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Use creative strategies for JCAHO’s medication goal
What’s the toughest new requirement for EDs in the 2005 National Patient Safety Goals from the Joint Commission on Accreditation of Healthcare Organizations? For many ED nurses, that’s an easy question: They point without hesitation to the goal requiring that medications are reconciled across the continuum of care.
"We have been working on all the goals and are achieving all but this one," says Kathleen Carlson, RN, MSN, CEN, operations manager for the ED at Sentara CarePlex Hospital in Hampton, VA. "We are struggling to find the best way to achieve this in the ED, as the patient is in the department for such a short time compared to the inpatient stay."
This goal must be planned and attempted during 2005, with full implementation by January 2006. "So the development of appropriate implementation strategies needs to begin now," says Bonnie Atencio, MS, RN, clinical educator for the ED at Mercy San Juan Medical Center in Carmichael, CA.
To comply, you must develop a process for obtaining and documenting a complete list of the patient’s current medications, including prescription drugs, over-the-counter drugs and herbal preparations, upon the patient’s admission from the ED. "This must be done with the involvement of the patient," she adds.
The process must include a comparison of the medications given in the ED with the other medications the patient is currently taking. "This is what we need to develop," says Atencio. "ED nurses are currently asking for a complete list of medications from the patient. If the patient has been a patient in our facility, or if the patient has a complete list of their medications, we then can compare," she says.
The goal is to check for potentially harmful drug interactions and to see what medications the patient has tried in the past that have not worked, to avoid ordering these same drugs again, says Kathleen Catalano, director of regulatory compliance at Dallas-based PHNS, a privately held company that provides information technology, medical records, transcription, coding, and business office outsourcing services to the health care industry, she adds.
In addition, a complete list of the patient’s medications must be communicated to the next provider of service when your ED refers or transfers a patient to another setting, service, practitioner, or level of care, either within or outside your organization.
The obstacles for the ED are many, according to Catalano. Patients may be comatose or unresponsive, and family and friends may have no idea what the patient is taking, says Catalano.
In addition, patients rarely come to the ED with a complete list of medications, or they may have an outdated list and are unsure as to the dosage changes, says Atencio. "The new requirements state that we will need to develop a way of obtaining this information that is more accurate and reliable," she says.
Electronic systems would be one way to accomplish this, but only if the patient had been seen in your ED previously, says Catalano. "But if the patient had been seen and the systems were electronic, with a push of a button, you’d have the patient’s past medical record," she says.
To comply with the medication goal, you must take the following steps:
"The floor to which the patient is being transferred then would be responsible for filling in the gaps," says Catalano. These gaps might include over-the-counter drugs or herbal supplements used by the patient, or new information obtained by a family member about the patient’s current medications.
"Maybe the patient says their medications are all in the kitchen cabinet, but they can only remember they take a heart medication and a family member had to go home to see what the items were," she adds.
Even if the patient isn’t being admitted, it’s still good practice to obtain medication information if possible, says Catalano. "The patient’s ED record will be maintained with the patient’s other medical records, so this information would be available if needed at a later date," she explains.
"The challenge will be for those patients who are unaware of, or unable to provide us with a complete accounting of their medications," says Atencio.
She suggests the following to address this problem:
— Instruct patients to keep track of their medications on one list. "The ED is an excellent place to educate patients about this," says Atencio.
— Start a community education program in collaboration with ED physicians about the importance of having medication information readily available.
— Use a pocket tool for patients to list their medications. (See resources, below.)
If a patient is unresponsive and no information is available, document this as follows, advises Catalano: "Patient unresponsive and unable to provide information regarding current medications, over-the-counter drugs, or herbal preparations."
For more information about reconciling medications across the continuum of care, contact:
To obtain a pocket card for patients to record their medications, go to www.madisonpatientsafety.org. Choose "Medication Safety Brochure with Wallet Card" on the right navigational bar, and click on "Accompanying Pocket Card to Record Medications."