Errors in medical records can have disastrous consequences, which is why many healthcare facilities outsource medical transcription to experienced service providers. Medication lists are one of the most important elements of the electronic health record (EHR). Patients’ medication records need to be accurate, up-to-date, and accessible. As patients change their medications frequently, maintaining these records is a challenge. When information on medications is incomplete or inaccurate, it can lead to discontinuities in care. In fact, adverse drug events (ADEs) or harm from medications are the most common type of medical error and can result from discrepancies in patient medications during transition of care.
Medical Reconciliation to Improve Patient Safety
Common medication errors include:
- Inadvertently excluding a medication a patient was taking at home during the hospital stay
- Not ensuring that home medications that may be temporarily stopped during hospital stay are restarted after patient transfer or discharge
- Duplicating medication orders which could occur either because the patient is already taking the drug or due to confusion between brand and generic versions.
- Prescribing wrong dosages
- Transcribing errors – Common transcribing errors include wrong drug name, dose, route, frequency or patient. Reasons for such errors include incomplete or illegible prescriber orders, incomplete or illegible nurse handwriting, using error-prone abbreviations, inappropriate EHR defaults, and lack of familiarity with drug names, doses, or frequencies.
There are various reasons why medication management is difficult, such as lack of patient knowledge about medication details, multiple care providers, different medication lists for the same patient from numerous sources, and industry regulations. Hospitals need to have a consistent, streamlined process that will improve medication management during a patient’s hospital stay. Implementing medical reconciliation at patient admission, transfer, and discharge is an effective strategy to reduce/prevent medical errors.
The Institute of Healthcare Improvement defines medical reconciliation as “the process of creating the most accurate list possible of all medications a patient is taking – including drug name, dosage, frequency, and route – and comparing that list against the physician’s admission, transfer, and/or discharge orders, with the goal of providing correct medications to the patient at all transition points within the hospital”. Medication reconciliation involves three steps:
- Verification: collecting an accurate medication history – involves documenting details of current and recently discontinued medicines such as antibiotics and corticosteroids as well as details of drug allergies or sensitivities if any.
- Clarification: Ensuring medication and dosages are appropriate for the patient. This involves comparing the medication history and the physician orders. Omissions or discrepancies such as a medication that appears on the history but not on the order and has no documented reasons for discontinuation, or changes in dose, frequency or route should be noted and documented.
- Reconciliation: Resolving discrepancies and documenting changes and new orders.
EHR Tools and Medication Reconciliation – Research Findings
According to a recent study, EHRs have an important role in improving hospitals’ medication reconciliation, though issues related to data quality, technology and workflow persist. Researchers from the National Institute for Health Care Reform (NIHCR) identified the main challenges to effective medication reconciliation as:
- improving access to reliable medication histories
- enhancing EHR usability
- engaging physicians more fully, and
- consistently sharing patient information with the next providers of care
The key findings of the study as reported by Healthcare IT News are as follows:
- Over a third of the hospitals in the study continued to rely on a partially paper-based process at admission, discharge or both, though they reported that EHRs had added medication reconciliation functionality over time.
- Many hospitals had some access to affiliated physicians practices’ EHRs which helped generate more accurate pre-admission medication lists from medication histories. However, there were doubts about the reliability of the information.
- Hospitals that have fully electronic admission or discharge processes had implemented EHR medication reconciliation modules which allow comparison of medication lists at those transitions. Actions taken on each medication are automatically converted into orders. This eliminated the need to re-enter data and improved workflow.
- Hospitals with fully electronic discharge processes benefited from information about discharge medications in the EHR and could used it to generate legible and more patient-friendly discharge instructions and electronic prescriptions. EHRs also allowed hospitals to integrate the same medication list into the discharge summary and share discharge medication information electronically with the next providers of care.
Another new study published in Pediatrics, reported on the efficacy of EHR software alerts that can reduce medication errors, such as concurrent prescriptions that might cause drug-drug interaction (DDI). However, the researchers point out that to provide truly reliable alerts to potentially dangerous DDI, EHRs must exchange data with other EHRs. The team found that only a minority of office-based physicians use such a health information exchange. As a result, the prescribing physician may fail to get an EHR alert to a problem. While medication reconciliation could fix this problem, the researchers noted that it has had limited effectiveness.
Internet Health Management reported on another recent study by Northwestern University researchers which found that while use of EHR tools in isolation improves medication reconciliation, it does not improve systolic blood pressure among patients with hypertension. The study, which was published online in JAMA Internal Medicine, found that expanded EHR use improved patients’ understanding their medications, access to digital monitoring tools at home did not result in continued use at or improve their conditions. They reported that blood pressure even worsened in the EHR-only group. Researchers note that information on adverse drug effects in the medication sheet may have led some patients to stop or reduce anti-hypertension medications when used without guidance from a healthcare professional.
The key takeaway from these studies is that it is necessary to find effective ways to support patient medication self-management and make the path easier for them. At the same time, it is critical to improve EHR usability, physician engagement, and access to reliable medication histories by next providers of care. Healthcare workers often work long hours, causing errors in transcription of medication orders. The support of an experienced medical transcription company can go a long way in improving the quality of nursing transcription. With a reliable medical transcription service provider managing the transcription of history and physical reports, clinic notes, office notes, or operative reports, clinicians can ensure EHR data accuracy and reduce the risk of documentation-related medication errors.