Medication Reconciliation
Medication reconciliation is a crucial process in healthcare that involves creating a comprehensive list of all medications a patient is currently taking, including prescription and over-the-counter drugs, supplements, and other treatments. The purpose of this process is to ensure that patients receive the correct medications, particularly during transitions in care, such as hospital admissions, transfers, and discharges. By accurately compiling medication lists, healthcare providers can prevent adverse drug events (ADEs) that may arise from dosing errors, drug interactions, or omissions.
During medication reconciliation, it is essential for medical personnel to document the drug name, dosage, frequency, and method of administration. This process is vital not only at the point of admission but also throughout a patient's stay and upon discharge to ensure continuity of care. When discrepancies are identified between the patient's current medications and their medical records, healthcare providers make necessary adjustments and communicate the updated medication list to both the patient and other care providers. This proactive approach helps to safeguard patients' health and enhances the overall safety of medication management in healthcare settings.
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Subject Terms
Medication Reconciliation
Medication reconciliation is the process of making a list of all medications a patient is taking. (Medications include prescription and over-the-counter drugs, herbal and nutritional supplements, vitamins, vaccines, diagnostic and contrast agents, radioactive medications, parenteral nutrition, blood derivatives, and intravenous solutions). Compiling a medication reconciliation ensures that a patient receives the correct medications. It is used to prevent adverse drug events (ADEs) such as dosing errors, drug interactions, duplications, or omissions. Health care providers should include the drug name, dosage, frequency, and route when listing the medications a patient is taking. This information is taken during all transitions in care such as during admission, transfer, and discharge at hospitals or medical facilities or if there are changes in the setting, service, practitioner, or level of care.
Overview
Patients receiving medical care either at hospitals or other medical care facilities usually receive new medications or have their medications altered while under care. If correct medications are not listed on a patient's records, it can create potentially life-threatening consequences for a patient during care or after release. While medications are listed prior to admission, these medications may change based on care. If medical personnel treating a patient are unaware of these changes, they can inadvertently give a patient incorrect instructions regarding medication, omit medications, give unnecessary medications, and more, all of which could increase a patient's risk of ADEs.
As a result, medication reconciliation is important to avoid inconsistencies that could lead to ADEs. Medical personnel should review all drugs a patient is taking at the time of admission, during transfer, and upon discharge and compare the list to patient records or medication orders.
Steps
The medication reconciliation process should be performed when a person is admitted to the hospital, during the patient's stay, and at discharge. This helps to ensure that patients receive the correct medication at all transitions in care and prevents medication errors that could result in serious consequences for the patient.
For a person newly admitted to the hospital, medical personnel should compile a list of current medications the person is taking and write orders for any medications to be prescribed during the hospital stay. These two lists are compared, and if discrepancies are found, a decision is made regarding the medications, such as changing a dose or particular brand of medication. Last, the new list of medications is communicated to caregivers and the patient.
When a patient is discharged, medical personnel should list all medications a patient is taking and include instructions for any new medications the patient was given. This list should be compared to previous lists, and any discrepancies should be resolved. The list of medications should be communicated to the patient's physician for use during follow-up care.
Bibliography
Barnsteiner, Jane H. "Chapter 38: Medication Reconciliation." In Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Ed. Ronda G. Hughes. Rockville, MD: Agency for Healthcare Research and Quality, 2008. http://www.ncbi.nlm.nih.gov/books/NBK2648/#top
"Medication Reconciliation." Patient Safety Network. Agency for Healthcare Research and Quality. March 2015. Web. 24 Nov. 2015. https://psnet.ahrq.gov/primers/primer/1/medication-reconciliation "Using
"Medication Reconciliation to Prevent Adverse Drug Events." Institute for Healthcare Improvement. Institute for Healthcare Improvement. Web. 24 Nov. 2015. http://www.ihi.org/topics/adesmedicationreconciliation/Pages/default.aspx
"Using Medication Reconciliation to Prevent Errors." Sentinel Event Alert. Joint Commission. 25 Jan. 2006. Web. 24 Nov. 2015. http://www.jointcommission.org/assets/1/18/SEA‗35.pdf