Medication Reconciliation Demonstration Project

The 2005 Quality Improvement Assessment Survey had identified medication reconciliation as a high QI priority area for Critical Access Hospitals. In response to this priority, a medication reconciliation demonstration project was developed and implemented by the Flex Program. Reconciliation is a process of identifying the most accurate list of all medications a patient is taking including name, dosage, frequency and route, and using this list to provide correct medications for patients anywhere within the health care system.

Four CAHs are participating in the demonstration project (Copper Queen Community Hospital, Southeast Arizona Medical Center, Page Hospital, and Little Colorado Medical Center). This project will improve the medication reconciliation procedures of the four participating hospitals. The result of these changes will reduce hospital medication errors, and improve patient safety and quality. The project is supported by a Medication Reconciliation Working Group that is comprised of the four participating hospitals, representatives from the Arizona Hospital and Healthcare Association, Health Services Advisory Group (Arizona’s QIO), Arizona Pharmacy Alliance, and Managed Care Pharmacy Consultants.

There are six phases in the demonstration project: (1) the administration of the Rural Hospital Medication Reconciliation Risk Assessment Survey, (2) the on-site visits by Dr. Howard J. Eng to assess the hospital’s medication reconciliation procedures, (3) the administration of the Rural Hospital Medication Safety Assessment Survey, (4) the selection of medication reconciliation area(s) that will be addressed (change) by hospital as the results of the Rural Hospital Medication Reconciliation Risk Assessment Survey, Rural Hospital Medication Safety Assessment Survey, and on-site visit findings, (5) the implementation of the medication reconciliation intervention(s), and (6) the evaluation of the intervention(s).    

The Rural Hospital Medication Reconciliation Risk Assessment was conducted in May 2006.  The Assessment examined what is done during the six medication reconciliation encounter points in a small rural hospital: (1) upon admission record current medications, (2) physician write medication orders, (3) pharmacy review and fill medication orders,  (4) nursing administer medications from orders, (5) nursing administer patient home medications, and (6) patient discharge discuss and review medications. For each encounter points, the following six questions were asked: (1) What is done? (2) When is it done? (3) Who does it? (4) Where is it done? (5) How is it done? And, (6) Is there a recording form used? There were four additional questions asked:

• What are the days and times that a pharmacist is on duty in your hospital pharmacy?
• When the pharmacist is not in the hospital, what is the procedure used in filling a medication order? 
• What is the medication reconciliation procedure used when the pharmacist returns to the hospital?
• Does your hospital have current medication reconciliation protocols / procedures in place?

For each medication reconciliation encounter points, the assessment provides a comparison of the four hospitals. An example is what done: upon admission (medication history) by the four hospitals. The time in which the medication histories were taken varies -- from upon admissions to within 24 hours.  Usually, it is the admitting nurse who records the medication history. Three of the four hospitals record the medication history in the patient’s room. The recording format varies among the four hospitals: (1) ward clerk transcribes to MAR and checked by the nurse, (2) admitting nurse records information on medication reconciliation and on MAR, (3) written on chart and entered into computer, and (4) recorded on a medication reconciliation form, if they remember and forms are available. After the completion of the risk assessment, there was a Working Group meeting that reviewed and discussed the results. Appendix B summarizes the results of the four completed risk assessments.

The on-site hospital visits occurred in June. Dr. Eng visited Southeast Arizona Medical Center and Copper Queen Community Hospital on June 13th. The following week, he visited Page Hospital (June 20th) and Little Colorado Medical Center (June 21st). During his visits, he assessed the medication reconciliation procedures used by the hospital and presented the Rural Hospital Medication Safety Assessment Survey to each of the hospital team on the medication reconciliation project.

The Rural Hospital Medication Safety Assessment examined seven medication-related areas that can be modified with very little cost to the hospital or little resources needed to improve patient safety: (1) Patient Information, (2) Drug Information, (3) Communication of Drug Orders and Other Drug Information, (4) Drug Labeling, Packaging and Nomenclature, (5) Drug Standardization, Storage and Distribution, (6) Medication Delivery Device Acquisition, Use and Monitoring, and (7) Staff Competency and Education. Questions from the Pathways for Medication Safety Website: Pharmacy Section provided the foundation for the seven sections. The Pathways for Medication Safety questions were developed through a collaborative effort of the American Hospital Association, the Health Research and Educational Trust, and the Institute for Safe Medication Practices. The Rural Hospital Medication Safety Assessment Surveys were completed in early July. Soon after, there was a Working Group meeting that reviewed and discussed the results. Appendix C summarizes the results of the four completed medication safety assessments.

The hospitals had selected the medication reconciliation areas that they will be modifying during the next six months in early July. Three of the four hospitals will be developing and implementing a new medication history form upon admissions that will also serve as the initial medication order form. The progress of the projects will be reviewed and discussed by the Working Group in early September and a written project evaluation report will be submitted to the Flex program at the end of 2006.   

If your hospital is interested in conducting a Rural Hospital Medication Reconciliation Risk Assessment and/or Rural Hospital Medication Safety Assessment, call Howard J. Eng at (520) 626-5840 or e-mail him at aeng@ahsc.arizona.edu for copies of the assessment surveys and technical assistance in conducting the assessments.