Definition of reconciliation
Q. What is meant by “completely reconcile?”
A. To “reconcile” is to compare and reach agreement. In the context of this safety goal, reconciliation is the process of comparing the medications (defined below) that the patient/client/resident is currently taking with the medications that the organization is planning to provide. The purpose of the reconciliation is to avoid errors of transcription, omission, duplication of therapy, drug-drug and drug-disease interactions, etc. It is up to each organization to determine how this process takes place. Medication reconciliation should take place early enough to improve the safety of the organization’s medication management processes, and hence patient/client/resident safety. Ideally, organizations will not prescribe a medication before obtaining a current list of the patient’s medications.
Definition of medication
Q. What is the definition of “medication?”
A. The Joint Commission;s definition of medication, as found in the glossary of each accreditation manual, is “any product designated by the Food and Drug Administration(FDA) as a drug, as well as any sample medications, herbal remedies, vitamins, nutriceuticals, over the counter drugs, vaccines, diagnostic and contrast agents, respiratory therapy treatments, parenteral nutrition, blood derivatives, and intravenous solutions (plain, with electrolytes and /or drugs). This defintion of medication does not include enteral nutrition soulutions (which are considered food products), oxygen, and other medical gases.”
Personnel allowed to perform reconciliation
Q. Who is supposed to do the reconciliation?
A. The organization determines who will perform the reconciliation. The organization is responsible for evaluating an individual’s qualification and competency to perform the reconciliation, consistent with applicable law and regulations. We are seeing two models: one in which the physician does the reconciliation when the orders are written and another in which the pharmacist or nurse does the reconciliation before preparing or administering the medications, and then notifying the physician if there are any concerns. Either is acceptable for meeting the requirements of this safety goal.
Incomplete medication information
Q. What if we are unable to obtain a complete list of the patient’s current medications?
A. The expectation is that the organization will make its best effort to obtain for each of its patients/clients/residents a complete and accurate list of the patient/client/resident’s current medications. It is recognized that for some patients/clients/residents this will not be possible, but failure to obtain a truly complete and accurate list should be because of patient/client/resident-specific factors, not for lack of trying. If a surveyor encounters an absent or incomplete list, the response will be to ask why a complete list could not be obtained. The reasons should be easy enough for the organization to identify. If there is no reasonable patient/client/resident-related explanation, then a RFI is indicated.
Multiple patient medication lists
Q. If a patient is admitted to the hospital from home, we create a list of the patient’s home medications and use it to reconcile against the admitting orders. Those new orders now become the patient’s “current medications.” That list will be further modified as the patient changes setting or level of care within the hospital. How many lists should we be keeping?
A. Two lists must be maintained during the hospitalization. The “home medications” list should be maintained unchanged and available for subsequent use in the reconciliation process. The list of the patient’s current medications while in the hospital is a dynamic document that will require updating whenever changes are made to the patient’s medication regimen. Whenever reconciliation is carried out, both lists should be considered. The reason for referring back to the “home” medication list is that some “home” medications may be held when a patient is admitted or goes to surgery. They may need to be resumed upon transfer to a different level of care, return from the OR, or at discharge.
Multiple providers lists
Q. We have a multi-specialty clinic. Would it be acceptable for each clinic to maintain its own list of the medications the patient is on relative to the care provided by that clinic? The patient would have all the lists.
A. No that would not meet the expectations of Goal #8, which requires a single, complete list to be developed and subsequently provided to the patient and to all of the patient’s providers of care. Everyone should have the same list and the list should include all medications that the patient is on. For each provider to maintain a separate list of “relevant” medications would defeat the intent of the reconciliation process and represents an extremely provider-centric approach; clearly less safe than the patient-centered approach we are advocating for all aspects of care.
Diagnostic imaging
Q. Who is qualified to do the screening interview with patients in the imaging services department? Is this required of the radiologist to perform or can this be delegated to a radiology technologist?
A. The Joint Commission does not specify who does what in the medication reconciliation process, only that whoever is assigned responsibility to do something must be qualified and competent to do it. The determination of qualification and competency is left to the organization to determine, consistent with applicable law and regulation. If a radiology technologist is permitted by law to do this function and the organization determines the person is qualified and competent to do it, then it will be acceptable to The Joint Commission.
Physician familiarity with medications
Q. Some physicians are reluctant to review and act upon (decide to continue/change/discontinue) the home/current medication list at discharge because of lack of familiarity with many of the drugs.
A. If the physician is not familiar with the drugs, he/she shouldn't be taking any action concerning them. In situations like this, it may be more practical for the reconciliation to be done by a pharmacist. Remember, the discharge list is not an order. If there are concerns about continuing some of the medications the patient was previously taking, the patient’s primary care physician or the original prescribing physician should be contacted.
Labor and delivery patients
Q. Is it necessary to reconcile medications upon admission for a patient in labor who is NPO except for sips of water until she delivers? Can the medications just be reconciled after delivery?
A. Since the intent is to avoid errors in the ordering of medications, every effort should be made to obtain a list of the patient’s current medications as soon as possible so that it will be available to the prescriber when medications are ordered. If the “patient in labor” has received prenatal care from the organization, this list should already have been obtained and included in the prenatal record. If not, it should be obtained as soon as possible. After-the-fact reconciliation is not acceptable unless the urgency to treat the patient precludes prospective reconciliation.
Operative and procedural patients
Q. How does National Patient Safety Goal 8 apply to surgery and other procedures? All medications are suspended during procedures and the physician is required to reorder medications post-op.
A. Assuming there is an up-to-date list of the medications the patient was prior to the procedure (“home medication” list for outpatients; MAR for inpatients), all that is required is for the physician ordering the post-op medications to look at the pre-op list and consider that information in determining what to order for the patient post-op. Alternatively, a nurse or pharmacist can compare the post-op orders with the pre-op medication list and if there are any discrepancies or concerns (omissions, duplications, potential interactions, etc), the physician should be notified.
Anesthesia medications
Q. What about intraoperatively? All kinds of potent medications are administered in the operating room for anesthesia. Is medication reconciliation required here?
A. Yes; medication reconciliation is required, but all that means is that a list of the patient’s current medications must be available and known to the anesthesia provider and that the information on that list must be taken into consideration when administering intraoperative medications. This is a routine aspect of planning and administering anesthesia.
Immunization clinics
Q. Does medication reconciliation apply to immunization clinics?
A. Influenza vaccine and other vaccines are medications. In the case of brief encounters where a single dose of a medication (such as a vaccine) is administered and there is no change to the patient’s continuing medication regimen, this would mean (1) obtaining a list of the patient’s current medications and (2) using that list to screen for any possible problems in relation to the medication to be administered. There would be no need to provide an “updated list” to the patient because the list of current medications would not have changed.
In the case of influenza vaccination, we have attempted to determine whether it is necessary and reasonable to gather a list of the patient’s current medications when providing the flu vaccine. In other words, would knowing all the medications a patient is on be of any use in determining whether it is safe to vaccinate the patient? The following review has been provided by our medication safety expert advisors:
There currently are two types of influenza vaccine available---the inactivated vaccine and the live vaccine. The inactivated vaccine is used most extensively. Potential drug interactions would be most clinically relevant with the live vaccine; patients receiving immunosuppressant therapy should not receive the live vaccine. Children receiving aspirin also should not receive the live vaccine because of the association of Reye's syndrome with wild-type influenza virus.
For the inactivated vaccine, there is no real contraindication to using it based on potential drug interactions. Some clinicians still recommend screening for anticoagulant (i.e., warfarin) use, particularly since the vaccine is administered IM; others state that the inactivated vaccine is not contraindicated in someone receiving warfarin. The main area of drug therapy that would be of interest is immunosuppressants (e.g., certain antineoplastics and corticosteroids) since the immune response to the vaccine may be blunted. The main effect is on timing of vaccination relative to the last dose of the immunosuppressant, if the latter drug(s) is only given periodically (e.g., intermittent cancer regimens). The risk is not in a potential toxicity from combined use but in possibly inadequate protection from the vaccine. Even here, the bottom line is that giving the vaccine rather than withholding it would still be better than risking not getting the vaccine at all since a blunted vaccine response still could provide some benefit (e.g., ameliorate clinical severity if infection were to occur).
Based on that assessment, it is The Joint Commission’s position that medication reconciliation is required whenever the live vaccine is used but that it will be left to the provider organization to decide whether to gather a list of the patient’s current medications and review that list prior to administering inactivated vaccine. If the organization’s decision is not to do this, then each patient must be provided information about the risks of vaccination and encouraged to share any relevant information before receiving the vaccine. Note that Federal law requires that a Vaccine Information Sheet (VIS) be provided to the patient prior to administering a dose of vaccine. For more information on this requirement, please visit http://www.cdc.gov/nip/publications/VIS/vis-facts.htm
LTAC hospitals
We are a long term, acute care (LTAC) hospital. Most patients have been hospitalized for weeks to months prior to coming to our organization. Are we required to document meds taken at home prior to the first hospitalization? Are they considered “current” meds?
A. No; in this situation the original “home” medication list is not the list of “current” medications at the time of entry into your LTAC facility. Upon entry into your facility, the patient’s “current” medications are those listed on the “discharge” list of medications provided to you by the sending organization. On the other hand, it might be a good idea to find out what the patient was taking at home to determine whether there are some medications that have been “held” that should be resumed or to counsel the patient about meds (especially OTCs, herbals, and other non-prescription meds) that were being taken, which, perhaps, should not be used.