Long-Term Care Survey Alert

Jump on the bandwagon of this safety practice before it's too late.

If your facility thinks "medication reconciliation" applies only to accredited facilities, it may have a bitter survey pill to swallow--or even malpractice litigation on the horizon.

Know the definition: Medication reconciliation simply means the facility ensures the resident receives the right medications at each transition of care, including admission and discharge and throughout his stay.

Facilities accredited by the Joint Commission on Accreditation of Healthcare Organizations must do "effective medication reconciliation" at all transitions in care, including instances where the physician orders new medications or rewrites existing orders, says Marianna Grachek, RN, MSN, executive director of long term care and assisted living accreditation for the accrediting agency.

When effective medication reconciliation does not occur, "patients may receive duplicative medications, incompatible drugs, wrong dosages or dosage forms," according to a recent Joint Commission Sentinel Alert. The medication reconciliation process also gives you an "important opportunity" to make sure the patient receives necessary medications--and to eliminate medications he no longer needs, states the alert.

Read the alert at www.jcipatientsafety.org/show.aspooshow.asp?durki=9798.

Government surveyors also appear to be on the trail of facilities that fail to ensure residents receive the right medications at various junctures of care. "Problems with medication reconciliation are becoming a more common citation in the overall pharmacy realm of the survey process," observes Gene Larrabee, a nursing home administrator in St. Augustine, FL. "For example, the nurse may miscopy the patient's medications or dosages onto the medication administration record," he says.

Solution: Develop a monitoring system to detect transcription errors, Larrabee suggests. The process should include both nursing and pharmacy, he adds.

Involve the Resident/Family in Medication Reconciliation

At admission, ask the resident and family about the medications he is taking. That's important because even though the resident's admission list of medications may be accurate, "he may not have been taking a certain drug"--or taking it incorrectly, says Fran Griffin, spokeswoman for the Institute for Healthcare Improvement. "For example, he may have been skipping his blood pressure medication in the morning because it makes him sleepy," she notes. And that could explain his "resistant" hypertension.  

Also ask the resident/family member "about any creams, patches, herbals, sample drugs and over-the-counter drugs he may be taking," suggests Della Lin, MD, at the Queen's Medical Center in Honolulu. Also find out if the resident has been "borrowing" medications from someone else, she says. "It's amazing how many drugs, including OTC ones, have anticholinergic properties" and "compounding them" can cause disorientation or other negative side effects, she says.

Clinical gem: Anticholinergics can cause delirium--and more than 600 drugs have anticholinergic activity that can produce cumulative anticholinergic toxicity, cautioned Susan Scanland, RN, MSN, in a presentation at the March American Association of Nurse Assessment Coordinators' conference in Las Vegas.

Keep asking:  Families will occasionally give the resident medications or herbal remedies from home without the facility or physician knowing, cautions May Adra, PharmD, director of drug information/medication safety coordinator at Tufts-New England Medical Center. "The healthcare provider needs to know if those remedies are contributing to the patient's symptoms, such as bleeding," she notes.

Example: Gingko biloba, which people take to improve mental function, or even fish oil for heart health can increase a person's risk of bleeding--especially if she takes an anti-coagulant. "Educate the patient/family about the need to let the staff know about any drug or OTC or herbal remedy the person is taking," advises Adra.

Streamline the Process at Admission

Boston Center for Rehabili- tative & Subacute Care has achieved 92 percent staff compliance with its medication reconciliation process by condensing its medication reconciliation form to a single page, says Anne Lavoie, RN, MSN, MBA, VP of clinical services at Partners HealthCare, which operates The Boston Center. The form includes the flu and pneumococcal vaccination consent, Lavoie says. "We also put the form in the medical record on a bright orange piece of paper" so people can easily recognize it, she adds. To perform medication reconciliation using the  form, the nurse takes these steps:

• Obtains the list of medications the patient is taking at the point of transfer from the hospital to the nursing facility. The nurse doesn't copy those medications on the form, which saves time and prevents transcribing errors.

• Asks the patient/family if the patient was taking any other medications at home.

• Uses the form to record medications that the patient was taking in the community but didn't receive in the hospital. Examples include "eye drops, inhalers and over-the-counter medications, such as calcium and vitamin C," says Lavoie. The physician reviews the list and decides which medications to order.