Research Activities, May 2013
Medication reconciliation meets its MATCH
Once a month on a Tuesday afternoon, Robbin St. John, R.Ph., doesn’t answer email or the phone. She closes her office door and sits down with a quality assurance nurse to review 20 complete medical records from St. Mary’s Hospital, a 200-bed hospital in Athens, Georgia. Each time, their mission is the same: to monitor medication reconciliation. They compare the patient’s current medication regimen against any admission, transfer, and discharge orders to identify medication discrepancies, and then they dig deeper.
"We want to know, for example, ‘Did the pharmacist enter every order correctly,’" explains St. John, a pharmacist at the hospital.
For 3 years, the percentage of charts that accurately portrayed a patient’s list of medications hovered below 90 percent. St. John, a pharmacist with 39 years of experience, knew St. Mary’s was performing better than many hospitals, but she wanted to improve. The need to do better is universal. AHRQ-funded researchers found that nearly 35 percent of hospital patients experienced a medication error at the time of admission. Of those errors, 85 percent originated in the patients’ medication histories. St. John took advantage of AHRQ’s MATCH toolkit to improve her hospital’s medication reconciliation process and patient safety.
Making a MATCH
MATCH stands for Medications at Transitions and Clinical Handoffs. "There’s been so much literature since as far back as 1985 about problems with medication discrepancies, but not enough about solutions," Kristine Gleason, M.P.H, R.Ph., a clinical quality leader at Northwestern Memorial Hospital in Chicago and one of the people who created MATCH, told Research Activities. "We wanted to put a spotlight on solutions such as medication reconciliation."
AHRQ’s MATCH toolkit was developed through an AHRQ Partnerships in Implementing Patient Safety grant that involved collaboration between Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine in Chicago, and The Joint Commission. The toolkit can help hospitals and other facilities address two U.S. Department of Health and Human Services "Partnership for Patients" priority goals involving better care transitions and fewer hospital readmissions and meet the Joint Commission’s national safety goal for maintaining and communicating accurate patient information.
"When we got experts around the table to talk about how to elicit medication information from patients that we needed, we discovered the way we frame the questions may impact the information we receive. I may ask a patient, ‘Have you started any medications recently?’ and the patient may define recent as the last couple of days or week," explains Gleason. "As a pharmacist, I may mean in the last month or even the last 3 months, as certain medications may take that long to achieve the full effect."
MATCH emphasizes standardizing the process for doctors, nurses, and pharmacists to document and confirm a patient’s home medication list on admission to the hospital. For example, the toolkit contains suggestions on how to phrase questions to ask patients about their medications, ways to engage management and clinical teams, as well as samples of flowcharts, templates, and other resources.
"We’ve been really excited to introduce the toolkit in hospitals, nursing homes, skilled nursing facilities, and home health care agencies that are often involved in health care transitions," says Gleason.
The team that developed the toolkit recruited hospitals to test MATCH by reaching out to Medicare Quality Improvement Organizations (QIO) across the country. Twelve States and more than 162 hospitals participated, according to Victoria Agramonte, R.N., M.S.N., a project manager of the Island Peer Review Organization, the QIO in New York. Agramonte also served on the team that enhanced the toolkit with findings from this collaborative.
"We didn’t anticipate this level of success," Agramonte told Research Activities. "Medication reconciliation can be a burdensome process, it’s deeply rooted in the hospital culture, and it can be hard to fix." For example, she says, "We know that there are hospitals today that have four or five medication lists in a patient’s record. Electronic systems are helping, but we’re not where we need to be."
She urges hospitals to try not to be overwhelmed by the magnitude of the problem. "Once you begin to identify the process and what you have to do, the fixes can be quite easy. A lot of the fixes that hospitals can put in place are system-level fixes," says Agramonte. "In one case, the hospital realized that the electronic health record only had a minimal amount of characters for putting in medications. When they fixed the problem, they got up to 85 to 90 percent compliance. We found that when hospitals really take the time to examine what they’re currently doing, they achieve a tremendous benefit in the end," says Agramonte.
How MATCH made a difference at St. Mary’s
St. Mary’s was one of 19 hospitals in the Georgia Hospital Association to implement the MATCH toolkit. "It focused us and put us on task," says St. John. "We flowcharted the process. We hadn’t done that in 5 years, and from flowcharting, we found bottlenecks." Those bottlenecks included the emergency room (ER) and the pre-operative area.
After spending 3 days in the emergency room and interviewing nurses, St. John concluded, "The ER has got to be the worst place to do medication reconciliation. Nurses don’t have a lot of time to dedicate to the medication reconciliation process, and there can be so many interruptions in the process." She watched as nurses made phone calls to the family and to the pharmacy. "The very process of gathering the correct data, including the last dose taken, is very intense, which can lead to errors."
The bottleneck St. John discovered in pre-op led to system changes. "We realized that our pre-op nurses were not doing medication reconciliation and that was a great opportunity, but they didn’t have the capability so we went to nursing and said, ‘You’ve got to put electronic records in pre-op.’ The system eliminates handwriting drugs. There’s a drop down menu with correct doses," St. John explains. "We’ve decreased errors and saved time."
To encourage patients to keep accurate lists of their medications and to bring their medications with them to the hospital, the hospital has medication cards and bags available in waiting areas. St. Mary’s Hospital also developed posters for drugs listing what St. John calls the "five rights or the five critical meds—blood thinners, heart meds, insulin, seizure meds, and psych meds that were crucial because they are high-risk and high-volume. We always need to get these right."
Usually St. Mary’s does get medication reconciliation right. Since using the MATCH toolkit, accuracy rates have risen to more than 90 percent. But for St. John, the job is never done. "I tell my boss, ‘You know medication reconciliation is never going away and it’s never going away from me as long as I work here. You just have to excuse my 39 years of enthusiasm!’"
Editor’s Note: To download the MATCH toolkit, go to http://go.usa.gov/TZum.