Three steps can help hospitals improve medication safety

Medication safety

There are many opportunities, big and small, from admission to discharge and beyond, to improve medication use by implementing well-designed medication reconciliation processes. Medication safety specialist Christina Michalek, BScPharm, FASHP, believes in a threestep process designed to reduce the risk of medication errors and improve patient outcomes.

Medication reconciliation process

It’s important to understand that medication reconciliation is “not just comparing one list of medications to another list of medications,” said Michalek during a session at the 2014 American Society of Health-System Pharmacists (ASHP) Midyear Clinical Meeting. She highlighted the Institute for Safe Medication Practices’ three-step process for improving medication use, which requires pharmacists and other health professionals to verify, clarify, and reconcile.

According to Michalek, studies show that poor communication of medication information at transition points is responsible for up to 50% of all hospital medication errors, and from 22% to 39% of these errors had the potential to cause moderate to severe harm.

Step 1: Verify

“We see [verification] as when we’re collecting and confirming an accurate list of the patient’s medications as well as their compliance with the medication,” Michalek told ASHP attendees. “It’s great that we can collect a list, but if they’re not taking the medication, [then] that is just as important for us to know.”

During the verification stage, “there are a lot of players in the process,” including nurses, pharmacists, and pharmacy technicians, she explained. A key factor to success is having a dedicated practitioner to take medication histories.

“Of course everybody recognizes that [a medication history] includes the drug, dose, and frequency, but what’s really important too is the purpose [of the medication] and the last dose they have taken,” said Michalek.

She also noted that it is important to identify medications that patients tend to forget about. Those medications include agents taken weekly, once monthly, or as needed; those that are kept in the refrigerator; and those that are not taken by mouth, such as patches, inhalers, and ophthalmic drops.

Michalek recommends using a scripted list of questions so that every person collecting a medication history can catch every medication, every dose, and the reason the patient is taking each medication.

Step 2: Clarify

Once the patient’s medication list is verified, pharmacists should take steps to clarify any discrepancies and make sure the medications make sense. Pharmacists need to “ensure that those medications and the doses and whatever is subsequently ordered is still correct for that patient at that point in time given their current health,” Michalek explained to session attendees.

The clarification step is sometimes conducted by multiple providers because often a lot of different practitioners are involved with assessing the patient, she noted.

“A failure point here is when practitioners don’t take into account what the patient has already taken,” said Michalek. “This is very troublesome to nursing and pharmacy staff because they are trying to make sure the patient is not going to receive a [duplicate dose], so they [need] to match up what has been ordered with what the patient has previously taken.”

Another failure point during the clarification step is if a hospital’s electronic health record system has a default setting for “continue all medications” or “order all medications.” This can lead to duplicate doses or continuation of outdated medications, noted Michalek.

Step 3: Reconcile

Reconciliation occurs when pharmacists consider and document all medications a patient is on before admission and with each change in the level of care, all the way through discharge.

During admission reconciliation, the patient’s home medication list is used to make decisions, but often failure points around this process occur when medications from a previous encounter aren’t documented, noted Michalek. “You have to think about [reconciliation] as a continuous process” on both the inpatient and outpatient side, she added.

The reconciliation step also includes patient education. Pharmacists need to make sure patients are “provided with clear and easy-to-understand discharge instructions,” said Michalek. A failure point during this step is when the discharge instructions fail to make it obvious to the patient, family, or caregiver which medications should be continued, which medications should be stopped, and how each medication should be taken, she noted.

Process challenges

Michalek highlighted the following roadblocks to a smooth medication reconciliation process:

  • Often there is no clear owner of this process.
  • There is not enough time to complete each step in the process.
  • Accurate sources of information may be difficult to identify.
  • Patients may have poor health literacy.
  • Patients don’t know (or aren’t in a position to explain) what they are taking, and family or their pharmacist is not available.
  • Patients may not want to admit what they have been taking.
  • Labels on bottles are outdated or incorrect.

In addition, Michalek noted that patients may take medications differently than prescribed or may take medications that are no longer prescribed.

It is important for pharmacists to “realize the importance and benefits of a checklist [for taking medication histories] to improve accuracy, decrease discrepancies, decrease omissions, and reduce readmissions,” said Michalek.

Other keys to successful medication reconciliation include using a dedicated practitioner to take medication histories and involving the patient, she added.

ISMP medication safety education

ISMP will hold a webinar, Evolution of Anticoagulants and the Effects on Patient Safety, from 1:30 pm to 3:00 pm (EST) on March 19.

Experts from the Sanford University of South Dakota Medical Center will provide an overview of the new anticoagulants on the market, focusing on potential risk points where errors may occur. Common errors with use of the agents will be highlighted. There will also be a discussion about practical steps to modify their use in health systems to prevent medication errors. For more information, visit https://

ISMP will hold three 2-day medication safety workshops led by ISMP faculty throughout 2015. Attendees will learn how to view their organization “through the eyes of ISMP” when it comes to medication issues that may lead to patient harm. Strategies to sustain safety efforts will be discussed. Upon completion of the workshop, attendees will have the knowledge and tools to establish a medication safety program at their institution.

The 2015 ISMP Medication Safety Intensive workshops will be held April 16 and 17 in Indianapolis, IN; September 17 and 18 in Bellevue, WA; and December 4 and 5 in New Orleans. For more information, visit default.asp.

Is your hospital following ISMP’s best practices?

The Institute for Safe Medication Practice (ISMP) has released the 2014–15 Targeted Medication Safety Best Practices for Hospitals. The practices have been reviewed by an external advisory panel and approved by the ISMP Board of Trustees. For more details about ISMP’s best practices or to download them, visit tools/bestpractices/default.aspx.

Best Practice 1:

Dispense vinCRIStine (and other vinca alkaloids) in a minibag of a compatible solution and not in a syringe.

Best Practice 2:

Use a weekly dosage regimen default for oral methotrexate. If overridden to daily, require a hard stop verification of an appropriate oncologic indication. For manual systems, require verification of an appropriate oncologic indication before dispensing oral methotrexate for daily administration. Provide patient education by a pharmacist for all weekly oral methotrexate discharge orders.

Best Practice 3:

Measure and express patient weights in metric units only. Ensure that scales used for weighing patients are set, and measure only in metric units.

Best Practice 4:

Ensure that all oral liquids that are not commercially available as unit dose product are dispensed by the pharmacy in an oral syringe.

Best Practice 5:

Purchase oral liquid dosing devices (oral syringes/cups/droppers) that display only the metric scale.

Best Practice 6:

Eliminate glacial acetic acid from all areas of the hospital. Laboratory use excluded if the lab purchases the product directly from an external source.