The importance of medication reconciliation
As people age, many develop a progressively complex mix of health conditions that require a growing number of medications to prevent the development of more serious illness. Older people take more medications than any other age group, and are therefore at risk of potential drug interactions or adverse drug events. Moreover, older people in Canada take four times more over-the-counter medications than any other age group. In 2009, 63% of them claimed five or more drugs from different drug classes. Twenty-three percent had claims for 10 or more drugs (1, 2). With many older people taking multiple drugs on a daily basis, effective medication assessment in the ED is critical.
Higher risk among older patients
Older patients are particularly vulnerable to medication discrepancies because they often have multiple disease states requiring treatment with multiple medications. Their risk for adverse drug events due to medication side effects, drug-drug interactions and adverse drug reactions is higher. This is often due to age-related pharmacokinetic and pharmacodynamics changes (3-5). Combined with a high prevalence of polypharmacy and frailty, the risk of adverse drug events in older patients is increased (6).
Adverse drug events lead to 11% of ED visits in patients older than 65 years versus 1% to 4% in the general population (7). Lack of medication reconciliation at points of transition (e.g. at hospital admission, transfer, and discharge) can lead to medication discrepancies and errors, which can potentially cause adverse drug events. The total cost of preventable drug-related hospitalizations is $2.6 billion per year (8).
Medication reconciliation is a process whereby health care professionals work together with patients, families and caregivers to gather and communicate accurate and comprehensive medication information consistently across transitions of care. Medication reconciliation involves a comprehensive review of all the medications a patient is taking to ensure that any medications being added, changed or discontinued are carefully assessed and documented.
Strategies for carrying out medication reconciliation
Medication reconciliation is a three-step process:
1. Create a complete and accurate Best Possible Medication History (BPMH) of the patient’s medications, including the drug name, dosage, route of administration and frequency. This step involves:
- Use of a systematic process to interview the patient/family (see Ten Practical Tips for a Best Possible Medication History and Best Possible Medication History Guide)
- Review of at least one other reliable source of information; clerical staff can assist in gathering other sources of information (eg. electronic provincial medication record; previous admission records/discharge summary; medication administration record (MAR) from another healthcare facility; medication vials; community pharmacy records)
2. Reconcile medications. Use the BPMH to create admission orders or compare the BPMH against admission, transfer or discharge medication orders; identify and resolve all differences or discrepancies between the patient’s BPMH and ordered medications.
3. Document and communicate any resulting changes in medication orders to the patient’s family/caregiver and to the next provider of care.
The goal is to use a process to obtain an accurate list that can be used to inform and enable prescribers to make the most appropriate prescribing decisions for the patient and reduce the potential for adverse drug events. This list can be used by all healthcare providers as patients are admitted, transferred throughout an institution, and eventually discharged.
The Pharmacist’s role
A heightened awareness of medication safety issues in older patients and comprehensive medication history-taking can lead to better detection and prevention of adverse drug events in the ED. Communicating with the patient’s other care providers and community pharmacy can be helpful. Clinical pharmacists in the ED can facilitate this process. Pharmacist–conducted medication reconciliation can reduce medication discrepancies, correct any erroneous information from prior acquired medication histories, and ensure that each intentional change in the medication plan is well documented during hospitalization and at discharge. Pharmacists are especially suited to conducting medication history interviews and assessments. They are experienced in using various sources of information to systematically gather an accurate and comprehensive BPMH (Best Possible Medical History), and have the expertise to scrutinize questionable medication orders, improve safe medication prescribing for older patients and optimize a patient’s drug therapy through collaboration with physicians and nurses in the ED.
References
- Canadian Institute for Health Information. Health Care in Canada 2011: A Focus on Seniors and Aging. (Ottawa, ON.: CIHI, 2011)
- Accreditation Canada, the Canadian Institute for Health Information, the Canadian Patient Safety Institute, and the Institute for Safe Medication Practices Canada. Medication Reconciliation in Canada: Raising The Bar – Progress to date and the course ahead. (Ottawa, ON: Accreditation Canada, 2012). https://accreditation.ca/sites/default/files/med-rec-en.pdf
- Shi S, Morike K, Klotz U. The clinical implications of ageing for rational drug therapy. Eur J Clin Pharmacol 2008; 64:183–99
- Cumbler E, Carter J, Kutner J. Failure at the transition of care: challenges in the discharge of the vulnerable elderly patient. J Hosp Med 2008; 3:349–52
- Olivier P, Bertrand L, Tubery M, et al. Hospitalizations because of adverse drug reactions in elderly patients admitted through the emergency department: a prospective survey. Drugs Aging 2009; 26:475–82
- McLean AJ, Le Couteur DG. Aging, biology, and geriatric clinical pharmacology. Pharmacol Rev 2004;56:163-184
- Hohl CM, Dankoff J, Colacone A, et al. Polypharmacy, adverse drug-related events, and potential adverse drug interactions in elderly patients presenting to an emergency department. Ann Emerg Med. 2001;38:666-671
- Hohl, CM, Nosyk B, Kuramoto L, et al. Outcomes of emergency department patients presenting with adverse drug events. Ann Emerg Med 2011;58:270-279
- Hohl CM, Yu E, Hunte GS, Brubacher JR, Hosseini F, Argent CP, et al. Clinical decision rules to improve the detection of adverse drug events in emergency department patients. Acad Emerg Med. 2012;9:640–9.