# Presentation: 370598

## Medication Reconciliation:The Inpatient Hospitalist Perspective

**Peter Kaboli, MD, MS**
***Iowa City VAMC***
***CRIISP (Center for Research in the Implementation of Innovative Strategies in Practice)***
***University of Iowa, Iowa City, IA***
***AHRQ-Washington, D.C.***
***September 27, 2007***

## JCAHO Definition of Med Reconciliation

**The process of comparing a patient's medication orders to all of the medications that the patient has been taking. **
**This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. **
**It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. **
**Transitions in care include changes in setting, service, practitioner or level of care.**

**Notes:**
Due to the lack of reliability of the medical record as an accurate source of medication history, many groups advocate computerized medication profiles and physician order entry.  

## Is Med Reconciliation New?

**Absolutely not.**
**JCAHO & IOM put it into the spotlight.**
**Transitions of care have *****always***** been a problem.**
**EMRs help, but don’t fix problem (VA).**
**Fragmented care is the norm, even as far back as 1872.**

## Beethoven's Doctor Accidentally Poisoned Him, 

**Pathologist Claims**

**Wednesday, August 29, 2007**

_**VIENNA, AUSTRIA**_** —  DID SOMEONE KILL BEETHOVEN? A VIENNESE PATHOLOGIST CLAIMS THE COMPOSER'S PHYSICIAN DID — INADVERTENTLY OVERDOSING HIM WITH LEAD IN A CASE OF A CURE THAT WENT WRONG.**
**OTHER RESEARCHERS ARE NOT CONVINCED, BUT THERE IS NO CONTROVERSY ABOUT ONE FACT: THE MASTER HAD BEEN A VERY SICK MAN YEARS BEFORE HIS DEATH IN 1827.**

## Are Computerized Med Lists Accurate?

**493 older veterans on **_**>**_**5 medications**
**Pharmacist “brown bag” interview**
**Mean of 12.4***** *****regularly scheduled meds**
**range 5-49**
**8.0 Rx, 2.9 OTC, 1.5 vitamins/herbals**
**Kaboli, *****et al*****.**_** Assessing the Accuracy of Computerized Medication Histories**_**, *****AJMC*****. 2004;10;872-877**

## Agreement Definitions

**% of Patients with **_***Perfect Agreement***_** between the interview and computer**
_***Omissions***_**: meds not on computer profile, but being taken by the patient**
_***Commissions***_**: meds on the computer profile, but **_**not**_** being taken by the patient**

## Findings

**Only **_**5.3%**_** of patients had **_***perfect***_** agreement**
**Omissions:**
**1.3 medications per patient**
**25% of all medications omitted**
**Commissions:**
**1.3 medications per patient**
**12.6% of all medications not being taken**
**23% of Allergies and 64% of ADEs missing**
_**Impossible**_** to have 100% accuracy all the time**

## Top 5 Omissions

| By Drug Class | By Drug Name |
| --- | --- |
|   Vitamins              26% |   Aspirin              10.4% |
|   Anticoag/platelet 12% |   Multivitamin        8.2% |
|   GI                        12% |   Acetaminophen  6.7% |
|   Herbals              9.2% |   Calcium              5.4% |
|   Cardiovascular   8.2% |   Vitamin E           4.2% |

**34% of omissions were prescription drugs**

## Top 5 Commissions

| By Drug Class | By Drug Name |
| --- | --- |
|   Cardiovascular    16% |   Aspirin               5.0% |
|   Derm/Topicals     13% |   Docusate           3.5% |
|   GI                        12% |   Diuretics            3.5% |
|   Respiratory        9.3% |   Albuterol            3.1% |
|   NSAID/COX-II    7.4% |   Tylenol               2.8% |

**66% of commissions were prescription drugs**

## Other findings from our VA outpatient clinical pharmacist/physician intervention:

_***Health literacy***_** was associated with medication knowledge, but NOT with taking meds correctly or ADEs at 6 and 12 months.**
**Outpatient pharmacist/physician evaluation can improve **_**medication appropriateness**_**, but hard to show improved clinical outcomes (ADEs).**
**Patients are just as likely to NOT be taking a **_**recommended medication**_** as they are to be taken **_**extra**_** medications (polypharmacy).**

## Implementing Med Reconciliation Kaboli, et al. Clinical Pharmacists and Inpatient Medical Care: A Systematic Review. Arch Int Med, 166, May 8, 2006 

**Clinical Pharmacists**
_**11 RCTs of Admission and/or Discharge Med Reconciliation**_
**↓ ****Preventable ADEs**
**↓ ****Time to input allergy information**
**↓ ****Readmission**
**↑ ****Medication knowledge**
**↑ ****Medication appropriateness **
**↑ ****Compliance**
**Why wouldn’t a clinical pharmacist help?**
**Unfortunately not cheap or available 24-7**

## Clinical Pharmacist InterventionSchnipper, et al. Role of Pharmacist Counseling in Preventing ADEs After Hospitalization. Arch Int Med, 166, Mar 13, 2006.  

**Discharge counseling with 3-5 day follow-up phone call (N=178).**
**30 day Preventable ADE rate 11% vs. 1%, but not all ADES**
_**Half**_** of patients had discrepancies from pre-admit to discharge**
**Did not improve medication adherence or ED/hospital re-admission**

## Inpatient Clinical Pharmacists: Roles

**Careful review of med lists, including contacting local pharmacy if necessary**
**Rounding with team, especially in ICU**
**Make recommendations to inpatient team at admit and/or discharge**
**Ensure patients get medications**
**3-5 day follow-up phone calls**
**Are they “better” than physicians or nurses?**

## What works for you?

**Clinical pharmacists**
**Hospitalists**
**Residents**
**Nurses**
**Pharmacy students**
**Pharmacy techs**

## Summary Keys for Success

**Pharmacist and Physician champions**
**Electronic or paper format**
**Team accountability**
**Involvement of patient/family**
**Health literacy and social support**
**Discharge counseling**
**Communication to primary care or SNF and outpatient pharmacy**
**Follow-up phone call**