If your patient turned in this medication list to you, what would your first action be?
- I’d double check with the pharmacy. This is a good option, and when the goal is ensuring that medication lists match during transitions of care, calling the pharmacy is a normal action step. The only problem is that this action may overlook the four over-the-counter (OTC) products.
- I’d discuss the list with my patient to find out their dosage on the OTC items. Upon doing this, you learn that your patient is taking three grams of Vitamin C daily to prevent colds, 900 mg a day of St. John’s Wort for depression, 8,000 IUs of vitamin D, and 1000 mg of vitamin B12. Investigating the significance of OTC and supplement use results in better understanding beyond collecting doses and names of products. If in doubt, reach out to a pharmacist for insight. In this case, the daily vitamin C can acidify the urine and make other drugs toxic.
What Is Medication Reconciliation?
It is all of the above and more. Finding out the dosing details and the patient’s experience with their medications is part of comprehensive medication reconciliation (CMR). CMR answers the what, when, how, how much, and why for each medication and product a patient uses. CMR is critical for all healthcare providers, including those working in therapy, particularly when a patient is taking several medications and supplements and during multiple transitions of care. Without CMR, healthcare professionals may have serious gaps in awareness of patient status.1
The Devil in the Details—Why Medication Reconciliation Matters
Medication reconciliation without detail can have serious clinical implications.
Joanne is a resident of an assisted living facility (ALF) who participates in physical therapy once per week. This week, her physical therapist noticed that Joanne seemed quiet. Joanne mentioned that she had a headache, and she seemed confused. She also had a few bruises on her right arm.
Her PT notified the head nurse that Joanne was not her usual engaged self today. Joanne manages her own medications in her own apartment and joins the dining room for most meals. The other residents reported that Joanne hadn’t been very social at dinner for the past two weeks. The head nurse recalled that another resident reported that Joanne had fallen down in the hallway earlier in the week, so the RN placed a call to the physician, who sent Joanne to the emergency department (ED).
The RN ensured that Joanne’s list of medications accompanied her to the ED, along with a bag containing her medication bottles (including OTCs). The physician at the ED requested a CT of Joanne’s head and found a hemorrhagic bleed, and Joanne went to emergency surgery. In Joanne’s medication bag, the hospital staff found all the products on her medication list. They also discovered that she’d been taking 325 mg aspirin tablets instead of 81 mg. Additionally, the bag contained a bottle of naproxen (Aleve®).
What Happened Here?
Joanne was overanticoagulated, and when she fell in the hall, she must have hit her head. Her anticoagulation led to a small but unstoppable intracranial bleed.
In addition to the high dose of aspirin, Joanne’s St. John’s Wort, naproxen, and sertraline (Zoloft®) all contributed to anticoagulation. Additionally, Joanne’s calcium level was quite high, possibly due to the high dose of OTC vitamin D. Elevated calcium levels can cause acute kidney failure, ECG changes, and confusion, which could have led to her fall and her recent lack of social engagement.2 Digging in even further, her hefty daily dose of vitamin C acidified her urine, making her high dose aspirin even more difficult to excrete, which also impacted her bleed.
Joanne successfully recovered from surgery and eventually went home. Her doctors discharged her with only her usual prescription medications and low-dose (81 mg) aspirin. She was instructed to avoid OTC products and have the ALF staff manage her medications for the near future.
This case illustrates that although accounting for patient medication lists is a good first step, taking the time to determine the details of actual use can make the difference between poor outcomes and clinical success for all patients, including those seen on an outpatient basis.
Why Healthcare Providers and Systems Miss Medication Details
It is estimated that 50 percent of patients are non-adherent to their medications,3 yet, the healthcare system makes decisions based on a major assumption—that medications listed are a) taken at all and b) taken as the directions indicate.4 Given the track record of medication analysis in the clinical setting, it seems that there’s a blind spot in the view of healthcare systems and providers when it comes to assessing medication use.
Healthcare providers are not intentionally avoiding robust medication use assessment during med rec; they often do not have the time to delve into what’s going on with each patient’s medication use. When a patient shows up with a list of six to twelve—or even more— medications, getting to the bottom of whether the medications are effective, causing side effects, or even being taken correctly is nearly impossible due to the constraints of the 15-minute clinic visit.5 That said, it doesn’t take much longer than a few minutes to ask open-ended questions and delve just a bit deeper into the real life medication use of our patients, especially when we know that doing so can be life-saving.
Spread Out the Work
One strategy for addressing the lack of time for thorough med rec in the allotted15 minutes is to spread out the work among the entire team—including the patients themselves!
Medical assistants are often the first professionals who encounter the patient, and they are often responsible for obtaining medication lists. You may find it helpful to create a standardized med rec form that cues members of your team (or yourself!) to discuss the medication list with the patient and document the what, when, how, how much, and why of each medication. You can then add to or learn from this information before updating medications in your electronic health record.
You can also start the process before your patient even arrives by:
- Obtaining information through an online patient portal from the patient or their caregiver
- Calling the patient
- Sending a form to be completed by the patient or caregiver
If your clinical setting has students or volunteers who are HIPAA-credentialed, they can be assigned to gather more robust med rec information. For students who are on a healthcare rotation or targeting a healthcare career, robust med rec can be a valuable learning experience.
Finally, make sure your patients understand how important it is for them to participate in this process. Take a minute of each encounter to coach your patients on the importance of keeping an accurate medication list, like this one, offered free online by the FDA. More tech-savvy patients may be interested in tracking their medications, doses, and reactions on an app, such as the ones offered by Medisafe or DoseCast.
Emphasize that patients should update their medication records frequently, especially when the dose changes. If possible, encourage patients to track their medication side effects and even whether or not the medication appears to be effective. You may even wish to create tracking forms your patients can use to help them engage in tracking, similar to this form offered by the Veteran’s Administration for tracking blood glucose to support diabetes management. And of course, trackers of this type are also available in app form, such as Glucose Buddy for diabetes or Daylio, which can help track mood.
Regardless of how the tracking occurs, continue to emphasize the importance of accurately reporting medication use at each visit. Even healthcare providers who do not prescribe medications can help prevent polypharmacy and potentially dangerous adverse effects.
- Greenwald, J., Halasyamani, L., Green, J., LaCivita, C., Stucky, E., Benjamin, B., et al. (2010). Making inpatient medication reconciliation patient-centered, clinically relevant and implementable: a consensus statement on key principles and necessary first steps. Journal of Hospital Medicine, 5(8): 477–85.
- Lexicomp Online. Lexi-Drugs Online, Hudson, Ohio: Wolters Kluwer Clinical Drug Information, Inc. Accessed Jan 31, 2019.
- DiMatteo, M. R., Giordani, P. J., Lepper, H. S., & Croghan, T. W. (2002). Patient adherence and medical treatment outcomes: a meta-analysis. Medical Care, 40(9): 794–811.
- Stojceva-Taneva, O., Taneva, B., & Selim, G. (2016). Hypercalcemia as a cause of kidney failure: case report. Open Access Macedonian Journal of Medical Sciences, 4(2): 282–286.
- Brown, M. T. & Bussell, J. K. (2011). Medication adherence: WHO care? Mayo Clinic Proceedings, 86(4): 304–314.