The Nurse's Role in Medication Reconciliation - BC Patient Safety ...

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The Nurse’s Role in Medication Safety • Nurses had to ask patients for lists of their current medications, which often were incomplete. • Physicians had to order new medications that were pertinent to the hospital diagnosis as well as to the patient’s current medication unless there was a duplication or an interaction. • Pharmacists had to evaluate all the medications ordered for food and drug interactions and drug-drug interactions. • Nurses were going to ask local pharmacies for pertinent information regarding patient’s medications over the telephone. • Family members would be involved to reconcile a patient’s current medication. The goal was to first make medication reconciliation on admission successful on the pilot unit and then to spread the process to the emergency department (ED), then to the remainder of inpatient nursing units, followed by the outpatient areas, the off-site areas, and eventually on discharge from a hospital. Diagnosis Discussion of the current and potential problems for the patient and the nurse When the Lourdes Hospital system first introduced medication reconciliation, it was to include one nurse, one physician, and one patient. It was successful on the pilot unit because of the nature of the unit and the staff working on the unit, which included the following: • An extremely dynamic cardiac telemetry unit where change is a daily thing • Nurses who knew their unit is often chosen for some project or test of change • A cardiologist whose patient population consisted of people with geriatric and cardiac issues who were taking several medications The hospital system initially chose the pilot unit for two reasons: One, a key member of the ADE team was a charge nurse on that unit, and two, that unit had (and still has) a highly collaborative relationship with the ED because of the number of admissions that occur on a daily basis. It only made sense to engage the ED next. And what a challenge it was. It took several revisions of the medication reconciliation process to meet the needs of the nurse, physician, and patient who entered the ED because patients seen belong to several categories, including the following: • Those who are assessed, treated, and released within an hour • Those who are assessed, treated, and released after some observation • Those who are assessed, treated, and admitted Patients from all walks of life enter the ED: those with disabilities and those resulting from disasters, those with little or no familial or financial support, those from nursing homes, and those who are homeless—all of whom need to have their 14
Chapter 1: The Nurse’s Role in Medication Reconciliation medications reconciled when entering the ED. Very early in the formation of the ADE PFA team, a key component to the success of this diligent process was to have an energetic, persuasive ED nurse who regularly attends team meetings and who could drive change. She served not only as a resource person for the team but as a champion of medication reconciliation because she believed it to be an important patient safety issue. When presented to the ED, medication reconciliation was met with the predictable physician and nurse resistance because it was perceived as time consuming and difficult. At first, the ED nurses and physicians resisted having to bear the burden of yet another change and the possibility for more paperwork. (And, yes, the process was time consuming and difficult to accomplish, in the beginning.) When the test of change was spread to the ED, it was done on the first day by the one persuasive nurse team member with one optimistic physician and one patient with a simple diagnosis and few medications. The ADE PFA team was this nurse’s committee (all nurses participate in committee membership at Lourdes Hospital) and her colleagues knew this. She believed in the importance of and accepted the challenge of medication reconciliation in the ED. Like anything that is repeated, the process became less complex with each new patient who came to the ED. And, if Lourdes Hospital’s PFA was patient safety, then it needed to be done 100% of the time. That was the explanation this nurse team member had to repeat several times a day until her colleagues were convinced that medication reconciliation was the right thing to do (and until it would soon be supported by policy). One complication specific to the ED setting was the fact that patients’ medication information could be difficult to obtain. At times, the patient had more than one physician in the community. Some patients could not even begin to report what medications they took, when they had taken them, or why. Patients from nursing homes had their medication lists but those lists were quite extensive. Still other patients had detailed lists of medications and could reiterate exactly when they took their last dose—medication reconciliation for those patients was relatively easy. In addition to the patients themselves, the nurses found they could rely on different sources of information to obtain accurate medication lists for their patients (for example, family members, local pharmacies, old charts, histories and physicals, and sometimes even the medication container labels). After the pilot unit and the ED adopted the process and after the ADE team provided intensive education for the nurses, pharmacists, and physicians, the process was very quickly spread to all inpatient and outpatient areas, including diagnostic imaging, perioperative services, ambulatory surgery, the GI laboratory, off-site physician offices, hospice, and home care. Essentially, the hospital system 15
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