Improving Medication Safety

Medication errors account for about 20 percent of all harmful events that occur in health care settings. Of these errors, more than half are associated with transitions between levels of care – for example, a transfer from a general inpatient unit to the Intensive Care Unit or during hospital admission or discharge.

At BCH, we’ve taken action to make our hospital safer by creating a Medication Utilization Safety Team (MUST) that coordinates a comprehensive, long-term effort to track, monitor and adjust medications as our patients move through the hospital. This program uses the expertise of the hospital’s pharmacists, physicians and nurses in a very structured and collaborative system that has reduced potential medication errors at the hospital, significantly improving quality of care for our patients.

What Is Medication Reconciliation?
Medication reconciliation is the process of creating the most accurate list possible of all medications a patient is taking, including over-the-counter drugs and herbal remedies.  This list includes the drug name, dosage, how often it’s taken and how it’s administered (for example, by pill or by injection).  This comprehensive list is then compared against any new medication orders so that a patient’s overall drug regimen can be adjusted when necessary.

An important final step of the process is to communicate the revised list of all medications a patient is taking to appropriate caregivers as well as the patient. The goal is to avoid errors such as omitting medications, duplicating drugs, giving too much or too little of a medication or causing a harmful reaction by “mixing” the wrong medications.  To be most effective, this process must be consistent.  It has to start when a person is admitted to the hospital and methodically track all medication changes as a patient moves through different parts of the health care system until that person is discharged to return home.

BCH has spent about five years developing and refining our system for medication reconciliation.  MUST was established  and charged with creating and managing effective processes and systems to help caregivers throughout BCH take a more consistent and thorough approach to medication management.  The team regularly reviews the results of this ongoing process and revises procedures as necessary. Team members represent the hospital’s Nursing, Pharmacy, Patient Safety & Quality and HomeCare departments.

The BCH Medication Reconciliation Program
At BCH, our goal is not only to reduce medication errors, but also to help our physicians make the best possible medication choices. We concluded that simply creating a medication list wasn’t enough – we expanded the value of our medication reconciliation (Med Rec) list by setting it up to function as a Physician’s Order form.

After the Med Rec list is compiled, the physician continues, discontinues or changes dosages for every listed item. The physician also orders any new medications that a patient needs. The original Med Rec list remains available as a resource for every caregiver who is involved with that patient.

Dedicated Med Rec Personnel
BCH also expanded our staff to include a clinical pharmacist dedicated specifically to the medication reconciliation process. This pharmacist meets with newly admitted patients, providing invaluable expertise that helps patients accurately catalog their current medications. The pharmacist spends time with patients and families to answer questions and correctly identify medications or dosages where the patient’s knowledge is limited.  The Med Rec pharmacist also can recommend minor adjustments to the way a patient’s drugs are administered in order to reduce side effects and improve the therapy.

The Med Rec pharmacist carefully reviews admission or transfer/discharge medication order forms compiled during his off-hours by nurses or doctors, then contacts the prescribers with any follow-up questions. He also reviews any physician-ordered changes as the patient moves between levels of care within the hospital. During the hospital’s evening hours (2:30-10:30 p.m., Monday-Friday), a patient flow nurse is assigned to create and update Med Rec forms for Pharmacy and physician review.

Valuable Wallet Card
The MUST team also developed a handy wallet card patients can use to list all of their currently prescribed drugs and doses. BCH inpatients are given the wallet card when released from the hospital. Patients are encouraged to keep the wallet card at all times and share their drug information with physicians or other caregivers at future appointments. 

Patients and families should update the card (and discard old versions) as their medication use changes.

The card is extremely helpful when a patient goes to a retail pharmacy or goes to any medical facility for care.

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