Nurse's Role in Medication Reconciliation

8/10/2019 Nurse's Role in Medication Reconciliation

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precipitate one or more allergic reactions, food and drug interactions, and/or drug-drug interactions. Medication reconciliation is an extremely important process thatneeds to take place every time a patient is involved with any health care system.

Therefore, medication reconciliation was clearly an excellent choice when, in July 2004, Our Lady of Lourdes Memorial Hospital, Inc., Binghamton, New York (Lourdes Hospital), was asked by Ascension Health Ministries to participate in oneof the eight Priority For Action Teams, whose goal was to have no preventabledeaths by July 1, 2008. Medication reconciliation was one way to achieve that goal.The Adverse Drug Event (ADE) Priority for Action (PFA) Team selected by Lourdes Hospital was to be mostly composed of direct patient care nurses from alldepartments (from inpatient to outpatient) and management from various clinicaland nonclinical backgrounds, including a pharmacist, a clinical nursing director, a physician, a management engineer, and the chief nursing officer. During the initialteam meetings, a crystal clear definition of medication reconciliation was agreedupon so that the medication reconciliation task could be implemented across theorganization. (See the box below for the definition ofmedication reconciliationas

well as the language for National Patient Safety Goal 8, which pertains to medica-tion reconciliation.)

Because this particular chapter pertains to the nurses role in medication recon-ciliation, it is presented in the nursing process format, wherein the nursingassess-

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The Nurses Role in Medication Safety

Medication Reconciliation: The process of comparing a patientsmedication orders (those newly prescribed) with all the medications thepatient takes (previously prescribed as well as self-prescribed, including over-the-counter products such as herbals and supplements).1

National Patient Safety Goal 8 Accurately and completely reconcile medications across the continuum of care.

Requirement 8A: There is a process for comparing the patientscurrent medications with those ordered for the patient while under thecare of the organization.Requirement 8B: A complete list of the patients medications iscommunicated to the next provider of service when a patient is

referred or transferred to another setting, service, practitioner, or levelof care within or outside the organization. The complete list of med-ications is also provided to the patient on discharge from the facility.


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ment leads to the diagnosis of the problem, the planning of the goals and outcomesis followed by theimplementationof the process, and subsequentevaluation and measurement dictate the success or failure of the process.

Assessment Assessment of the issues involved with implementing medication reconciliation by using a pilot unit

In September 2004, the organization chose the cardiac telemetry unit as a pilotunit in which to assess and introduce the idea and subsequent use of medicationreconciliation. The first test of change for the new process included the following participants: One nurse (who was a member of the ADE team) One physician (who admitted a high number of patients to the pilot unit and

would be amenable to change) One patient (who was typical of the patient population and had an accurate list

of current medications)Prior to enacting the new process on the pilot unit, medication reconciliation

was designed with the nurse, physician, and patient in mind. In the beginning, thehospital system considered several factors: change theory, adult-learner theory, addi-tional paperwork, staffing crises, and the typically hectic, busy nature of a nursing unit. The nurse on the pilot unit as well as the selected physician had to be con-vinced that the benefit of medication reconciliation outweighed the burden of yetanother change, more paperwork, and the potential for being overwhelmed. At

first, the medication reconciliation process seemed complicated. Staff members per-ceived the additional paperwork as tedious. The nurses were naturally resistant andreluctant to embrace another change. They needed to know that the ADE teamempathized with them and the ADE team needed the support of the nurses for theprocess to be successful.

The process was to compare the patients current medications with the medica-tions that the physician ordered on admission to the hospital. That seemed simpleenough; however, it was a change to the process and procedure, which created a new,time-consuming, detailed system that was absolutely necessary (and soon would besupported by policy). Fortunately, when the organization presented the processchange to nurses from the perspective of patient safety, nurses recognized its impor-tance. After the test of change on the pilot unit by the core individuals involved wassuccessful, the idea was to spread the change. Nurses were beginning to incorporateand streamline medication reconciliation. The first test of change identified issuesthat the health care team had not considered, including the following:

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Chapter 1: The Nurses Role in Medication Reconciliation


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medications reconciled when entering the ED.Very early in the formation of the ADE PFA team, a key component to the

success of this diligent process was to have an energetic, persuasive ED nurse whoregularly attends team meetings and who could drive change. She served not only as a resource person for the team but as a champion of medication reconciliationbecause she believed it to be an important patient safety issue. When presented tothe ED, medication reconciliation was met with the predictable physician andnurse resistance because it was perceived as time consuming and difficult.

At first, the ED nurses and physicians resisted having to bear the burden of yetanother change and the possibility for more paperwork. (And, yes, the process wastime consuming and difficult to accomplish,in the beginning .) When the test of change was spread to the ED, it was done on the first day by the one persuasive nurse team member with one optimistic physician and one patient with a simplediagnosis and few medications. The ADE PFA team was this nurses committee (allnurses participate in committee membership at Lourdes Hospital) and her col-leagues knew this. She believed in the importance of and accepted the challenge of medication reconciliation in the ED. Like anything that is repeated, the processbecame less complex with each new patient who came to the ED. And, if LourdesHospitals PFA was patient safety, then it needed to be done 100% of the time.That was the explanation this nurse team member had to repeat several times a day until her colleagues were convinced that medication reconciliation was the rightthing to do (and until it would soon be supported by policy).

One complication specific to the ED setting was the fact that patients medica-

tion information could be difficult to obtain. At times, the patient had more thanone physician in the community. Some patients could not even begin to report what medications they took, when they had taken them, or why. Patients fromnursing homes had their medication lists but those lists were quite extensive. Stillother patients had detailed lists of medications and could reiterate exactly whenthey took their last dosemedication reconciliation for those patients was relatively easy. In addition to the patients themselves, the nurses found they could rely ondifferent sources of information to obtain accurate medication lists for theirpatients (for example, family members, local pharmacies, old charts, histories andphysicals, and sometimes even the medication container labels).

After the pilot unit and the ED adopted the process and after the ADE teamprovided intensive education for the nurses, pharmacists, and physicians, theprocess was very quickly spread toall inpatient and outpatient areas, including diagnostic imaging, perioperative services, ambulatory surgery, the GI laboratory,off-site physician offices, hospice, and home care. Essentially, the hospital system

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implemented medication reconciliation from admission to discharge to avoid any confusion with nursing and physician documentation, especially because documen-tation, by its nature, is ever-changing. National Patient Safety Goal 8 was reiteratedthroughout the organization. The words medication reconciliation were incorporatedinto most meeting agendas and discussed in most conversations.

PlanningStatement of the specific goals, action plans, and outcomes for patient safety

National Patient Safety Goal 8 defines the purpose of medication reconcilia-tion, which is to avoid errors of transcription, omission, duplication of therapy, anddrug-drug and drug-disease interactions. The Joint Commission answers the ques-tion as to who is supposed to complete the medication reconciliation process in itsFrequently Asked Questions, which are posted on its Web site.2 According to the

Joint Commission, there are the following two models:1. The physician completes the medication reconciliation process when he or she

writes the orders.2. The pharmacist or nurse completes the medication reconciliation process before

preparing or administering the medications, and then notifies physicians if any concerns arise.

The team decided that throughout the Lourdes Hospital system every nurse will ask each one of his or her patients, on admission to the patient care unit, for a list of the medications they are currently taking and will fill out a medication rec-onciliation form accordingly, with a good faith effort to obtain as complete a list

as possible, within 24 hours or less.1

Besides the actual medication, the nurses willinclude the following information: dose, route, frequency, reasons for taking themedication, and the time of the last dose taken.

Creating the Medication Reconciliation Form The hospital system designed the medication reconciliation form to be used

as a physician order form. (See the Medication Reconciliation/Physician InitialMedication Order Form in Figure 1-1 on page 17.) After the physician indicates

whether he or she wants the same medications to be continued or stopped, or if the medications have been ordered by the physician elsewhere on previous ordersheets, the form can be used as an official physician order form. In addition, theform contains language that indicates how to use the form and thatherbals/naturals and supplements will not be dispensed to inpatients. It refer-ences Lourdes Hospitals Patient Care Services Policy #29, which states that allproducts not regulated by the Food and Drug Administration (for example,

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herbal/natural products) will not be made available to hospital patients. A mul-tidisciplinary team made this decision to prevent adverse drug events, and thedirector of the pharmacy and the Lourdes Hospital Patient Care Services Policy

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Figure 1-1: Medication Reconciliation/Physician Initial Medication Form

NKA, no known allergies; US, unit secretary; RN, nurse; MD, physician; Pt, patient.


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and Procedure Committee approved the form in October 2005.To promote safe decision making, the form included information on allergies

and intolerances, height, and weight for all patients. Check boxes indicated wherenurses could or would obtain information to complete the form (for example, thepatient, their medication list, the family, the outpatient pharmacy). For the form tobe used as a physician order form, the licensed independent practitioner with pre-scription privileges was required to sign and date it. Only then was the hospitalpharmacist authorized to prepare the medications for the nurses to administer.Every patient who entered the hospitals portals, for any reason, was to have themedication reconciliation form initiated and completed in 24 hours or less.

From the ADE teams perspective, the process sounded very simple andstraightforward. But after several tests of change on the pilot unit, the team foundit necessary to accommodate the nurses and physicians who were actually going touse this form on an hourly basis . Suggestions for change came fast and furiously from the staff, and each week for many weeks the form was changed. The ADEteam continually readjusted, rearranged, reconfigured, reconsidered, redesigned,reformatted, and revised the form to meet the safety needs of the patients and staff members.

Creating a Master Medication List As the need for medication reconciliation spread throughout the organization,

the team determined that nurses and physicians caring for outpatients (in the pri-mary care network) needed access to a form with a design similar to the medication

reconciliation form to easily transfer medication information if those patients wereadmitted to the hospital. The hospital system charged a small task force of nurses with designing the Master Medication List that primary care physicians and theirnurses could use each and every time a patient came for an office visit. This formfacilitates the process of looking at the list when new medications are ordered andupdating the list to reflect any changes in the medication regimen.1 And nursescan keep one copy of the list in the patients chart, record any changes to thepatients record and the patients copy, and return the list to the patient. (See Figure1-2 on page 19 for the Master Medication List.) To increase physician compliance,task force members emphasized thebenefits to staff nurses and physicians over andover again, which include the following: If the medications are listed, the physician only has to circle or check the same

medications and/or add new ones. The physician or nurse does not have to handwrite the very long list of their

patients medications in the chart or at each visit.

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There will be fewer transcription errors. The nurse and the patient can discuss exactly what medications are still pre-

scribed and what medications are no longer necessary.

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Figure 1-2: Master Medication List

DOB, date of birth; MD, physician.


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If and when the patient ever needs to be hospitalized, the updated medicationlist from the primary care chart can be used with ease as the medication reconcil-iation/physician initial medication order form in the hospital chart. The only items required will be the physician signature, date, and time at the bottom of the list, and they can be included in the admission paperwork as medicationsreconciled and medications ordered, thus saving time and steps and ensuring each patients medication safety.

Creating Medication Cards for Patients While one task force of nurses was formatting the Master Medication List,

another small task force of nurses from the primary care network was designing a medication card for patients. The hospital system trialed several tests of change inone outpatient setting. Once again, it was necessary to enlist the help of a multidis-ciplinary team composed of nurses, physicians, and patients (who were going to beusing this medication card). Not only did the medication card list the patientsdemographics and the primary care physicians name and telephone number, it con-tained a section for the patients brief medical history, a place to denoteallergies/intolerances, and a grid in which to list current medications (including herbals and supplements and over-the-counter drugs) that the patient was currently taking. The grid also included a place to list the dose (by simply asking, How much?), the route, the frequency (by asking, How often?), and the reason why.(The language used was basic to facilitate teaching and learning.) This grid on thepatients medication card was designed exactly like the columns on the inpatient

medication reconciliation form. Soon, all patients who entered the outpatient arena would be given instructions on how to fill out their medication cards. They werealso instructed to bring these cards with them each time they had an office visit sothat their medication lists could and would be updated, ensuring their safety. (Seethe medication card for patients in Figure 1-3 on pages 2122.)

For those patients who have not received a medication card from the outpa-tient setting, a blank card is included in the paperwork for all patients who areadmitted and discharged from the hospital. Often nurses on these units assistpatients or their families with filling out the medication cards. Nurses encouragepatients to update their medication cards at discharge. The Lourdes system hasfound that it only takes a few moments for a nurse to teach a patient about theimportance of the right drug, dose, route, and the reason for their medications. Atthe same time, nurses can give medication-information teaching sheets to patientsand their family members. These sheets describe any new medication initiated as

well as dosage, administration, side effects, and contraindications. This is not a new

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practice because pharmacies across the nation are compelled to provide medication-information teaching sheets for any drug that is dispensed.

Medication Reconciliation in Home Care and Hospice

Another area of concern for appropriate medication reconciliation was withinhome care and hospice. To ascertain that every patient in the system would havetheir medications reconciled, Lourdess home care agency, Lourdes at Home (LAH),and the Lourdes Hospice Program were included in the medication reconciliationprocess. LAH nurses reconciled their patients medications using a slightly differentform (see Figure 1-4 on page 24). Every single time an LAH nurse entered a patients home, the nurse reconciled medications in the following ways: By discussion with the patient or the family By the discharge paperwork from the hospital With any new prescriptions filled or unfilled From the actual medication bottles in the home By calling the patients primary care physician or local pharmacy

These nurse home care visits created several opportunities for teaching andlearning, while at the same time maintaining patient safety as a top priority.

Similarly, Lourdes Hospice nurses relied mostly on families for the medicationreconciliation, as well as on the primary care physician and local pharmacy. Thehospice forms are simpler, but two strong statements at the bottom of the formsalert the patient to disclose any and all medicationsincluding herbals, supple-

ments, and vitaminsthey are currently taking so that any possible interactionscould be discussed. (See the hospice care forms in Figures 1-5 on pages 2627 andFigure 1-6 on pages 2829.)

ImplementationIncluding tasks in the process and documenting observations

Now that the medication reconciliation forms were somewhat finalizedacrossthe systemit was time to implement the process from the point of entry to thepoint of exit.

On the inpatient side of the hospital system, each patients current medicationlist is computer generated every night at midnight. The nurses medication admin-istration records (MARs) for their patients are also computer generated every nightat midnight. During the day shift, patients (or their family members if patients areunable to comprehend it) receive their current medication list. The patient copy of the list (entitled Postop/Transfer Medication Reconciliation Record) is similar in

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Figure 1-5: Hospice Medication Flow Sheet As-Needed Medications


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Figure 1-5: Hospice Medication Flow Sheet As-Needed Medications (continued)


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Figure 1-6: Hospice Medication Flow Sheet Routine Medications


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Figure 1-6: Hospice Medication Flow Sheet Routine Medications (continued)


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assessed and initially treated, the primary nurse in the ED asks for her current list of medications. The patient produces a Lourdes Hospital medication card from her wallet that contains an up-to-date list of her medications, the doses in milligrams,the times she takes them, and why. Her primary care physicians name and telephone number and an emergency contact and telephone number are also on the card, as well as a brief summary of her health history, her allergies, and a list of questions to ask about herself. Because she is alert and oriented and has been ini-tially treated for dyspnea, the patient is able to tell the ED nurse exactly what medication she has already taken today and what medication she still needs. This information is then put on the medication reconciliation form that stays with her chart for the entire hospitalization. When her admitting physician arrives to eval-uate the patient, he can use this form (by simply circling the appropriate words) tocontinue the same medications and/or stop other medications and/or order new medications. By signing the medication reconciliation form at the bottom, the medication reconciliation form becomes a physician initial medication order formand is faxed to the pharmacy. At this time, the pharmacy is authorized to prepare the medications for the nurses to administer. The ED nurse gives a face-to-face report to the receiving nurse on the telemetry unit together with all that he/she knows about this patient, including the medication reconciliation information. By the time the patient arrives on the telemetry unit, her current medications have been ordered and reconciled, the MAR has been printed, and the medications that the patient did not already take today are ready to be administered. If there are any new medications ordered or current medications stopped, the nurse can incor-

porate this information into the initial plan of care.

Example 2: A woman in her forties is brought into the ED by paramedics because she was found wandering a residential neighborhood at 3:00 A. M . She knows whoshe is and knows that yesterday was her birthday. She says she was celebrating and her blood alcohol content on arrival was 0.29%. After she is assessed and treated, the ED nurse attempts to ask her about her health history. The patient continues to alternate between dozing off and repeating incomprehensible words.

The ED physician decides to admit the patient. The ED nurse cannot possibly complete the medication reconciliation form, there are no family members present,and the hospital pharmacy is closed because a 24-hour pharmacy does not exist at Lourdes Hospital yet. Any retail pharmacy would also be closed at this time of night and the hospitalist assigned to this admission does not know the patient at all. When giving the report to the receiving unit, the ED nurse apologizes for the

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incomplete medication reconciliation form and asks the receiving nurse to make a good faith effort in the morning toward reconciling this patients medications.The next morning, the patient is more coherent and is questioned about any and all medications that she may have been taking prior to her admission to the hospi-tal. At this time, the patient is able to state to her nurse what she takes but does not know the doses and she cannot remember anything about the day before. She uses a local pharmacy and has given the nurse permission to contact the pharmacy to obtain the medications and doses she takes. The nurse on the medical unit towhich the patient is assigned places a call to the pharmacy, and identifies herself and the reason for her call. The local pharmacist asks for the patients demograph-ics and then gives the nurse the requested information as to her patients medica-tions and dosages. The nurse now places a call to the patients physician to request the current medications and appropriate dosages for the patient. (She is taking esc-italopram oxalate, metoprolol, ciprofloxacin, a nicotine patch, and ibuprofen.) Her medications are reconciled and she is started back on her same drug regimen except for the over-the-counter ibuprofen. (To prevent any potential gastric reflux or ulcers, the ibuprofen was discontinued and pantoprazole sodium was ordered, as well as folic acid, thiamine, vitamins, and diazepam to move her safely throughalcohol withdrawal.)

These two examples are at opposite ends of the spectrum when considering medication reconciliation, but, as stated previously, it is the primary goal of keeping patients safe that compels nurses to continue toward completing the medication

reconciliation process, regardless of how difficult this is to accomplish, at every por-tal of the system. Most of the time, medication reconciliation is successful becauseof the initial steps the nurses take. There has been remarkable success in reducing adverse drug events with the incorporation of medication reconciliation at LourdesHospital as evidenced by the evaluation and measurement described below.

Evaluation and MeasurementNote success or failure across the system and adopt, amend, or abandon

By August 2005, the goal of medication reconciliation (to reduce nonrecon-ciled medications to


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tics above, medication reconciliation is a process that is performed, primarily by nurses, with success.

The goal for 2007 is to sustain improvement in the percentage of nonrecon-ciled medications on admission to


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The trusted nurse-patient relationship yields improved outcomes and a plan of care that can be instituted when medication reconciliation and subsequent med-ication safety prevail.

Nurses are usually the first caregivers whom patients see when entering a healthcare system. Medication reconciliation as well as patient teaching takes place atthis time.

Nurses are usually thelast caregivers whom patients see when exiting a healthcare system. Medication reconciliation as well as patient teaching takes place atthis time.

Nurses may use any and all resources to make a good faith effort to ensure that a patients medications are reconciled appropriately. Their perseverance is necessary at this juncture.

Nurses may design and use different forms unique to their departments whilestaying within the guidelines of medication reconciliation. Their creativity ishelpful at this juncture.

Nurses perform chart reviews and serve on committees where data is gatheredand where suggestions for changes to the medication reconciliation process are

welcomed.

Looking to the FutureThe future design includes using the electronic medical record to record the

patients medication history, height, weight, and allergies, with alerts to all membersof the health care team if any of this information is unavailable. The pharmacist

will receive alerts for potential allergic reactions, drug-drug interactions, and drug-food interactions, as well as alerts based on laboratory results or other patient infor-mation. The system will alert caregivers when medications are scheduled to begiven and will document medication administration in the electronic medicationadministration record. These capabilities will also support computerized providerorder entry.

References1. Miller L., Mannino C.A.: Taking the Lead in Medication Reconciliation.The Cerner

Quarterly 2(2):4047, 2006.2. The Joint Commission: FAQs for the 2006 National Patient Safety Goals.http://www.joint

commission.org/NR/rdonlyres/7C116D6D-AE82-449E-BA45-1DE49D2A0A34/0/06_npsg_faq.pdf (accessed Jan. 22, 2006; site now discontinued).

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Nurse's Role in Medication Reconciliation

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