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MASSACHUSETTS NURSE NEWSLETTER ::
April 2008
Medication reconciliation in the emergency department setting
By Richard A Lambos RN
Interim ER/ICU Clinical Coordinator,
Martha’s Vineyard Hospital
The Joint Commission’s 2008 National Patient Safety Goals for hospitals once again has medication reconciliation as one of its goals.
The section dedicated to this topic is Goal 8, which reads: “Accurately and completely reconcile medications across the continuum of care.” This year’s Goal 8 is no different from The Joint Commission’s 2007 National Patient Safety Goal 8.
The publication of The Joint Commission’s 2007 National Patient Safety Goals concerns about the impact on efficient operation and implementation of medication reconciliation in emergency departments prompted three groups with direct knowledge of ED procedures — Emergency Nurses Association (ENA), American College of Emergency Physicians (ACEP) and theAmerican Association of Emergency Medicine—to get involved. Below are excerpts from a May 30, 2006 letter sent jointly by Nancy Bonalumi, RN, MS, CEN, president of ENA, Frederick C. Blum, MD, FACEP, FAAP, president of ACEP, and Tom Scaletta, MD, FAAEM, president of AAEM to Dennis S. O’Leary, MD, president, Joint Commission on Accreditation of Health Care Organizations:
“This correspondence is to express our grave concern regarding JCAHO’s medication reconciliation standard (MM 4.10) and National Patient Safety Goal 8 that will seriously impact the ability of already overtaxed emergency departments (EDs) to effectively care for our patients while, at the same time, will not improve the quality of patient care or patient safety for the over 110 million patients we see annually.”
The correspondence further states: “Regarding the compilation of a drug list for essentially each ED patient and the dissemination of that list to either the admitting physician or the primary care physician if the patient is discharged, it is contended that:
- EDs would be disproportionately burdened with this task because of the large number of patients seen in the ED compared to other areas of the hospital
- For the vast majority of patients, the compilation of a comprehensive medication list will not be germane to the patient’s visit in the ED
- The majority of medications administered in the ED are given on a one or two time basis and, as such, drug interactions with prior medications are highly unlikely
- ED medications are fundamentally not danger-prone drugs (mostly pain medications, antibiotics and GI medications) and those that are (thrombolytics, blood, etc) are administered using tight protocols
- Primary care physicians are the appropriate physicians to determine all of the drugs that their patients are taking and they are in the best position to modify medications based on their knowledge of the patient
When we posed a question to the JCAHO about the medication list for ED patients we were told that any patient receiving a drug in the ED must have a medication list made for them and if the patient is not be able to provide the list of medications, it is the ED staff ’s responsibility to contact the patient’s pharmacy, physician(s) or family members.
Historically, these two requirements mandated by the JCAHOare unprecedented in their impact on the day-to-day operation of hospitals and, in particular, their EDs. Just the fact that the JCAHO gave hospitals a year to prepare for the implementation of these mandates reflects the magnitude of the required changes and their unprecedented nature.
It is our position, based on the available data and the views of our constituencies that the following should occur:
Reconciliation of medication lists should be limited to patients admitted to the hospital and conducted by in-patient personnel.”
(JCAHO changed its name last year and is now known as The Joint Commission.)
This correspondence and a follow-up letter in Nov. 9, 2006 from the same three organizations, with specific recommendations about Goal 8 to The Joint Commission’s executive director for patient safety initiatives prompted The Joint Commission to release a clarification of Goal 8 in a 17-page FAQ document released in January 2007 that embodied the ENA, ACEP, and AAEM recommendations.
To my knowledge, however, there has been no updated interpretation of Goal 8 since the release of The Joint Commission’s clarification. Seeing that there have been no changes in the text of Goal 8 in this year’s Safety Goals, I look at the following two questions and answers taken from that 17-page document as definition of the core requirements for medication reconciliation in the ED:
[8A] What is the current expectation for medication reconciliation in the Emergency Department (ED)? Can we use different levels of medication reconciliation depending on the severity of the patient’s condition?
A consensus recommendation of the American Association of Emergency Medicine (AAEM), the American College of Emergency Physicians (ACEP), and the Emergency Nurses Association (ENA) provides for three levels of intensity of the medication reconciliation process in the ED, as follows:
a. “Screening reconciliation” for all ED patients should include routinely obtaining from each patient at each ED visit a list of the patient’s current medications (usually done by the triage nurse)
b. “Focused reconciliation,” as directed by the emergency physician, based on medical relevance, should include seeking additional information about the patient’s medications (exact drug list, dosage/route, etc.) from the patient’s pharmacy, primary care physician, family, etc.
c. “Full reconciliation,” for admitted patients should be completed by the receiving inpatient unit and pharmacist
This consensus recommendation from the AAEM, ACEP and ENA is in full compliance with NPSG requirement 8A since each level includes obtaining a list of the patient’s current medications to be used when ordering or prescribing medications in the ED. Therefore, this approach is acceptable to The Joint Commission in meeting requirement 8A. [New, 1/07]
[8A&B] Will The Joint Commission be expecting to see a specific form or document in the clinical record?
No. On admission/entry to a care setting, the expectation is that the patient’s current medication list is documented in some identifiable fashion as part of the patient/client/resident’s record. The organization should specifically define the expected time frame for that to occur. A surveyor may during the course of a patient tracer review a patient/client/resident’s record to see if the medications on admission/ entry were noted. If this information is only available electronically, the surveyor may ask the organization to describe or demonstrate how information about medications upon admissio n/entry is obtained and made available to appropriate staff. [2/06]
It is my belief that the Joint Commission’s agreement with ENA, ACEP and AAEM recommendations will assist EDs across the nation in functioning more efficiently. Their recognition that the expectations of medication reconciliation in EDs prior to the January 2007 clarification document would greatly impede the delivery of quality care in the already overburdened ED system is outstanding and the elimination of the need for additional paperwork to accomplish compliance with Goal 8 will maximize efficiency in the delivery of nursing care in the emergency department setting.
I would be interested in receiving feedback from RNs around the state as to how their EDs are dealing with this issue. Please email me at rickbos2001@yahoo.com.
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