Medication reconciliation is of paramount importance for proper care. That means the most accurate list of all medications the patient is taking, including the name, dosage, frequency and route, is documented in the records
Posted in Malpractice Insurance on Tuesday, August 11, 2020
Probably one of the most difficult tasks faced daily by healthcare workers is medication reconciliation. It’s not the task itself that’s challenging, but the task of getting complete and credible information. The goal of medication reconciliation is to prevent adverse reactions or interactions, minimize errors in transcription, omission, and duplication of therapy. In addition, according to a study completed in 2016 (attached below), medication-related claims result in a higher percentage of patient deaths and are more frequently closed with an indemnity payment.
One way to start the conversation with the patient or caregiver is to make sure they understand the importance of you knowing all the medications and products they use. Encourage your patients to learn about the medications they are taking.
As reference, the patient/caregiver should understand:
- The name of the drug and why it is being taken
- How and when to take the drug; what to do if a dose is missed
- Precautions to take (sun exposure, certain foods, activities, etc.)
- Side effects and what to do if they occur
- The importance of reading the label each time the drug is taken to confirm it is the correct drug
- The importance of reading the label at each prescription refill, confirming the patient name, name of drug and dosage
- Letting the pharmacist know if the color, size, or shape changes
- Use only the cup or measuring device supplied with the drug
82% of American adults are using one or more prescribed medications1
93% use over the counter medications2
86% use dietary supplements3
If you are not using an electronic method of having the patient review their medications (including all prescription medications, herbal products, vitamins/minerals and supplements, over-the-counter medications, respiratory therapy treatments, injection and IV solutions/medications, sprays and drops, transdermal patches and topical creams) such as a tablet in the office or a portal, it is important the list is reviewed visually and verbally with the patient. This review exercise includes stating the medication name, dose, frequency and route of administration. Any changes or comments noted by the patient should be documented and the provider notified of the changes/comments. The provider should then document they have reviewed the list. Medications should be verified and documented at each patient visit.
When completing a medication review, in addition to the above noted list of what to review, it is important to understand if the patient is using medical or recreational marijuana, CBD products, alcohol, opioids, and antibiotics or pain medication left over from previous illnesses or medications obtained from family or friends.