The JCAHO doesnt specify who should compile the list, but has noted that nurses, pharmacists or physicians conducting the reconciliation are acceptable for meeting the requirements, according to a list of frequently asked questions about the goal thats posted on the JCAHOs Web site. Patient-safety goals usually spell out a process that hospitals can meet, but some have complained that the JCAHO hasnt given enough direction on the process.
Some of the NPSGs (national patient-safety goals) were very straightforward; this one is not, according to an anonymous response from a survey on medication reconciliation conducted by the Institute for Safe Medication Practices. While I think most of our staff feel it is important and do some level of reconciliation, the process is still foggy.
The institutes survey was taken in April and May and included results from 1,257 hospital respondents. The results showed that 94% of the time nurses were responsible for collecting the initial medication history, and 77% of the time nurses were responsible for making sure the list was accurate. Only 5% of the time were pharmacists responsible for collecting the initial list, and 23% of the time pharmacists were responsible for making sure the list was accurate.
Pharmacists at Froedtert are responsible for collecting patients medication lists, which allows nurses to focus on their areas of expertise, Klauck says. Nurses probably would be taking the medication history if Klauck hadnt conducted research that showed pharmacists are more adept at recording medication histories.
Klauck led an internal study that showed, on average, there were about two discrepancies between medication lists that nurses and physicians compiled when compared with lists pharmacists compiled. A review proved that the lists compiled by pharmacists were more accurate. Klaucks research also showed that adverse drug events were costing Froedtert up to $3.1 million per year and extended lengths of stay by an average of 4.6 days.
One more cost-effective way to meet the patient-safety goal might be to use pharmacy students, some observers say.
The 646-bed University of Iowa Hospitals and Clinics, Iowa City, is using students at a total annual cost of $50,000. Students interview patients upon admission and enter into a computer the medications patients are taking. Peter Kaboli, an assistant professor at the VA Iowa City Health Care System and the University of Iowa Carver College of Medicine, says its a more efficient use of time to have students who are making $9 per hour track the medication information rather than nurses, pharmacists or physicians.
The JCAHOs Croteau says its reasonable that students could take a list of medications and cross-check doctors orders with the list. However, he adds that its up to hospitals to make sure the students are capable of handling the tasks.
While many of the respondents to the institutes survey agreed that medication reconciliation is something that should be done, many report difficulty instituting the programs.
While the vast majority of respondents (82%) felt that medication reconciliation is of great value to patient safety, more than 300 insightful comments submitted with the survey clearly showed a high level of frustration and difficulties with implementing these processes, according to a summary of the results.
Although most agree that medication reconciliation should have been a burning issue for years, there hasnt been much talk about the subject until recently.
Nothing like a JCAHO mandate to make something a hot topic, says Jeffrey Schnipper, director of clinical research for the hospitalist service at Brigham and Womens Hospital, Boston. Like many hospitals, 735-bed Brigham and Womens is trying to spread the increased workload of the medication-reconciliation process among its staff. The new responsibility isnt exactly the news hospital staffers want to hear.
A lot of people see this as busy work and dont see it as patient safety, Schnipper says. He adds that the staff bemoans the new tasks and some have sent anonymous e-mail messages saying, Why are you making me do this?
Schnipper agrees that its best to have pharmacists interview patients to learn their medication history, but given the shortage and salary cost of pharmacists, thats not always feasible. One compromise may be having pharmacists intervene for high-risk patients, he adds. One way of finding those high risk patients would be administering a test to patients upon admission similar to a medical literacy test, he says.
Brigham and Womens is part of the Partners HealthCare System, which has been building an electronic medical-record system throughout the entire organization. The EMRs can assist with tracking medication reconciliation, but implementing the EMR system has also been complicated.
Its taken a year to get all (computers) to talk, he says. And thats just about medication.
Schnipper is happy that hospitals are instituting medication-reconciliation programs, but he and others interviewed for this story say the JCAHO didnt allow much preparation time or direction for hospitals to be in compliance.
The JCAHO mandate was perfectly appropriate, but they didnt give anyone a whole lot of time, he says.
The JCAHO disagrees. We gave them leeway, Croteau says. We gave them a whole year.
In July 2004, the JCAHO announced that all accredited hospitals needed to have a medication-reconciliation process in place for 2005. For one year, they were required to test the process and be in compliance by this past January.