Abstract
Objective:
The objective of this study is to conduct a review of pertinent literature, assess pharmacy involvement in medication reconciliation, and offer insight into best practices for hospitals to implement and enhance their medication reconciliation programs.
Method:
Pharmacists in hospitals nationwide were asked to complete an anonymous survey via the American College of Clinical Pharmacy online database. The multiple choice survey analyzed the roles that healthcare professionals play in medication reconciliation programs at hospitals.
Results:
Of the survey responses received, 32/91 (35%) came from pharmacists at hospitals with a pharmacy-led medication reconciliation program. Of these pharmacy-led programs, 17/32 (53%) have a dedicated pharmacist or pharmacy staff to perform medication reconciliation.
Conclusion:
A comprehensive review of literature suggests that pharmacy involvement has the potential to reduce medication reconciliation errors and may improve patient satisfaction. Focused, full-time medication reconciliation pharmacists can help hospitals save time and money, improve outcomes, and meet higher standards issued by the Joint Commission. Data obtained in this study show the extent to which pharmacists contribute to achieving these goals in healthcare systems nationwide. This baseline study provides a strong case for hospitals to implement a pharmacy-led medication reconciliation program.
Keywords
Introduction
Medication reconciliation is the process of recording and passing along correct information about a patient’s home and hospital medications. Since July 2011, the Joint Commission has stipulated guidelines for healthcare systems to implement medication reconciliation objectives following revised standards to the National Patient Safety Goals (NPSG 03.06.01). 1 According to the Joint Commission, medication reconciliation is in the top five (5.8%) of medication management non-complaints standards in 2013. 2
Proper medication reconciliation has the potential to reduce errors regarding patient medication resulting in patient harm. Essential information often overlooked includes home medication (prescription, over-the-counter, and herbal), therapy duplication at discharge, and incorrect dosage form, strength, or frequency. 3 In a study by Soler-Giner et al., 4 medical errors were found in 86.8% of emergency departments without defined medication reconciliation programs. A recent study by Bishop et al. 5 showed that two out of five patients on the hospitalist service have discrepancies in their medications at discharge that can be identified and corrected by pharmacist intervention.
In a study by Reeder and Mutnick, 6 the lowest number of medication discrepancies was found in the internal medicine service where a pharmacist was present. Another study demonstrated that pharmacist-recorded medication histories are more effective in critical emergency room situations than those obtained by other healthcare professionals. 7 The National Institutes of Health showed in their own research that pharmacist-led medication reconciliation may reduce discrepancies from 19% to as much as 44%. 8 By identifying and addressing medication discrepancies, pharmacists can lower the rate of preventable adverse drug events after discharge, according to a study by Schnipper et al. A study at Brigham and Women’s Hospital also shows less adverse drug events post-discharge in pharmacy-led intervention groups versus non-pharmacy-led usual care groups (1% and 11%, respectively). Prevention of serious adverse drug events can reduce costly readmissions. 9
A study conducted at the Oregon Health and Science University (OHSU) showed that the addition of a pharmacist to a medication reconciliation service significantly reduces hospital readmissions. Such departments with pharmacists show a decline in readmissions by 9.3%, while the rest show an increase in readmissions by 8.5%, compared to the previous year (p = 0.001). 10 Another study by Jack et al. showed that medication reconciliation programs intervened by clinical pharmacists and pharmacy-trained nurses enable a lower rate of readmission post-discharge than programs run by usual care groups (without pharmacy involvement). A cost–benefit analysis of the study showed an average cost savings of US$412 per patient discharged in the intervention group. 11
Barriers to medication reconciliation include cost, time, inadequate staffing, unreliable patient information (both from the patient and from the electronic medical records), lack of program ownership by a particular discipline, and difficulty relaying information between the hospital and outpatient settings. 12 Information regarding how hospitals are overcoming these challenges is important to enhance medication reconciliation programs.
The studies mentioned above show how medication reconciliation programs involving pharmacists can improve the overall quality of patient care by decreasing adverse drug events, therapeutic duplications, and readmission to hospitals. The purpose of this study was to assess the degree to which pharmacy personnel are involved in medication reconciliation in hospitals nationwide. In addition, this study created a baseline for future studies and trending health systems response to ever-evolving Joint Commission initiatives.
Methods
Design
A cross-sectional design using a descriptive, anonymous electronic survey was utilized for this study.
Survey development
The survey (Supplementary Material) consisted of 23 questions pertaining to medication reconciliation programs. The first section consisted of questions about the presence of a medication reconciliation program within the institution, whether the program was led by pharmacy staff, whether the program was computerized, and the average time spent conducting medication reconciliation. The second section consisted of questions pertaining to how the three components of medication reconciliation (as identified by the authors)—recording home medication list, reconciling orders, and discharge counseling—were each conducted, and by what type of personnel.
Questions for both sections were developed by the authors of this study with the help of focus groups consisting of pharmacists from the Memorial Sloan-Kettering Cancer Center’s Medication Reconciliation department and the review of pertinent literature. Demographic information was obtained regarding the geographic region of the hospitals, the type of setting (urban, rural, or suburban), and the total bed size of the hospitals.
All survey questions were reviewed for face content validity and then converted into an electronic survey using the baseline assessment platform formerly known as StudentVoice in 2011. The study was reviewed by the Institutional Review Boards (IRBs) of Long Island University and the Brookdale Hospital and received expedited approval.
Survey administration and data collection
The study was conducted from 1 October 2011 through 31 October 2011. An electronic link to the survey was administered via email to participants in the list serve of the two largest groups within the American College of Clinical Pharmacy’s (ACCP) Practice and Research Networks (PRNs)—the adult medicine group (750 members) and the ambulatory care group (1100 members). These PRN groups include pharmacists nationwide and serve as a means for pharmacists to share ideas and information with their peers. Approximately 1850 members received the survey and had the option to complete it. Health system–employed pharmacists were chosen because of their possible knowledge and/or involvement in medication reconciliation.
Data were analyzed using descriptive statistical comparisons and the chi-square test using IBM SPSS Statistics, Version 20. The chi-square test was used to determine whether pharmacist participation, in any of the three components (recording home medication list, reconciling medications, and performing discharge counseling) of medication reconciliation, varied based on hospital size and location, with a p value of 0.05 to show significance.
Results
A total of 1850 surveys were sent via email; 91 completed surveys were received and used in this study. Demographics of the survey responses are as follows: there were respondents from almost every state represented in the survey. Of the completed surveys, 43/91 (47%) were from hospitals in urban settings, 14/91 (15%) from suburban settings, 13/91 (14%) from rural settings, and 21/91 (23%) did not indicate a setting. Hospitals varied in bed capacity. Hospitals were considered small hospitals if the bed capacity was from 1 to 199 beds, medium hospitals ranged from 200 to 399 beds, and large hospitals had bed capacities of over 399 beds (Table 1).
Hospitals’ demographics.
From the responses received, 32/91 (35%) reported that their healthcare facility had pharmacy-led medication reconciliation programs. The majority (53%) of pharmacy-led programs claimed to have dedicated pharmacists or pharmacy staff performing medication reconciliation (Table 2). According to completed surveys, respondents chose 10–20 min most frequently for completing all three aspects of medication reconciliation (Table 3).
Survey responses.
The last question allowed for respondents to choose all that apply.
Survey responses.
MD: medication.
Data were also analyzed based on whether the medication reconciliation program was conducted by pharmacists versus non-pharmacist healthcare providers. Each of the three major components of medication reconciliation—home medication list, reconciling orders, and discharge counseling—were analyzed separately (Figures 1–3).
Types of personnel involved in obtaining home medication lists.
Reconciling home medications and hospital orders.
Discharge counseling.
Home medication history
When obtaining home medication lists, hospitals with programs not led by pharmacists were predominantly run by nurses, according to survey respondents. Nurses were identified as responsible for recording patients’ home medication lists in the majority of the hospitals (51/59; 86%), while within the pharmacy (in non-pharmacy-led programs), clinical pharmacists played the largest role in obtaining home medication history (13/59; 22%). In hospitals with programs led by pharmacists, nurses were less involved in the medication reconciliation process (15/32; 47%), while clinical pharmacists, staff pharmacists, pharmacy residents, pharmacy students, and pharmacy technicians all had substantial increases in involvement (Figure 1).
Reconciling orders
In both the pharmacy-led and non-pharmacy-led programs, physicians were extensively involved in order reconciliation, 14/32 (44%) and 33/59 (56%), respectively. A major difference between pharmacy-led and non-pharmacy-led groups was the level of involvement of the pharmacy department. Clinical pharmacists, staff pharmacists, pharmacy residents, pharmacy students, and pharmacy technicians in pharmacy-led programs showed increased involvement in their institutions medication reconciliation programs by at least 42% and in many cases were greater than double that of the non-pharmacy-led groups. Nurses also played a much smaller role in the pharmacy-led group (Figure 2).
Discharge counseling
For discharge counseling, nurses had the most involvement in both pharmacy-led and non-pharmacy-led groups (20/32 (63%) and 49/59 (83%), respectively), and physicians had the least involvement (4/32 (13%) and 11/59 (19%), respectively). Clinical pharmacists showed 85% more involvement and staff pharmacists showed over double the involvement in pharmacy-led medication reconciliation discharge counseling than non-pharmacy-led medication reconciliation programs (Figure 3).
Urbanity and hospital size
No significant difference was found between large-sized and small- to medium-sized hospitals in the categories of reconciling home medications and discharge counseling; however, there was a significant difference in the category of pharmacist involvement in recording medication histories (p = 0.02). Neither was there any significant difference found for reconciling home medications and discharge counseling with respect to location. However, there was a significant difference between pharmacist involvement in home medication lists between hospitals in urban environments and suburban or rural environments (p = 0.0004).
Discussion
In this nationwide survey of hospitals, 32/91 (35%) of respondents reported having a pharmacy-led medication reconciliation program. Of the hospitals represented by these respondents, 17/32 (53%) have a pharmacist or pharmacy staff designated to perform various elements of medication reconciliation. While this and other studies show that pharmacy-led medication reconciliation programs can decrease hospital readmissions, time and cost of employing appropriate healthcare professionals must be considered.
Time constraints are a major limiting factor in performing adequate medication reconciliation. Hospitals involved in this study reported most frequently that it could take at least 10–20 min to complete each part of the medication reconciliation process—obtaining a home medication history, reconciling orders, and discharge counseling—a possible 30–60 min per patient (Table 3). Jack et al. 11 reported that the discharge component alone can take approximately 30 min per patient. Time constraints put extra pressure on healthcare professionals who are expected to perform medication reconciliation services along with their usual daily responsibilities. Dedicated medication reconciliation pharmacists can alleviate that pressure.
Under time constraints and pressure, physicians may be prone to error. Researchers in Tam’s 3 study analyzed five cases in which physicians were responsible for obtaining home medication histories; the results showed that up to 54% of patients had at least one medication history error. Similarly, Boockvar’s 12 study illustrated that physicians considered other responsibilities as a higher priority when time is a limitation.
Reeder explained that although it is rare to see pharmacists responsible for collecting home medication histories (only 5% of hospitals in their study), these histories are considerably more accurate than the ones collected by physicians and can lead to less adverse drug events. 6 Pharmacists who have other responsibilities, such as verification of orders (staff) or participating in patient rounds (clinical), can experience time constraints as well.
The survey results of this study showed that other hospitals have moved in the same direction as the Memorial Sloan-Kettering and the OHSU Hospital: they have implemented pharmacy-led medication reconciliation programs. Out of 91 respondents, 17 had a dedicated pharmacist or pharmacy staff to perform medication reconciliation.
Our study showed that 51/59 (86%) of home medication histories were recorded by nurses in non-pharmacy-led programs. However, in programs led by pharmacists, there was significantly less nurse involvement when dealing with medication reconciliation, 15/32 (47%). The difference is often made up by utilizing clinical pharmacists, staff pharmacists, pharmacy residents, pharmacy students, and pharmacy technicians.
Physicians were extensively involved in reconciling home medications and hospital orders, in both pharmacy-led and non-pharmacy-led groups. Some of the larger differences between the groups included the level of involvement of clinical pharmacists and pharmacy residents which was doubled or greater in the pharmacy-led group (Figure 2). With regard to discharge counseling, clinical pharmacists had the most involvement of the pharmacy department, second were staff pharmacists, and both were considerably more involved in the pharmacy-led group when compared with the non-pharmacy-led group, 15/32 (47%) versus 15/59 (25%) and 7/32 (22%) versus 5/59 (9%), respectively (Figure 3).
Pharmacists can be an integral part of medication reconciliation services in healthcare settings, by providing medication education, informing the importance of maintaining updated medication list, and encouraging patients to schedule follow-up appointments. 13 This pharmacist involvement enables patients to feel ready for discharge and to feel comfortable managing their medications. Moreover, these pharmacy services may improve overall patient satisfaction.
The benefits of pharmacy involvement were made clear in previous studies and a need for proper allocation of staff and resources were found in ours. Future studies may show a further increase in pharmacy-led medication reconciliation programs.
Limitations
A disproportionate number of responding pharmacists in this survey represented large hospitals in urban settings. According to this study’s chi-square analysis, home medication histories collected in larger and urban hospitals were found to have significantly more pharmacist involvement. Although the survey did not request the name of the hospital to be disclosed, demographic questions, such as the state, number of beds, and location of institution (suburban/urban/rural), may provide sufficient information to suggest that the majority of respondents did not come from the same institution.
Cross-sectional nature of this study is a limitation due to the fact it was carried out at one time point and results are a snapshot of hospital practices at the time the study was conducted. However, this can be used as a baseline for similar studies to track pharmacy involvement in medication reconciliation process.
Conclusion
Medication reconciliation has been recognized as an important National Patient Safety Goal by the Joint Commission. Studies have shown that hospitals with medication reconciliation programs led by pharmacists, as part of the interdisciplinary team, may have improved outcomes in the following areas of assessment: the rates of medication errors, adverse events, and readmissions. This study assessed the degree to which pharmacy personnel are involved in medication reconciliation in hospitals nationwide, and it explores pharmacists’ role related to medication reconciliation programs in healthcare systems.
Large urban hospitals were found more likely to have pharmacy-led medication reconciliation programs than their smaller, rural/suburban counterparts. Other pharmacy personnel were often involved in the medication reconciliation process. More than half of these programs employed a dedicated pharmacist or pharmacy staff to perform medication reconciliation. It was reported most frequently that it could take at least 10–20 min to complete each part of the medication reconciliation process—obtaining a home medication history, reconciling orders, and discharge counseling—up to 30–60 min per patient (Table 3).
This study can serve as a baseline to trend hospitals’ response to the new standards set for medication reconciliation programs by the Joint Commission. Future studies can use these data to determine the extent to which pharmacy has contributed to reducing medication reconciliation errors, improving outcomes, and improving patient satisfaction in healthcare systems nationwide.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.