Medication Reconciliation

The Institute for Safe Medication Practices suggests the following steps for implementing medication reconciliation, a 2006 JCAHO national patient safety goal (ISMP, 2005a; JCAHO, 2005c), at the interface between care settings: obtain the most accurate list of medications possible, plus information such as the dose, frequency, indication, and time of last dose for each medication; prescribe needed medications, taking into consideration the patient’s current medications; reconcile medications and resolve discrepancies; reconcile medications again upon each transfer and at discharge; fully resolve any medication discrepancy; share the list with all health care providers; give the list to patients; and encourage patients to share the list with their providers and pharmacists.

In a study in an adult surgical ICU, a medication reconciliation process was instituted. Medical and anesthesia records were reviewed, allergies and home medications were verified with patient/family, and the findings were compared with orders at the time of discharge from the ICU. In a sample of 33 patients, 31 (94 percent) had their discharge orders changed (Pronovost et al., 2003).

The Ambulatory Clinic Setting

Strategies proposed to reduce medication prescribing errors in the ambulatory clinic setting are varied and include prescription writing aids, electronic prescribing with standardized variable fields that prohibit the use of unsafe abbreviations for medication instructions, medication-related computer signals, clinical practice guidelines, in-service education for physician trainees, a physician–pharmacist collaborative medication therapy management service, patient-specific medication-management reports, and voluntary medication error reporting programs. Only a few of these strategies have been evaluated.

Prescription Writing Aids

An educational program for 12 family practice residents that involved evaluation of and feedback on prescription writing by a clinical pharmacist over a 2-year period helped reduce medication prescribing error rates from 14.4 to 6 percent during the last 6 months of the intervention (p = 0.0002) (Shaughnessy and D’Amico, 1994).

Eleven providers in an adult internal medicine clinic participated in a trial of a modified paper prescription form. This form contained prompts for medication name, form, strength, dose, route, frequency, refills, quantity, indication, and additional directions. Use of the modified form reduced

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