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    Pharmacists take aim at med errors during care transitions


    Government mandates and increasingly complex patient medication regimens are fueling a need in hospitals for medication reconciliation systems that will provide close and thorough review of patients’ drug lists upon admission, transfer, and discharge, in order to prevent inconsistencies or errors across transitions of care.

    Error prevention

    The subject is not new to healthcare institutions. Medication errors, including those resulting from unsuccessful medication reconciliation, have come under increasing scrutiny for more than a decade and continue to be a persistent problem.

    “Preventing Medication Errors,” a report published in 2006 by the Institute of Medicine (now the National Academy of Medicine), said the average hospitalized patient is subject to at least one medication mistake per day, putting drug errors at the head of the list for patient safety errors.

    A study published in The Joint Commission Journal on Quality and Patient Safety in 2004 found that more than 40% of medication errors were believed to result from inadequate reconciliation in handoffs during admission, transfer, and discharge of patients. Of these errors, approximately 20% were believed to result in harm.

    The Joint Commission made medication reconciliation a National Patient Safety Goal in 2005, and meaningful use requirements include a medication reconciliation mandate.

    Industry insiders suggest that one way to prevent medication errors is for healthcare organizations to make it a priority to develop, implement, and sustain effective medication reconciliation practices.

    State of the art

    Hospitals and health systems are turning to state-of-the art reconciliation systems.

    Munroe Regional Medical Center in Ocala, Fla, has adopted the MedsTracker MedRec system from First Databank. So far, the program has been well received by the medical, nursing, and pharmacy staffs.

    David Willis, MD, chief medical information officer, said users have found the system very intuitive. “On admission, we have benefited from a couple of the key features from the MedsTracker app. We’ve been able to pull information from the community when a patient may not remember all of his meds — we can find some lists within the community so we can at least have a conversation [with the patient],” said Willis.

    Another beneficial feature, he said, is system groups. Providers can easily compare the patient’s home medication list to the list of hospital medications, as the lists are presented side-by-side and delineated by color.

    Willis noted that his facility met Stage 2 Meaningful Use on all measures after using the system for only 11 days.

    “The system itself draws people along to better practice and behavior in doing the right thing, because it’s easier to do the right thing,” Willis said.

    Anthony Vecchione
    Anthony Vecchione is Executive Editor of Drug Topics.


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