Medication discrepancies are a cause of avoidable harm when patients are discharged from the hospital. As such, the Joint Commission has made medication reconciliation at discharge a requirement for hospital accreditation. However, in practice, the quality of medication reconciliation varies enormously. Review of medication discrepancies at discharge can be used to design better clinical systems.
To reduce medication discrepancies at discharge using a Web‐based tool with several novel, functional enhancements for medication reconciliation.
A clinician task force was convened to develop a discharge module with a customized medication reconciliation tool. In November 2011, the Web‐based discharge module, which included multiple discharge medication reconciliation enhancements, was implemented at our tertiary‐care hospital. Patient safety reports related to discharge medication errors and near misses were reviewed in an ongoing fashion, guiding additional enhancements. Current functionality includes the following features: (1) enforced individual reconciliation of each preadmission and active inpatient medication; (2) highlighting of differences in dose and/or frequency between preadmission, inpatient, and discharge medications; (3) sorting medications to be reconciled by drug class; (4) prompting to adjust medications that are tapers or of fixed duration based on doses administered in the hospital; (5) enforced attestation of medication reconciliation within 24 hours of discharge; (6) notification of changes to the preadmission and/or inpatient medication list after reconciliation has been initiated and reversion to “incomplete” if reconciliation had already been finalized prior to a medication change; (7) ability to import the time of the last dose given for each discharge medication from the inpatient medication administration record; (8) ability to distinguish “discontinued” from “held” medications, so as to specify the reason and time frame/plan for holding a medication; (9) ability to indicate “reason for taking” each medication in patient‐friendly terms; (10) anticoagulation‐related enhancements including fields for indication, duration, monitoring parameters, and who will monitor, as well as a display of last 3 doses given and last 3 INRs in patients who are on Coumadin. Implementation of an electronic discharge module with multiple features to promote medication reconciliation resulted in a trend toward a reduction of medication discrepancies at discharge (relative risk, 0.75; 95% CI, 0.63–1.1, P = 0.2) in a pre/post analysis, before and after implementation of the discharge ordering module. Ongoing analysis will see if further experience with the tool results in continued improvement over time.
Electronic clinical systems can both facilitate and enforce the medication reconciliation process. Beyond basic reconciliation of medication lists, additional features should be considered when designing medication reconciliation systems.
To cite this abstract:Boxer R, Zarakovich L, Likhtareva N, Postilnik A, Cardito M, Garrett L, Fraser P, Carty M, Miller A, Eric P, Schnipper J. Beyond Attestation: Functional Enhancements to a Medication Reconciliation System to Improve Medication Safety at Discharge. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 181. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/beyond-attestation-functional-enhancements-to-a-medication-reconciliation-system-to-improve-medication-safety-at-discharge/. Accessed July 23, 2019.