Best Possible Medication History in the Emergency Department
Medication reconciliation is a formal process of obtaining a complete and accurate list of each patient’s current home medications and comparing the list with orders written at each transition of care. The Safer Healthcare Now! Campaign is a national program intended to improve the safety of the Canadian health care system. The campaign consists of a variety of initiatives, one of which is preventing adverse drug events by means of medication reconciliation.
The most intricate part of medication reconciliation is obtaining the best possible medication history (BPMH). The BPMH is a comprehensive, systematically derived list of regularly used medications, both prescription and nonprescrip- tion agents. Obtaining an accurate and complete medication history is crucial, as it forms the basis of medication reconciliation from admission through to discharge. Incomplete or inaccurate medication histories can increase the risk of medication-related errors and complications.
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The process of obtaining a patient’s BPMH can be initiated by any member of the health care team. Pharmacists have extensive training in obtaining medication histories, and it has been proven that BPMHs obtained by pharmacists are more accurate and more complete than those obtained by other health care professionals. In an emergency department setting, Carter and others4 compared medication histories obtained by clinical pharmacists with those obtained by other health care providers, including physicians, nurses, and medical students. Although no statistical analyses were carried out, the researchers found that the pharmacists identified 279 additional home medications among 252 patients relative to the other health care providers (1096 versus 817 medications). Reeder and Mutnick conducted a similar study comparing medication histories obtained by physicians and pharmacists for patients admitted to an internal medicine service and concluded that the medication histories obtained by pharmacists were significantly more complete. Pharmacists identified 58 more medications than physicians; they also identified 353 discrepancies in 55 patients.
Although research to date has shown that pharmacists obtain the most accurate and comprehensive BPMHs, pharmacist shortages and time constraints may make it impractical to routinely assign this duty to this group of health care professionals. As such, new practice models must be considered to ensure that accurate and complete medication histories are obtained by properly trained members of the health care team. One group of individuals that might be considered for this role is pharmacy technicians. Several studies have investigated the involvement of pharmacy technicians in medication reconciliation, all with positive results. In one study, Michels and others found that utilization of well-trained pharmacy technicians to obtain medication histories before scheduled surgical admissions reduced potential adverse drug events by more than 80% within 3 months of implementation, relative to the 6 weeks before involvement of technicians. Another study, performed in a preoperative clinic in the Netherlands, compared the number of medication discrepancies before and after implementation of medication reconciliation by pharmacy technicians. The number of patients with medication discrepancies decreased significantly (by 13.2%) following assignment of technicians to this task. online canadian pharmacy
At The Moncton Hospital, medication reconciliation at the time of admission has been performed by pharmacists, nurses, and physicians for more than 12 years. Pharmacy technicians are teamed with pharmacists in multiple direct patient care areas, including the emergency department. Pharmacist coverage in the emergency department is from 0830 to 2030, Monday to Thursday, and from 0830 to 1630 on Friday; technician coverage is from 0800 to 1500, Monday to Friday. On average, 16 BPMHs are obtained daily by pharmacists in the emergency department. One duty undertaken by pharmacy technicians working in the emergency department is to obtain a preliminary medication list before the pharmacist completes the BPMH. The technician reviews the patient’s medication vials and medication profile and contacts community pharmacies if necessary for clarification of prescriptions. The pharmacist uses the information obtained by the technician to complete the BPMH, and this record is then used by the physician to write the admission medication orders.
The primary objectives of this study were to prospectively determine whether pharmacy technicians could obtain a BPMH in the emergency department with accuracy and completeness similar to that of pharmacists, and to determine if the pharmacists and pharmacy technicians at the authors’ institution met the national norms for unintentional discrepancies and the success index for medication reconciliation, as reported by Safer Healthcare Now! A secondary objective was to determine the average length of time for technicians and pharmacists to obtain a BPMH.