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 - Northwestern Memorial Hospital - Chicago

Education & Training Curriculum on Medication Reconciliation

Now that you have formed your implementation team and finalized your roll-out plan, it is time to educate and train all discipline(s) that will be involved in your medication reconciliation process. This section contains information on effective strategies, materials and tools for educating physicians, nurses and pharmacists on medication reconciliation.

A. Education and Training Strategy

After trial-and-error with various training strategies (i.e., by discipline coupled with train-the-trainer and coach support), we found the greatest success with multi-disciplinary classroom training followed by coach support during implementation. Based on the magnitude of the project - involvement of three disciplines (physicians, nurses and pharmacists), tackling hospital-wide implementation and current cultural beliefs around medication reconciliation - the train-the-trainer approach was not robust enough.

Multidisciplinary training (i.e., physicians, nurses and pharmacists attending training classes together), supported by introductions from hospital leaders, can be an excellent strategic decision because:

  • Key leaders in the organization set the tone for training and implementation
  • Promotes a team approach
  • Creates an appreciation of the interdependency of each discipline in the medication reconciliation process
  • There is a clear understanding about who is supposed to do what
  • All disciplines are consistently trained on each step within the process

A member from our medication reconciliation leadership group or a "physician champion" provided a five minute introduction to explain the "why," emphasizing the hospital's endorsement of the model and support for this mandatory patient safety and regulatory responsibility. An introduction, such as the one offered below, may be customized for use by your hospital leadership or clinical champions:

"The medication reconciliation process consists of three main components: (1) obtaining and documenting the patient's home medications in a single, shared location within the patient's medical record; (2) confirming the accuracy of this list with the patient/family and/or other sources as needed to help ensure "accuracy and completeness;" and (3) performing medication reconciliation at admission, transfer and discharge. Not only is the medication reconciliation process a mandatory Joint Commission requirement, our own organizational risk assessment and the literature highlight the utmost importance of this effort to ensure patient safety and to decrease patient harm."

The introduction can be concluded with a case example of a medication reconciliation failure to illustrate the point.

To supplement classroom training, a video clip to illustrate process steps can be developed. A link to access your video clip can be easily communicated to staff via e-mail or through your typical organizational communication mechanisms. A video clip creates an additional means to communicate your process quickly and efficiently and can be used as a "refresher" post-training. Software and steps to prepare video clips can be downloaded for free from the internet.

B. Education and Training Curriculum on Medication Reconciliation

An overarching message throughout training needs to be that medication reconciliation provides a standardized, consistent approach for:

  • Obtaining, documenting and verifying a patient's current medication list
  • Comparing this list with medications ordered within your facility
  • Ensuring any discrepancies identified (i.e., omissions, modifications, deletions, etc.) are appropriate based on the patient's care plan
  • Resolving unintended discrepancies with supporting documentation, and
  • Communicating medication information during transitions in care

It is also important that physicians, nurses and pharmacists understand how your medication reconciliation process is designed to integrate into their current workflow and support medication management efforts to prevent medication errors and the potential for patient harm.

Our education and training curriculum at NMH focused on four main elements:

  • A multi-disciplinary approach to medication reconciliation
  • Utilizing the Med Profile tab, a single location shared by all disciplines, for documenting and updating the patient's current medication list ("one source of truth")
  • Obtaining, documenting and verifying the patient's current medications and referencing this list throughout the patient's stay, and
  • Reconciling medications ordered for the patient upon admission (entry), during intra-hospital transfers (if applicable) and upon discharge (exit) with the patient's list of current medications


A tri-fold pocket card highlighting the process and a supplemental one page attachment providing an overview on medication reconciliation can be given to staff during training.

Medication Reconciliation Tri-Fold (PPT)

Medication Reconciliation Overview (PDF)

Training should focus on how to conduct a patient interview to inquire about patients' current medications and the thought process or "critical thinking" involved with performing reconciliation.

This section contains materials developed for training on medication history taking and performing reconciliation, which can be customized to meet your organization's training needs. For more information on medication histories and reconciliation literature, please see “Medication Reconciliation Talking Points” in the “Making the Case” section.

1. How to Conduct a Patient Interview to Obtain, Verify, and Document Patient's Current Medications

This section describes the medication history interview process to help ensure a "best-faith" effort has been made to obtain the most complete, up-to-date list of the patient's current medications. The process of who conducts the initial patient medication history interview and/or history verification may vary across your organization depending on the patient population, workflow and patient status (inpatient, outpatient, Emergency Department visit, pre-registered patient, etc).

The information below highlights elements that should be captured when inquiring about a patient's current medication regimen and tips for conducting the patient medication interview.

The Patient Medication Interview: Medication History Prompts (PDF)

As the patient's ability to recall medications, doses and/or frequency of use may be compromised when the patient is not feeling well and/or is being admitted to the hospital, we found that verifying the list of the patient's current medications initially collected upon admission at a later point in the hospital stay is an essential step to ensuring "accuracy and completeness." In addition, it provides an opportunity to educate the patient on the medications ordered during the hospitalization and identify any discrepancies from the patient's perspective. This medication history "verification" interview can be approached in this manner:

"Hi Mrs. Jones. I'm your nurse, Katherine Johnson. Dr. Smith just documented the list of medications you were taking at home into your chart based on the information you provided when you arrived at our hospital. I want to verify that we have documented your list of current medications correctly and that we did not omit anything. Also, I want to go over what medications have been ordered for you to take while in the hospital."

Additional resources such as a family member or the patient's community pharmacy may be utilized to resolve any discrepancies that are identified. Below is a list of resources that may be referenced.

Resources for Obtaining Medication Histories and/or to Clarify Medication Discrepancies (PDF)

When nurses and/or pharmacists learn new information during medication history verification, the physician should be contacted. The physician should determine if this information will alter his/her care plan for that particular patient, and if so, subsequent orders can be written with supporting documentation.

For patients who are scheduled in advance for surgeries, procedures, tests, etc., patient reminders can be incorporated into the registration process to remind patients to bring their full, complete medication list and/or bottles with them on the day of their visit. A medication list template can be included in patient materials regarding their procedure/surgery. Below is a sample script to remind patients to bring in their medication list or bottles and a sample medication list template for patients.

Sample Script for Patient Reminders to Bring Medications or a Complete Medication List to their Procedure / Test (PDF)

Sample Patient Medication List to be Completed in Preparation for Surgery/Test (PDF)

2. How to Perform Medication Reconciliation

Once medication lists have been obtained, verified with patients and other resources if needed, and documented within the medical record, this information can then be compared to medications ordered during the episode of care to identify unintended discrepancies, potential drug interactions and/or contraindications. Upon discharge, medications administered during the episode of care are then compared to the patient's pre-admission list and the patient's list is then updated, if needed, to reflect any changes.

The overall goal of the reconciliation process is to ensure that any changes made to the patient's current medications, such as omissions, dose changes and or deletions, are intentional based on the patient's current clinical status and desired care plan. Discrepancies identified that are inconsistent with documented care plans and/or are not explained by the patient's current clinical status should be discussed with the physician for resolution, and resulting changes and/or clarifications should be documented accordingly. Patients should be educated on any changes to their medication regimen to ensure complete understanding.

Below is a table to help disciplines performing reconciliation walk through the "critical thinking process" to identify discrepancies and determine if clarification is required. It is important for physicians to provide clear documentation and communication regarding medication ordering decisions and care plans to minimize unnecessary pages or telephone calls. Developing scripts for nurses and pharmacists for clarifying medication discrepancies with physicians may also be useful for all disciplines and helps standardize the clarification and communication process for medication discrepancies.

"Critical Thinking" - Clarifying Medication Discrepancies Identified During Reconciliation (PDF)

Below are specific definitions of the types of unintended discrepancies requiring clarification.

Types of Unintended Medication Discrepancies (PDF)

3. Special Considerations for Medication Reconciliation Education - Health Literacy and Cognition

Patients with limited health literacy and/or cognitive impairment may be at risk for medication reconciliation errors. You should consider including these issues as part of your education and training curriculum on medication reconciliation.

Health literacy

The most recent National Assessment of Adult Literacy (2003) found that 30 million adults (14% of the American adult population) read below the basic level required to function in society, and another 47 million (22%) were able to read and understand only basic materials.

The definition of health literacy is neither simple nor universally agreed upon. No matter how health literacy is defined, patients with limited health literacy have an increased likelihood to experience difficulty processing information about health and healthcare encounters. Within the realm of medication reconciliation, patients with limited health literacy may have problems adhering to a medication regimen and may be unable to provide an accurate medication history. These individuals often do not understand prescription instructions and warning labels, and they may be at increased risk for medication errors and non-compliance. When these patients are discharged from the inpatient setting, instruction on changes to their prior medications and/or a new medication may require more targeted efforts on the part of providers.

The most widely used measures in the assessment of health literacy status are the Rapid Estimate of Adult Literacy in Medicine (REALM)1 and the Test of Functional Health Literacy in Adults (TOFHLA).2,3 Each test measures selected domains that are thought to be markers for an individual's overall capacity. The REALM is a 66-item word recognition and pronunciation test that measures the domain of vocabulary. The TOFHLA measures reading fluency via sections testing reading comprehension and numeracy; both sections assess patients' capacity to read and understand actual hospital documents and labeled prescription vials. Although these tests measure different capacities, they are highly correlated with one another4 and with general vocabulary tests.5

These screening tests, however, require too much time to be administered in a realistic healthcare environment. Studies6,7 suggest that two questions, when validated against the TOFHLA or REALM, have a reasonably high predictive value for identifying patients with inadequate literacy. Each question has 5 possible response options along a Likert scale. The questions and responses are:

a) "How often do you have someone help you read hospital materials?" (Always, often, sometimes, occasionally, or never), and;

b) "How confident are you filling out medical forms by yourself?" (Extremely, quite a bit, somewhat, a little bit, or not at all).

Patients who say they "often" or "always" have someone help them to read hospital materials, or who are "a little bit" or "not at all" confident filling out forms, are more likely to have reading problems. These patients should be given special attention during the medication reconciliation process, such as during patient interviews to obtain medication histories upon admission and at discharge for medication education and counseling.

Ideally, staff should ask patients these two screening questions when they establish care and all providers should be mindful of patient responses during encounters. However, screening tools will never be able to perfectly predict or measure patient characteristics and behavior. Thus, it may be better to assume that all patients experience some degree of difficulty in understanding health information, and we should adopt the perspective of "universal precautions" when interacting with patients. These methods include the use of plain language, communication tools (e.g., multimedia), and "teach back" (having an individual repeat back instructions to assess comprehension) with all patients.

The following websites provide general information and background on health literacy, and may be helpful if you would like to learn more.

Harvard School of Public Health. Health Literacy Studies. (Accessed June 25, 2007)

Pfizer Public Health and Policy Group. Health Literacy. (Accessed June 25, 2007)

U.S. Department of Health and Human Services. National Institutes of Health. Improving Health Literacy. (Accessed June 25, 2007)

Cognition

Cognitive impairment may also pose challenges for medication reconciliation when obtaining medication histories from patients upon admission and/or providing medication education and counseling to patients at discharge. Screening for cognitive impairment can be time-consuming. If cognitive impairment is a concern, a simple screening test is the Mini-Cog (http://www.hospitalmedicine.org/geriresource/toolbox/pdfs/clock_drawing_test.pdf). As opposed to the Mini-Mental State Examination (MMSE - http://www.minimental.com/), which takes roughly 10 minutes to administer, the Mini-Cog can be administered in well under 5 minutes. The Mini-Cog uses a three-item recall test for memory and a simply scored clock-drawing test. The test has been shown to have good predictive value in diverse populations, both in relation to the MMSE and more thorough cognitive exams.8,9

Lessons Learned

  • Organizational leaders should promote medication reconciliation training to help reinforce the organization’s commitment to this patient safety initiative.
  • Physicians, nurses and pharmacists attending training sessions together promotes a team approach, provides a clear understanding of each discipline’s role in the process and ensures all disciplines are consistently trained on medication reconciliation.
  • Multidisciplinary training sessions should include education on how to conduct a patient interview to obtain, verify and document a patient’s current medications and how to reconcile this information with medications provided by the organization.
  • The “critical thinking” required for identifying intended (i.e., purposeful) vs. unintended medication discrepancies based on the patient’s plan of care and the process for resolving unintended discrepancies should be incorporated in medication reconciliation training.
  • Education should also focus on the importance of developing good communication patterns regarding patient’s medication information during handoffs and transitions of care.


References:

  1. Davis TC, Long SW, Jackson RH, et al. Rapid estimate of adult literacy in medicine: a shortened screening instrument. Fam Med. 1993;25:391-5.
  2. Baker DW, Williams MV, Parker RM, Gazmararian JA, Nurss J. Development of a brief test to measure functional health literacy. Patient Educ Couns. 1999;38:33-42.
  3. Parker RM, Baker DW, Williams MV, Nurss JR. The Test of Functional Health Literacy in Adults (TOFHLA): a new instrument for measuring patient's literacy skills. J Gen Intern Med. 1995;10:537-42.
  4. Fisher LD, van Belle G. Biostatistics: A Methodology for the Health Sciences. New York, NY: John Wiley and Sons; 1993.
  5. Jastak S, Wilkinson GS. WRAT-R, Wide Range Achievement Test, Administration Manual, Revised Edition. Wilmington, DE: Jastak Assessment Systems; 1984.
  6. Chew LD, Bradley KA, Boyko EJ. Brief questions to identify patients with inadequate health literacy. Fam Med. 2004;36:588-94.
  7. Wallace LS, Rogers ES, Roskos SE, Holiday DB, Weiss BD. Screening items to identify patients with limited health literacy skills. J Gen Intern Med. 2006;21:874-7.
  8. Borson S, Scanlan JM, Watanabe J, Tu SP, Lessig M. Simplifying detection of cognitive impairment: comparison of the Mini-Cog and Mini-Mental State Examination in a multiethnic sample. J Am Geriatr Soc. 2005 May;53(5):871-4.
  9. Borson S, Scanlan JM, Chen P, Ganguli M. The Mini-Cog as a screen for dementia: validation in a population-based sample. J Am Geriatr Soc. 2003 Oct;51(10):1451-4.
Last UpdateJune 21, 2011
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