Medication reconciliation is a vital patient safety process, particularly during transitions of care where medication errors are more likely. The Joint Commission defines it as comparing a patient's current medications with new orders to resolve any discrepancies. This process follows three core steps: verification, clarification, and resolution.
The First Step: Verification (Gathering the Best Possible Medication History)
Verification is collecting a comprehensive and accurate list of all medications a patient is taking, known as the Best Possible Medication History (BPMH). Relying only on patient memory can be inaccurate. This step involves multiple sources and is often done by a trained professional like a pharmacist or nurse.
How to achieve thorough verification:
- Patient Interview: Talk to the patient or caregiver about their medications.
- Review Multiple Sources: Compare interview information with other records like pharmacy lists or medical charts.
- Include All Medications: The BPMH should list all prescription, over-the-counter drugs, vitamins, and supplements to avoid interactions.
The Second Step: Clarification (Ensuring Appropriateness)
Clarification reviews the medication list to ensure all medications and dosages are appropriate for the patient's current health. This step aims to prevent medication errors.
Key elements of the clarification process:
- Identify Discrepancies: Compare home medications with new orders, looking for omissions or duplicates.
- Screen for Interactions: Check for possible drug-drug or drug-disease interactions.
- Address Inconsistencies: Investigate unclear information by consulting with prescribers or other care team members to understand changes.
The Third Step: Resolution (Reconciling and Documenting Changes)
Resolution involves addressing the findings from verification and clarification. Discrepancies are resolved, and the updated medication list is documented and shared.
The process of resolution includes:
- Making Clinical Decisions: The prescribing provider, often with pharmacist input, decides how to address each discrepancy.
- Documenting Changes: A formal record of the reconciled medication list and reasons for changes is added to the patient's chart.
- Communicating the New List: The updated list is shared with the patient, family, and other providers, often with written instructions at discharge.
Comparison of the Three Medication Reconciliation Steps
| Feature | Verification (Step 1) | Clarification (Step 2) | Resolution (Step 3) |
|---|---|---|---|
| Core Purpose | Collect the most accurate and comprehensive list of patient medications (BPMH). | Critically review the gathered medication list for safety and appropriateness. | Resolve identified discrepancies, and communicate the updated plan. |
| Primary Goal | Avoid omissions by creating a complete medication history from multiple sources. | Identify potential medication errors, drug interactions, or inconsistencies. | Ensure a final, accurate medication regimen is documented and understood by all. |
| Key Activities | Patient interview, reviewing pharmacy records, checking previous charts, and collecting bottle information. | Comparing the BPMH with new orders and assessing clinical appropriateness. | Making final decisions on medication orders, documenting the changes, and communicating with the patient and team. |
| Potential Errors Addressed | Missing medications, wrong dosages, incorrect frequency due to incomplete history. | Drug-drug interactions, drug-disease interactions, dosing errors, therapeutic duplications. | Lack of communication, outdated medication lists, patient misunderstanding of their regimen. |
Challenges and Best Practices for Effective Medication Reconciliation
Challenges include limited resources and technology issues like difficulty sharing information between different EHR systems. Patients may also have trouble remembering their full medication list.
Best practices to improve the process include:
- Define Roles: Assign responsibilities clearly, often with pharmacists taking a leading role.
- Standardize: Use consistent workflows.
- Use Technology: Leverage EHRs while still conducting patient interviews.
- Involve Patients: Educate patients on bringing medications to appointments. Resources like the {Link: AHRQ's MATCH toolkit https://www.ahrq.gov/patient-safety/settings/hospital/match/index.html} can help.
- Prioritize High-Risk Patients: Focus on patients more likely to have discrepancies.
Conclusion
Medication reconciliation, using the steps of verification, clarification, and resolution, is vital for patient safety. This structured process helps reduce medication errors, especially during transitions. Addressing challenges through teamwork, technology, and patient involvement supports accurate and safe medication management.
