Prescription drugs are an omnipresent part of our healthcare system. Administering them might seem like one of the easiest things a hospital does, but the sheer volume and array of pharmaceutical options makes the system incredibly complicated and complex, particularly when a patient is first admitted to the hospital.
Because most people are already taking a few or, in some cases, a lot of medications, understanding which drugs and what dosage levels a patient is taking is critical to accurately diagnosing and caring for them going forward. Through a process of “medication reconciliation,” an accurate list of what the patient is currently taking is created and then compared closely with a physician’s orders so that the correct medications are given to the patient.
Typically, a nurse will create the initial list and work through the reconciliation process with the physician, then the hospital’s pharmacy re-examines the order and does a secondary reconciliation, making corrections or changes to about one out of every three “active” medication lists.
The pharmacists at Beaufort Memorial saw a better way.
“We were looking at what else we could do to increase patient safety, to better serve the patient and aid the clinical workflow,” recalls Khang H. Pham, PharmD. and Director of Pharmacy Services at the hospital.
“The initial process with the nurse wasn't truly medication reconciliation. They just didn't have enough time to dig into the patient profile and check with the pharmacy [about the medications]. It was cumbersome and convoluted.”
What Pham and his team realized, though, was that if they initiated the medication reconciliation process on the front-end, before the nurse and the physician, that they could do a better, more efficient job while cutting down on mistakes in the active medication list and potentially reducing adverse drug events.
“If my med rec team gets to the patient before the physician, and we do CPOE [computerized provider order entry], all of the orders will pop on through,” explains Samuel Wornall, Assistant Director of the program. “If they are already in good shape you might not touch it, but you're talking about 2-3-4 clicks, and maybe a minute or two minutes per order. If you look at the orders that come through before we get there, the likelihood that I'm going to have to go in and formally edit every one of those orders is very high.
“You're talking about an increase in time and clicks that's probably 4-5 minutes per order, plus an increase amount of risk to the pharmacists because they're having to go in and manually make changes to an order,” he continues. “Any time you have a human editing something the physicians already pushed through, you put in opportunity for error. So, we really slow down and take our time with those.”
Pharmacists and pharmacist technicians work to verify the medication list by checking with providers, other pharmacists, and insurance records and can spend time delving deep in a way that’s difficult for a busy nurse to do effectively. They are also more familiar with the names of more drugs and the variety of current brands, making them more adept at identifying correct medications.
“The nursing staff was 100% go forward with this. They don't have enough time and expert level and knowledge to [do it],” points out Khang. “We're the experts in many cases. For us, a complicated profile takes 45 minutes up to hours. Nurses don't have that kind of time.”
Stephanie Whiteside, one of the pharmacists hired specifically to do the front-end medication reconciliation process, says the difference is abundantly apparent.
“As a pharmacist, we just know the meds so much better,” she explains. “We know when something's not right. When that happens, I will immediately start formulating a set of questions to ask the patient or family or call the doctor's office about. Our background allows us to dig a little deeper and find out things you would never have otherwise without asking the right questions.”
To initiate this process, Khang performed a gap analysis and presented a proposal to hospital leadership, emphasizing that the approach would require pharmacists in different positions but would ultimately save money—up to the equivalent of one full-time pharmacist—with increased efficiency.
Now, nearly a year into the program, the pharmacy has found that the new medication reconciliation process has performed exactly as promised, with the error rate in the active medication list dropping from 34% to 2% when the reconciliation process is performed by a pharmacist first. Khang estimates there’s a roughly 200% return on investment.
“When a nurse gets a new patient to be admitted, the list of assessments and checkboxes and questions and things you have to do with that patient—it’s pages,” Wornall points out. “If you can take this task that you're not comfortable with and it's not high on the priority list and take it away, they jump all over it, they really do.”
Physicians were a little harder to integrate effectively into the workflow, but Whiteside says they did a number of things to make the transition comfortable for them, too, including some internal marketing and having the reconciliation-assigned pharmacist stationed in the emergency department so they would be a familiar face.
“A lot of them really value having that med list there [now], and their buy-in is key,” she asserts., noting that both nurses and physicians alike “love having a pharmacy-led medication reconciliation team” now.
These pharmacists are justifiably proud of the impact they’ve made, and others, including The Joint Commission for Transforming Healthcare, are taking notice. And it all stemmed from an honest look at a process everyone was comfortable with.
“Seeing those [initial] numbers was really eye-opening,” Wornall concludes. “To see that it's not just in other people's hospitals, it's in your hospital. And to know that we are making a difference is huge.”