Annals of Long Term Care

1. What are the potential issues related to failure to reconcile medications between the hospital and SNF in this case?

2. How could potential adverse events in this case have been avoided?

Introduction

Transitions in care can present serious challenges and potential harm to frail, older patients as they move from the hospital to a SNF or from a SNF to home. In particular, comprehensive review of the patient’s medications through the process of medication reconciliation, as will be described, is crucial for determining exactly which drugs patients should be taking when they arrive in their new care setting. As demonstrated in the above clinical scenario, there are typically numerous opportunities for mishaps and adverse events to occur. The following article will provide a brief overview of the evidence for medication reconciliation and describe practical approaches for implementing medication reconciliation in the LTC setting.

Medication Reconciliation and Seamless Care

While the terminology may vary by profession and geographic area, it is generally accepted that seamless care, continuity of care, smooth transitions of care, and coordination of care are important components of a high-performing healthcare system. As Bodenheimer¹ argued in an editorial in The New England Journal of Medicine, “recent research strongly suggests that failures in the coordination of care are common and can create serious quality concerns.” Unfortunately, as was observed in the 2007 Commonwealth Fund international survey, a large percentage of the population in seven western industrialized nations, including the United States, reported that they did not have a medical home in which their care was coordinated.²

The need for seamless care is especially important for optimal medication use. It has been proposed that there are eight essential elements of a safe and effective medication-use system,^3,4 several of which relate to aspects of seamless care: ongoing monitoring, proper documentation and communication, and active participation of patients in their own care. In Canada, there has been considerable activity in recent years to promote seamless pharmaceutical care.⁵ A 2005 Australian publication suggests ten principles that should be followed to help achieve seamless pharmaceutical care.⁶

A subset of seamless pharmaceutical care that has gained prominence in recent years is medication reconciliation. Medication reconciliation, commonly known as “med rec,” involves reviewing the patient’s medication profile to ensure they are on the right medications. This review typically occurs during transitions in care. While the activities involved in medication reconciliation have been in existence for a long time, medication reconciliation as a specific concept is relatively new, first proposed by the Institute for Healthcare Improvement (IHI) within the past decade.⁷ Since then, it has been widely adopted by professional associations, patient safety campaigns, and accreditation bodies. This adoption has expanded well beyond the United States, as the World Health Organization has included medication reconciliation as one of the core strategies in its multi-nation collaborative initiative, “Action on Patient Safety: High 5s.”⁸

When medication reconciliation was first proposed by IHI as a strategy to improve the safety of the medication use system, empirical evidence supporting its utility was scarce. However, as has been previously discussed, there is a wealth of empirical evidence showing that patients may experience problems during transitions in care, and medication reconciliation appears well-suited to address these problems. Since it was first proposed, fortunately, the evidence in favor of medication reconciliation has caught up with the perceived benefits.^9-11