Annals of Long Term Care

One setting where there would appear to be a special need for medication reconciliation is in LTC, given the published evidence of problems with medication use. Bootman et al¹² estimated the total annual cost of drug-related morbidity and mortality in nursing homes (NHs) in the United States to be $7.6 billion, and they conclude that for every dollar spent on drugs in NHs, $1.33 in healthcare resources is consumed in the treatment of drug-related problems. Another study by Gurwitz and colleagues¹³ estimated that 350,000 adverse drug events occur each year in NHs in the United States, with over half of these being preventable. In a study of patient transfers from LTC facilities to hospitals, a mean of 3.1 medications were changed upon hospital admission, while a mean of 1.4 medications were changed on readmission to the LTC facilities.¹⁴ Adverse drug events that were attributable to medication changes occurred in 20% of transfers.¹⁴

Adoption of medication reconciliation in the LTC setting has been limited to date, although it is expanding. Canada’s national patient safety campaign, Safer Healthcare Now!, adopted medication reconciliation in LTC as one of its new patient safety strategies in 2008. Some evidence has emerged to support the value of medication reconciliation in this setting. Boockvar and colleagues¹⁵ observed the impact of pharmacist medication reconciliation and communication in a consecutive sample of 168 residents of a LTC facility who were hospitalized and then returned to the LTC facility over a two-year period. The authors conclude that “pharmacist-conducted medication reconciliation in combination with physician communication can improve medication safety and patient outcomes at the time of transfer between facilities.” In another study of multiple hospitals and LTC facilities, a pharmacist transition coordinator did improve inappropriate medication use but had a mixed impact on clinical outcomes and healthcare resource utilization.¹⁶

Answers to Clinical Scenario Questions:

1. SNF did not realize which medications were added and which were home medications; SNF was not aware of any home management issues with warfarin/INRs; SNF was not aware of adherence issues at home. Failure to reconcile ibuprofen (patient never took this at home) may have led to interaction with warfarin; failure of hospital and SNF to communicate on most recent INR trends may have led SNF provider to prescribe higher dose of warfarin than was indicated; failure to appreciate that patient routinely skipped his medications at home led to a higher dose of digoxin and digoxin toxicity; use of meclizine to treat dizziness without a thorough work-up may have actually worsened the dizziness (anticholinergic) and caused other symptoms (increased confusion); patient was taking fluoxetine at home, which might have been causing or contributing to dizziness; however, unclear whether patient was even taking this medication.

2. Institute SNF policy for nurses to ask new patients/families about home medications (do not rely on hospital medication reconciliation alone for all relevant information). Consider provider-to-provider communication around complex cases, rather than simply relying on a transfer form or medication list.

The Nursing Home Medication Safety Project