The Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) issued a new Sentinel Event Alert
in late January that urges intensified attention to the accuracy of
medications given to patients as they transition from one care
setting to another or from one practitioner to another. Effective
medication reconciliation should be done to avoid medication errors
such as omissions, duplications, dosing errors or drug
interactions. If you desire to read the entire Alert, you can use
this link:
http://www.jointcommission.org/SentinelEvents/SentinelEventAlert/sea_35.htm
Medication
reconciliation is the process of comparing a patient's medication
orders to all of the medications that the patient has been taking.
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:
- develop a list of current
medications;
- develop a list of medications to
be prescribed;
- compare the medications on the two
lists;
- make clinical decisions based on
the comparison; and
- communicate the new list to
appropriate caregivers and to the patient.
Medication errors related to
medication reconciliation typically occur at the "interfaces of
care"—when a patient is admitted, transferred, or discharged from a
health care facility. The Joint Commission's sentinel event
database includes more than 350 medication errors resulting in death
or major injury. Of those, 63 % related, at least in part, to
breakdowns in communication, and approximately half of those would
have been avoided through effective medication reconciliation.
Medication reconciliation is a key
initiative in the Institute for Healthcare Improvement's (IHI)
100,000 Lives Campaign. The IHI website includes a section on
Medication Reconciliation Review, with samples of reconciliation
tracking tools and a flowsheet. A selection of tools can be found
at
www.ihi.org/IHI/Topics/PatientSafety/MedicationSystems/Tools/#Medication%20Reconciliation.
The Joint Commission’s 2006
National Patient Safety Goals are:
-
Implement a process
for obtaining and documenting a complete list of the patient's
current medications upon the patient's admission and with the
involvement of the patient. This process includes a comparison of
the medications the organization provides to those on the list.
- A
complete list of the patient's medications is communicated to the
next provider of service when a patient is referred or transferred
to another setting, service, practitioner or level of care within
or outside the organization.
In addition, the Joint Commission
recommends:
- Placing the medication list in a
highly visible location in the patient's chart and including
dosage, drug schedules, immunizations, and allergies or drug
intolerances on the list.
- Creating a process for reconciling
medications at all interfaces of care (admission, transfer,
discharge) and determining reasonable time frames for reconciling
medications. Include patients, responsible physicians, nurses and
pharmacists.
- On discharge, in addition to
communicating an updated list to the next provider of care,
provide the patient with the complete list of medications that he
or she will be taking, as well as instructions on how and how long
to continue taking any newly prescribed medications. Encourage
the patient to carry the list with him or her and to share the
list with any providers of care (primary care and specialist
physicians, nurses, pharmacists and caregivers).
Jane Artz Bergeron RN, BSHA
LHCR Home Health
Team Leader |
Join our Email List for Quality Updates
