Annals of Long Term Care

These challenges are readily apparent in the case scenario described in the beginning of this article. Mr. H is a medically complex elderly patient who does not always adhere to the medical regimen he has been prescribed. He is reluctant to take medications and unwilling to accept any assistance from his family. His fragile medical condition is further exacerbated by lack of careful review of his medications on his initial hospital discharge and subsequent NH admission; an unjustified increase in the dose of digoxin (leading to a toxic level); failure to identify a drug-drug interaction between warfarin and ibuprofen (predisposing him to gastrointestinal bleeding); and inappropriate prescription of meclizine, placing him at risk for delirium and falls.

Establishing a reliable, consistent process of medication reconciliation in the LTC setting is both achievable and effective. Numerous organizations, including the IHI, Joint Commission, Institute of Medicine, and World Health Organization have raised the priority and fostered a culture in favor of medication reconciliation. Mounting evidence from clinical trials points to the utility of medication reconciliation in reducing medication discrepancies, adverse drug events, and mortality. The promising results of the Massachusetts Nursing Home Medication Safety Project point to a number of useful strategies for implementing careful and consistent medication review during transitions in care.

Although encouraging progress has occurred to date, there are further improvements to be made in improving communication, refining electronic records to facilitate accuracy and the timely transmission of information, and educating patients, clinicians, and health system administrators about the benefits of, and optimal methods for, performing medication reconciliation. A recent summary of 15 care coordination programs published in The Journal of the American Medical Association revealed that in-person contact and collaboration with the patient’s physician around medication issues are critical.^19,20 Medication reconciliation does not lend itself to a one-size-fits-all solution, but there are nonetheless practical approaches that can be implemented with an expectation for success.

Acknowledgements

The authors are grateful to the individuals at Masspro and the Betsy Lehman Center for Patient Safety and Medical Error Reduction who supported and collaborated on the development of the Safe Medication Practices Workbook, and to the Massachusetts nursing homes that pilot- tested the tools and processes for the workbook.

The authors report no relevant financial relationships.

Dr. MacKinnon is Associate Director for Research and Professor, College of Pharmacy, Associate Professor, School of Health Administration and Department of Community Health & Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Dr. Kaiser is Associate Professor, Geriatrics and Palliative Care, George Washington University School of Medicine, and Attending Physician, Geriatrics and Extended Care, Washington, DC Veterans Affairs Medical Center; Ms. Griswold is Executive Director of the Massachusetts Coalition for the Prevention of Medical Errors, Burlington, MA; and Dr. Bonner is Executive Director of the Massachusetts Senior Care Foundation, and Assistant Professor, University of Massachusetts Graduate School of Nursing, Worcester, MA.

Resources for Information on Medication Reconciliation

Internet

Masspro. A Systems Approach to Quality Improvement in Long-Term Care: Safe Medication Practices Workbook. http://www.masspro.org/NH/docs/tools/SafeMedPrac06_8-07Upd.pdf

Institute for Health Care Improvement. Medication Reconciliation Review. http://www.ihi.org/IHI/Topics/PatientSafety/MedicationSystems/Tools/Medication+Reconciliation+Review.htm