The cost of designing, developing, and marketing a new pharmaceutical drug can literally exceed a billion dollars. Even millions more are invested in non-industry trials to demonstrate the efficacy — or lack thereof — of these drugs with certain medical conditions or clinical parameters. The process of getting FDA approval is another separate adventure in itself. Given the enormous effort in ensuring that drugs are safe and efficacious, it is curious that the same stringency is not applied in prescribing these drugs at the time of health care delivery.
Disclaimer: this is not a critique of health care professionals, but a discussion of some challenges surrounding medication reconciliation.
The MATCH (Medications At Transitions and Clinical Handoffs) Study recently found that 35.9% of patients admitted to the hospital had a medication error at admission with 85% of errors originating from an inaccurate medication history. Almost half of detected errors involved omissions. Over half (52.4%) were considered to normally require increased monitoring or intervention, while 11.7% were considered potentially harmful. The study added though that presenting a medication list or pills bottles at the time of admission decreased the risk of receiving a drug that would require increased monitoring or cause harm.
I can very easily relate to the challenges of obtaining an accurate medication list at the time of admission, despite best efforts and “due diligence”. Interestingly, the extreme examples of the John Does who were “found down” without any other contact information only comprise the minority of cases where medication reconciliation has been challenging. Instead, you have the completely lucid patient who says, “I was on two blood pressure medications, but I cannot remember their names”. Alternatively, you may hear, “I take these pink pills two times a day,” or “The dose may be 25 or 75.” Unfortunately, calling the primary physician’s office or pharmacies too commonly results in incomplete or conflicting medication lists.
This is not necessarily a fault of the physician’s office or pharmacies, but reflects a wider systems-based issue. The patient who sees multiple health care providers may “inherit” new drugs without the knowledge of other prescribers. This is particularly prevalent when the patient visits different Emergency Departments or is admitted at different hospitals. And with the growing ranks of uninsured individuals, many do not even have a primary care physician to oversee the cornucopia of drugs prescribed. In the outpatient world, particularly among my geriatric patients who are more prone to polypharmacy, I compare their medication lists to their actual pill bottles at each doctor’s visit and have too commonly discovered discrepancies between the two.
Another challenge to medication reconciliation is that prescriptions may be filled at different pharmacies, so each place may only have a partial record of a patient’s medications. Moreover, medication “refills” do not automatically expire when a physician discontinues a drug. A patient may inadvertently refill his hydrochlorothiazide (blood pressure medication) pills even after the drug had been switched to metoprolol (another blood pressure medication) by his primary care provider, running the risk of hypotension (low blood pressure) from overmedication.
Any solutions? At the hospital where I work, we have implemented various mechanisms to reconcile medications by both the nursing and physician staffs at the time of admission and discharge. This system is nevertheless still encumbered by the difficulty to obtain accurate medication lists at the time of admission (GIGO; garbage in equals garbage out). I feel that a universal medical record (or medication list) would provide a much more cost-effective and accurate inventory of a patient’s medications. The list would be accessible and editable by the patient, his or her care providers, pharmacists, and hospitals. This system, which would probably require a Federal mandate or open communication among EMRs, would greatly facilitate medication reconciliation and surely promote patient safety. There’s Medicine 2.0 for you! The next challenge? … improving medication compliance (taking medications as prescribed).
- Source
- Gleason KM, McDaniel MR, Feinglass J, Baker DW, Lindquist L, Liss D, Noskin GA. Results of the Medications At Transitions and Clinical Handoffs (MATCH) Study: an analysis of medication reconciliation errors and risk factors at hospital admission. J Gen Intern Med 2010 [epub]
