Comprehensive medication history: the need for the implementation of medication reconciliation processes
Introduction: Providing comprehensive medication history (CMH) upon hospital admission is of outmost importance for proper patient evaluation and prescription of drug treatment. The aim of this study was to evaluate the implementation of medication reconciliation in clinical practice.
Methods: Patients admitted to a teaching hospital in Slovenia were randomly selected and included in the study. For each patient a CMH was obtained by a research pharmacist using various sources of information. Next, the medication history in the hospital medical record was reviewed. The prescribed drugs were assessed for completeness of information, and possible discrepancies between both medication histories were recorded and classified.
Results: Overall, 108 patients with a median age of 73 years were included in the study. The research pharmacist recorded the use of 651 medicaments, with all relevant details being available for 94.9% of these drugs. Of the 464 medicines listed in the hospital medical record, only 42.0% were considered complete. A comparison of the medication history and the medical record with the CMH revealed at least one discrepancy in 72.4% of the drugs listed. The majority of the identified discrepancies were often present both in the medication order on the drug chart (76.2%) and in the discharge letter (69.9%). Most medication discrepancies were due to drug omissions (20.9%) and commissions (6.5%).
Conclusion: The high rate of discrepancies between the recorded drug history and CMH reported in our study stresses the need for the implementation of medication reconciliation. The participation of pharmacists in the reconciliation process, described in this study, resulted in more complete and accurate drug histories acquired.
Lau HS, Florax C, Porsius AJ, de Boer A. The completeness of medication histories in hospital medical records of patients admitted to general internal medicine wards. Br J Clin Pharmacol 2000; 49: 597-603.
FitzGerald RJ. Medication errors: the importance of an accurate drug history. Br J Clin Pharmacol 2009; 67: 671-5.
Gates C. Drug history taking - avoiding the common pitfalls. Hospital Pharmacist 2006; 13: 98-100.
Tam VC, Knowles SR, Cornish PL, Fine N, Marchesano R, Etchells EE. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. CMAJ 2005; 173: 510-5.
Nassaralla CL, Naessens JM, Chaudhry R, Hansen MA, Scheitel SM. Implementation of a medication reconciliation process in an ambulatory internal medicine clinic. Qual Saf Health Care 2007; 16: 90-4.
Varkey P, Cunningham J, O'Meara J, Bonacci R, Desai N, Sheeler R. Multidisciplinary approach to inpatient medication reconciliation in an academic setting. Am J Health-Syst Pharm 2007; 64: 850-4.
Vira T, Colquhoun M, Etchells E. Reconcilable differences: correcting medication errors at hospital admission and discharge. Qual. Saf. Health Care 2006; 15: 122-6.
Tizard J. Taking drug histories - an audit of technician accuracy. Hospital Pharmacist 2007; 14: 351-2.
Nickless G, Noble H. How to take an accurate medication history when a patient is admitted. Clinical Pharmacist 2009; 1: 31-2.
Dawson P, Gray S. Clinical significance of pharmacist-obtained drug histories. Pharm J 1981; 227: 420.
Lewis PJ, Dornan T, Taylor D, Tully MP, Wass V, Ashcroft DM. Prevalence, incidence and nature of prescribing errors in hospital inpatients. Drug Saf 2009; 32: 379-89.
Tully MP, Ashcroft DM, Dornan T, Lewis PJ, Taylor D, Wass V. The causes of and factors associated with prescribing errors in hospital inpatients. Drug Saf 2009; 32: 819-36.
Pickrell L, Duggan C, Dhillon S. From hospital admission to discharge: an exploratory study to evaluate seamless care. Pharm J 2001, 267: 650-3.
Zavod za zdravstveno zavarovanje Slovenije. Prenova sistema kartice zdravstvenega zavarovanja z uvajanjem neposrednega (on-line) dostopa do podatkov zdravstvenega zavarovanja. Retrieved 30 November 2009 from: http://www.zzzs.si/
Glintborg B, Poulsen H, Dalhoff K. The use of nationwide on-line prescription records improves the drug history in hospitalized patients. Br J Clin Pharmacol 2007; 65: 265-9.
Duggan C, Feldman R, Hough J, Bates I. Reducing adverse prescribing discrepancies following discharge. Int J Pharm Pract 1998; 6: 77-82.
Cornish PL, Knowles SR, Marchesano R, Tam V, Shadowitz S, Juurlink DN, et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med 2005; 165: 424-9.