A nurse is conducting medication reconciliation for a client who is newly admitted to the facility

Now that you have formed the implementation team and finalized the rollout plan, it is time to educate and train all disciplines that will be involved in the medication reconciliation process. This section contains information on effective strategies, materials, and tools for educating physicians, nurses, and pharmacists on medication reconciliation.

Education and Training Strategy

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.
• Training together promotes a team approach.
• Group sessions create an appreciation of the interdependency of each discipline in the medication reconciliation process.
• Roles and responsibilities are clearly defined and understood.
• All disciplines are consistently trained on each step within the process.

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 the facility.
• Ensuring that any discrepancies identified (i.e., omissions, modifications, deletions, etc.) are appropriate and intentional based on the patient's care plan.
• Resolving unintended discrepancies with supporting documentation.
• Communicating medication information during transitions in care.

It is also important that physicians, nurses, and pharmacists understand how the 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.

As an example, an education and training curriculum might focus on:

• A multi-disciplinary approach to medication reconciliation.
• Using a Medication Profile tab, identified as a "One Source of Truth" (e.g., a single list and common location shared by all disciplines) for documenting and updating the patient's current medication list upon admission and referencing this list throughout the patient's stay and at discharge.
• 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.

Training should focus on two concepts:

1. How to conduct a patient interview to inquire about patients' current medications.
2. The thought process or "critical thinking" involved with performing medication reconciliation.

This section contains materials developed for training on medication history taking and performing medication reconciliation, which can be customized to meet the organization's training needs. 

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 "good 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 the organization depending on the patient population, workflow, and patient status (inpatient, outpatient, emergency department visit, pre-registered patient, etc). Figure 9 highlights elements that should be captured when inquiring about a patient's current medication regimen and tips for conducting the patient medication interview.

Because the patient's ability to recall medications, doses, and/or frequency of use may be compromised when he or she is not feeling well and is being admitted to the hospital, verifying the patient's medication list upon admission and 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 about 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 included in your chart the list of medications you were taking at home, 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."

If a patient is unable to participate in a medication interview, other sources may be used for obtaining medication histories or clarifying conflicting information. Other sources should never be a substitute for a thorough patient medication interview for patients who are able to participate. Sources of information include:

• Patient.
• Family/caregiver.
• Patient's medication bottles.*
• Patient's community pharmacy.
• Patient's primary care or specialty physicians and their offices or clinics.
• Past medical records.
• Patient's own medication list.*

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 the care plan for that particular patient and, if so, subsequent orders can be written with supporting documentation.

How to Perform Medication Reconciliation. Once medication lists have been obtained, verified with patients and other sources 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 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 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 deletions, are intentional based on the patient's current clinical status and desired care plan. Discrepancies identified that are inconsistent with documented care plans or are not explained by the patient's current clinical status should be discussed with the physician for resolution, and resulting changes or clarifications should be documented accordingly. Patients should be educated on any changes to their medication regimen to ensure complete understanding.

Table 3 helps everyone performing medication reconciliation walk through the "critical thinking process" to identify discrepancies and determine whether 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.

Unintended discrepancies identified during reconciliation can be categorized using the criteria below:

• Omission: Patient reports taking a medication before hospitalization. It was not ordered on admission or it was not listed on the patient's discharge instructions. No clinical explanation supports omission.
• Commission: Medication is ordered at admission that the patient did not take before hospitalization. Medication is listed on the patient's discharge instructions, but it was not ordered during the hospital stay and the patient did not take before hospitalization. No clinical explanation supports commission.
• Different dose, route, or frequency: Different doses, routes, or frequency of medication listed on the patient's discharge instructions than what was ordered during the hospital stay or that the patient reports taking before hospitalization. No clinical explanation supports differences.
• Different Medication Ordered: Medication in the same therapeutic class is ordered on admission or is listed on the patient's discharge instructions and differs from what the patient reports. No clinical explanation or formulary substitution supports difference.

In each case, the physician should be consulted for resolution, and the resulting changes should be documented.

Chapter 5 Lessons Learned

Lessons learned from staff of facilities that have implemented MATCH and facilities that received technical assistance on MATCH through the AHRQ QIO Learning Network include:

• 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 (e.g., a good-faith effort) 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 patients' medication information during handoffs and transitions of care.

Users of this toolkit from the QIO Learning Network offered many ways to use the educational tools in the medication reconciliation project:

• Using tools from this section, providers developed PowerPoint® presentations for staff education on how to conduct a medication history.
• The "Questions to Ask During a Medication History" template was used by one provider as nurse prompts and questions were put on a card, laminated, and added to the nurse ID lanyard.
• Using pharmacists in the emergency room or on floors to perform medication histories or having pharmacy students on rotations do medication histories or validate initial lists was successful for many providers.  
• Handing out the medication history form to patients in the emergency department waiting room proved successful in beginning the medication history process.
• Involving community partners, including community physicians, pharmacies, and emergency medical services to assist in providing medication history information enhance process changes.
• Included training on medication reconciliation into the core competency staff training requirements.

* For patients who present prescription bottles and/or a medications list, each individual medication and corresponding dosing instructions should be verified, if possible; a patient may be taking a medication differently than what is reflected on their prescription label. Also, a patient may have forgotten to update their personal list with newly prescribed medications.

Patients who are scheduled in advance for surgeries, procedures, tests, etc., should be reminded to bring their complete medication list and/or the medication bottles with them on the day of their visit. A script to remind patients to bring their medications or medication list to their appointment is at Figure 10. A medication list template can be included in patient materials regarding their procedure/surgery. Go to the sample patient medication list template in the Appendix.