Medication Reconciliation Meets Patient Safety: The Changing Formulary Winds
I’ve spent a lot of time addressing the accuracy of the initial medication list in the context of what patients (or their family or friends) remember. I certainly cannot argue about the importance of ensuring that medication orders, written anew for each setting of the hospital, are scrupulously checked to verify that a medication has not been lost to follow-up. But I want to make one final point regarding reconciliation of the patient’s discharge list of medications with the in-hospital list.
As P&T committee members, we know that hardly a committee meeting goes by that we are not asked to approve the automatic substitution of one or many drugs for our formulary. A patient who was taking (atorvastatin) in the “free world” is now given in the hospital because our group purchasing organization or other buying entity now gives us the best price on the latter drug. Of course, the patient’s health plan or pharmacy benefits manager may get better rebates from the manufacturer of atorvastatin (to stick with our example). Thus, patients who might be coming to the hospital for a three-day stay and who are forbidden from bringing their own stash of medications used at home must be switched from the home drug to the hospital-sanctioned drug; the discharging clinician needs to remember to change the drug back or—in the case of new medications begun in the hospital—to choose the proper, covered item on the health plan formulary. In effect, then, we are reconciling not only medication changes, made from admission to discharge, but also formularies.
So what began as such a Disney moment (the launching of the medication reconciliation project) turns out to be an experience that can be confusing, complex, and time-consuming— for the hapless clinician and the hospital.
Of course, let’s not forget about the hapless patient. Maybe it will help if we move from mere discourse to a bit of visual imagery:
. . . It’s midnight, and 80-year-old, 200-pound Edith Edematous wakes up gasping with an exacerbation of congestive heart failure. She is barely able to dial 9-1-1, which brings flashing sirens and a group of paramedics, who rapidly ferry her to the local emergency room in her pajamas.
Leaning forward on her gurney, using all her accessory neck muscles, with the desperate goal of trying to pull air into her lungs, she finds herself surrounded by members of the health care team, all of whom have goals of their own. The intake nurse is peppering her with questions about what drugs she is taking (or not, as the case may be), even as the administrative clerk lunges for her Medicare card, while the admitting resident tries to ascertain whether she has signed a Do Not Resuscitate order.
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Intake nurse: “Honey, we’ll get you a bed, but first you need to tell us what medications you’re on. . . . OK, Edith, we know you’re on a water pill, but what else and how much and when? Something else for the heart, perhaps? What about your lipids, Edith? You look as if your lipids could be out of whack. No, I didn’t say ‘back,’ although I’m sure yours hurts. I said . . . oh, forget it. I’m yelling as loud as I can . . .”
Do you think we should stop and ask instead: What are we doing? What are we collecting? What are we reconciling? What is this all about?
Yet it seems I’m a little tardy with my questions and castiga-tions—lo, the regulations have already gone into effect! And regulations definitely drive behavior. Between sending out notices about the latest physician emeritus to shuffle off this mortal coil, medical directors and chiefs of staff are trumpeting word that we all need our shoes polished and our hair combed stat! Hurry, hurry . . .the Joint Commission (JCAHO) inspectors are coming, the inspectors are coming, and we’re not in compliance with this important quality/safety measure. And if we’re not in compliance, we fail, and you know what that means . . .
In response, front-line physicians who formerly couldn’t type are suddenly dispatching e-mails like nobody’s business—and you can actually read their notes. Maybe the pharmacists should be responsible for the reconciliation, some propose, creating a discharge list from a combination of the admitting list and the medication administration record (MAR). Maybe clinicians should use a single form that shows a column for admitting medications (collected by the nurse), followed by a column for verifications and corrections (provided by the physician), followed by a column for changes made during hospitalization, followed by the final discharge drugs that the physician wants the patient to take.
A few audacious souls have suggested in writing that it might be wiser not to list the discharge medications in the discharge summary at all. Instead, they recommend stating “Discharge medications reviewed with patient,” because they say that the current regulation requires only that a list be given to the patient ifthe discharge medications are listed or dictated for the chart. How’s that for gaming the game?
Sadly, this should not be a game, and it certainly was never intended to be. But even good intentions can go before a fall, and it would be a shame to see patients and clinicians suffer further because the “whole patient” and “whole system” perspectives are not being considered. We must get beyond the treatment of an isolated eyeball, the treatment of an elevated white blood cell count in a tube of blood absent assessment of the patient, or the treatment of a health care industry that has systemic idiosyncrasies and challenges that need to be considered in their totality.
It would be nice if information technology could help us communicate better one day, but technology alone is not likely to solve all of our problems. We must fully comprehend our current systems in order to appreciate the potential impact of new policies. We must try to understand our patients, perhaps by first understanding ourselves (and ultimately human behavior); then our well-intentioned solutions may stand a chance of working.