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Medication Reconciliation: Barriers and Facilitators from the Perspectives of Resident Physicians and Pharmacists

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Medication Reconciliation: Barriers and Facilitators from the Perspectives of Resident Physicians and Pharmacists ORIGINAL RESEARCH Medication Reconciliation: Barriers and Facilitators from the Perspectives of Resident Physicians and Pharmacists Kenneth S. Boockvar, MD, MS1,2,3, Susan L. Santos, PhD4,5, Andre Kushniruk, PhD6, Christopher Johnson, PhD7,8, Jonathan R. Nebeker, MD9 1Geriatrics Research, Education, and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, New York; 2Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, New York, New York; 3Jewish Home Lifecare, New York, New York; 4VA New Jersey Health Care System, East Orange, New Jersey; 5Department of Health Education and Behavioral Science, University of Medicine and Dentistry of New Jersey, New Brunswick, New Jersey; 6School of Health Information Science, University of Victoria, Victoria, British Columbia, Canada; 7Department of Health Policy and Management, Texas A&M Health Science Center, College Station, Texas; 8VA South Central Mental Illness Research, Education, and Clinical Center, and Houston Center for Quality of Care and Utilization Studies, Michael E. Debakey VA Medical Center, Houston, Texas; 9VA Geriatrics Research, Education, and Clinical Center, and University of Utah, Salt Lake City, Utah BACKGROUND: Medication reconciliation can prevent barriers and facilitators. Interviews were recorded and medication errors and harm when patients transition analyzed using social science methods for analyzing between hospital and other care settings. Though a Joint qualitative data. Commission hospital Patient Safety Goal since 2006, RESULTS: Participants agreed that a central goal of organizations continue to have difficulty implementing the medication reconciliation is to prevent prescribing errors, process. but disagreed about whether it achieves this goal. OBJECTIVE: To determine factors that influence performance Computerization facilitated the task, but participants said of medication reconciliation in a hospital setting with a that computers and patients can be unreliable sources of computerized medication reconciliation tool. information. Participants varied in how they sequenced DESIGN: Cognitive task analysis (CTA) and focus group components of the task. When time was limited, interviews. physicians considered other responsibilities higher priority. Both physicians and pharmacists expressed low SETTING: Urban, academic, tertiary-care Veterans Affairs self-efficacy, ie, low perceived capability to achieve the medical center. objectives of the process. PARTICIPANTS: Internal medicine house staff physicians (n CONCLUSION: Key barriers to medication reconciliation ¼ 23) and inpatient staff pharmacists (n ¼ 12). are unreliable sources of medication information and tasks MEASUREMENTS: CTA participants verbalized their that compete for providers’ time and attention that they thoughts while they completed medication reconciliation consider higher priority. Addressing these barriers while with the computerized tool. Focus group participants increasing providers’ self-efficacy might improve medication described medication reconciliation’s purpose and reconciliation and its outcomes. Journal of Hospital Medicine effectiveness, how they completed the task, and its 2011;6:329–337. VC 2011 Society of Hospital Medicine Adverse drug events (ADEs) occur when patients tran- patient history-taking, and poor provider decision- sition between the hospital and other care settings. making5 continue to contribute to transition-related Medication reconciliation, a process by which a pro- ADEs. vider obtains and documents a thorough medication The Joint Commission introduced medication recon- history with specific attention to comparing current ciliation as a hospital National Patient Safety Goal in and previous medication use, can prevent transition- 2006. However, because organizations have had diffi- related errors and harm in a variety of care loca- culty implementing the process, it stopped citing medi- tions.1–3 Nevertheless, poor intersite communication,4 cation reconciliation deficiencies in its accreditation flawed reconciliation of drug regimens,2 unreliable surveys.6 Although regional and national initiatives have attempted to improve implementation of medica- tion reconciliation—using provider education, work- *Address for correspondence and reprint requests: Kenneth S. flow, and process reorganization, and organizational Boockvar, MD, MS, James J. Peters VA Medical Center, 130 West 7 Kingsbridge Road, Bronx, NY 10468; Tel.: 718-584-9000, ext. 3807; change —a recent field review by the Joint Commis- E-mail: [email protected] sion suggests that healthcare organizations remain Additional Supporting Information may be found in the online version of unable to ensure effective medication reconciliation, this article. citing factors beyond the organizations’ control, espe- Received: July 2, 2010; Revised: November 16, 2010; Accepted: cially unreliable patient histories.8 Still, the process is November 28, 2010 2011 Society of Hospital Medicine DOI 10.1002/jhm.891 slated to return as an accreditation requirement of the 8 Published online in Wiley Online Library (Wileyonlinelibrary.com). Joint Commission on July 1, 2011. An Official Publication of the Society of Hospital Medicine Journal of Hospital Medicine Vol 6 | No 6 | July 2011 329 Boockvar et al. | Medication Reconciliation Barriers The objective of this study was to determine factors Participants that influenced physicians’ and pharmacists’ perform- Participants consisted of internal medicine house staff ance of medication reconciliation in a hospital setting physicians rotating on the inpatient service (n ¼ 23) with a computerized medical record and medication and inpatient staff pharmacists (n ¼ 12). Overall, 14 reconciliation tool, with the goal of informing an (40%) were female. The 23 house staff physicians rep- organization’s approach to implementation. We con- resented approximately 64% of the total house staff ducted individual cognitive task analysis (CTA) inter- inpatient staffing. Thirteen (57%) were in postgradu- views and focus group interviews to ascertain physi- ate year 1 (PGY1), and 10 (43%) were in PGY2 or cians’ and pharmacists’ opinions on the purpose higher. The 12 pharmacists represented approximately and effectiveness of medication reconciliation, their 50% of the total pharmacist inpatient staffing. Indi- approach to completing the task, and task facilitators vidual CTA interviews took place at the end of the and barriers. academic year (June) with participants who were highly experienced with the process of medication rec- onciliation in the VA setting. Focus groups took place at the beginning of the academic year (August) with METHODS participants who had to endorse the statement that Setting and Medication Reconciliation Process they were experienced completing medication recon- The study setting was an urban, academic, tertiary- ciliation. Subjects participated in either the individual care Veterans Affairs (VA) medical center. A compu- or focus group interviews, but not both. Physicians terized medication reconciliation tool and process and pharmacists were interviewed separately. All par- were developed in 2005 to comply with the Joint ticipants provided written informed consent, and the Commission’s National Patient Safety Goal.6 The tool Institutional Review Board of the James J. Peters VA was embedded in the VA’s Computerized Patient Re- Medical Center approved the study procedures. cord System (CPRS) and consisted of a dialogue with which a provider (physician, pharmacist, or other pro- Data Collection vider) could: 1) view the patient’s outpatient medica- Theoretical Model tion use, for the last 90 days, from VA computerized The Integrated Change Model9 guided our approach pharmacy data; 2) view current VA inpatient orders; to data collection and analysis. It indicates that a per- 3) record discrepancies between patient-reported med- son’s motivation, intention, and ability determine ications, and outpatient and inpatient medications in whether a behavior will be carried out. A person’s the VA computerized database; 4) record diagnostic motivation is influenced by attitudes (eg, perceived indications for, and responses to, these discrepancies; pros and cons of the behavior), social influences, and and 5) produce a medication reconciliation document, self-efficacy (eg, perceived capability). The behavior is which was a separate progress note (Figure 1). The also influenced by environmental and physical fac- tool did not directly facilitate ordering; however, in tors—in this case circumstances of the patient encoun- CPRS, outpatient orders could easily be copied to ter, information systems, and the medication reconcili- inpatient orders and vice versa. ation tool. Two versions of the medication reconciliation pro- cess were implemented upon hospital admission: one Individual Interviews in which the physician initiated and completed a rec- We conducted individual CTA interviews with 7 onciliation that was then reviewed by a pharmacist physicians and 5 pharmacists. During CTA, partici- (Figure 2A)—the process primarily used on the medi- pants verbalized their thoughts while they completed cal and surgical services; and one in which, after the medication reconciliation for at least 1 actual case, physician wrote admission orders, the pharmacist ini- and at least 1 standardized (fictitious) case, using the tiated and completed the reconciliation and communi- computerized medical record and tool. The purpose of cated his or her findings with the physician
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