Jeffrey Schnipper, MD, MPH, senior author on the study and hospitalist at BWH.
There are usually 1.44 errors with potential for medication harm, says Schnipper, and his team's randomized controlled clinical trial lowered that number to 1.05 during the course of their study.
Of the 322 total patients who were part of the study, 160 patients in the control group receiving the hospital's normal medication reconciliation processes could have suffered 230 potential adverse events; the 162 patients who were part of the intervention could have suffered 170 potential adverse events.
The Joint Commission's National Patient Safety Goals have contained a goal concerning medication reconciliation since 2005. The Joint Commission is currently reviewing that goal to determine how to better use it to prevent medical errors, as many hospitals have struggled to effectively reconcile medications across the continuum of care and comply with the goal.
Both BWH and MGH were using computer physician order entry (CPOE) systems already, so researchers designed the study around using the existing system and workflow. The study took the existing system and made it easier for staff members to compare a patient's preadmission medication list with both their inpatient and discharge medication lists. This is one area where many hospitals create their own medication reconciliation problems, says Schnipper.
"In many hospitals, a lot of people take a patient's medication history, but it's done in silos—all of these people keeping separate, different lists," says Schnipper, who gave examples of various entry points, such as an emergency room nurse, inpatient nurse, or pharmacist.
The goal of this study, he says, was to reduce redundancy; create only one in-hospital medication list that staff members could refine, but with increased attention on verification and communication among caregivers.
Since the study ended, BWH and MGH staff members have worked on further refining the computer application so that it can detect even more detailed differences in the three medication lists, down to distinctions in the class and dose of medications, says Schnipper. The application alerts caregivers to any of these differences, which could help in preventing adverse drug events.Process Redesign
Another part of the study involved redefining the roles that certain caregivers play in reconciling medications, specifically the home and the discharge medication lists. Pharmacists and nurses were given a larger role in checking to be sure that patients' preadmission medication lists were accurate.
"Pharmacists get this, and they were thrilled to be involved," says Schnipper.
Prior to the study, Schnipper's team found that pharmacists were spending more time finding and questioning discrepancies between patients' preadmission medication lists and the inpatient medication lists. However, it turned out that a bigger problem existed with the creation of the home medication, which was often inaccurate.
Now, pharmacists at BWH and MGH are doing whatever they can to make sure a correct and up-to-date home medication list is created when a patient enters the hospital. That might mean making an extra effort to find and speak with family members or call a patient's home pharmacy to discover his or her most recent home medications, says Schnipper.
Additionally, nurses, who often are in charge of educating patients about their medication regimens after discharge, have found that because there is one concise list to refer to, they can do a better job with discharge counseling.
:“Any hospital with CPOE should strongly consider having an integrated EMR," says Schnipper.
A computer system that can compare lists and serve as one place for medication data can be a good starting point to cut down on potential adverse events.
Also important is the allocation of personnel. Schnipper says hospitals should evaluate if they need to hire more pharmacists, or if they could use pharmacy techs for some of the tasks associated with a more integrated CPOE system.
Heather Comak is a Managing Editor at HCPro, Inc., where she is the editor of the monthly publication Briefings on Patient Safety, as well as patient safety-related books and audio conferences. She is also is the Assistant Director of the Association for Healthcare Accreditation Professionals. Contact Heather by e-mailing firstname.lastname@example.org.