Medication Reconciliation Process and Compliance: Ensuring Patient Safety and Accuracy

Patient care is a complex and sensitive process, and medical reconciliation is one of the most critical components of that process. Medication reconciliation involves making an unadulterated list of a patient’s current medications, including dosage, frequency, and route. It serves as a safeguard that allows nurses to detect abnormalities in medication patterns more easily and to ensure patient safety. Pharmacy and nursing programs require students to be well-versed in medication reconciliation so that they can maximize their healthcare compliance and become torchbearers in nursing best practices. As a result, it is also one of the most taught and studied topics in medical studies; however, there are not many people out there who can provide help with medication reconciliation assignments. Let us explain to you how Do My Assignment can help you in writing your medication reconciliation assignment and why it is such an important issue.

What Is Medication Reconciliation?

As we discussed in the previous section, medication reconciliation is the process of listing a patient’s current medications, including specific details. You also have to make note of details like the admission date of a patient in a hospital and when they are being transferred/discharged. The main reason this is performed is to avoid medication errors, which is a priority for nurses, as the patient’s life is on the line.

It is also worth noting that medication reconciliation is a very interconnected process, as it requires the collaboration of different departments in a hospital. Physicians, pharmacists, and nurses are all equally involved in ensuring that the medications are registered correctly and that they are being safely administered to the patient.

Why Medication Reconciliation Compliance Matters?

Medication reconciliation is considered to be one of the most important among the Australian National Patient Safety Goals for a reason. Reconciliation is far more than a work of documentation, as its main objective is to create a safety net for the patient by monitoring their medications. Here are some of the reasons why healthcare compliance is absolutely critical to ensure patient safety.

Minimizes Preventable Medication Errors

The main goal of medication reconciliation is to reduce and eliminate medication errors before they occur. A minor discrepancy can lead to unwanted drug interactions (also known as Adverse Drug Events), which can be potentially life-threatening for the patient.

Mandatory for Regulatory and Accreditation Standards

Compliance with healthcare standards and hospital safety protocols is not optional; it is mandatory. Bodies like the Joint Commission will only provide accreditation to those healthcare institutions that mandatorily comply with reconciliation standards.

Reduces Readmission Rates and Associated Costs

Poor compliance will most likely lead to the patient’s health worsening, which will lead to readmission. Readmission is neither good for the patient nor the hospital, which is why it is an outcome we would like to avoid. Strong compliance will directly lead to better clinical outcomes, which will consequently reduce the chances of readmission.

Strengthens Legal and Liability Protection

Medication reconciliation requires constant documentation and adherence to nursing best practices, which strengthens the hospital’s legal standing in case something unwanted happens. Demonstrating full compliance in the court of law will automatically give you/the hospital a safeguard against liabilities.

Key Steps In The Medication Reconciliation Process

You can describe the process of medication reconciliation as a 4-step operation that is specifically designed to ensure patient safety and follow the nursing best practices. Here is how the process of reconciliation is practiced.

1.Develop the Best Process Medication History (BPMH)

This is the process we refer to as the ‘verification phase.’ In this step, we gather information about the patient’s medication history from different sources, including their health reports, information from the patient and their family, and inquiries from their previous healthcare professionals. This is instrumental in developing the best medication plan for the patient later on.

2.Compare the BPMH to the Provider’s Orders

Once the BPMH is finished, it has to be directly compared with the medications ordered by the healthcare provider. Your job is to find discrepancies and immediately contact the physician to confirm if the discrepancies were intentional. Medication list accuracy precisely depends on how diligently you perform the comparison and clarification process.

3.Make Clinical Decisions and Resolve Discrepancies

After briefing with the physician, you can begin documentation by noting if any medications are being intentionally withheld. Make sure that you pay close heed to medication errors and remove them if they are unintentional.

4.Communicate the New Medication List

Finally, the reconciled list of medications should be communicated to the patient and their healthcare provider. Make sure that the patient, their family, their provider, and their physician are all on the same page when it comes to ensuring medication and healthcare compliance according to the list.

What Are The Common Challenges In Medication Reconciliation?

Unfortunately, as important as medication reconciliation is, it is still a difficult process to streamline. There are several challenges that make the reconciliation process difficult to complete. Generally, hospital safety protocols can be an interference that hinders the completion of the process. Here are some of the common challenges faced by medication reconciliation.

Inaccurate Medication History

Obtaining the BPMH (Best Possible Medication History) is probably the most difficult process of medication reconciliation. It is easy to overlook over-the-counter drugs or forget names. Also, gathering accurate information is hard, as patients might not remember what medications they were using.

Time Constraints in High-Paced Settings

Preparing a list of medications is a time-consuming process that requires thorough investigation and multiple patient interviews. It is also important to maintain medication list accuracy while racing against time, as the patient’s life is at stake in some settings.

Poor Health Literacy and Patient Communication

Unfortunately, elderly patients and those with ailments that affect cognition might have difficulty understanding the requirements of your list. They might not know when to take a specific medication and in what amount. Patient literacy is a key topic in nursing assignments, which is why it is recommended that you get nursing assignment help for that as well.

Interoperability and Technological Gaps

Although EHRs (Electronic Health Records) are helpful, it is interoperability that makes medication reconciliation difficult. Different hospitals and clinics use different systems, which makes sharing information even more difficult, which can lead to delayed clinical outcomes.

What Are The Strategies To Improve Healthcare Compliance?

Healthcare compliance cannot be the responsibility of a single nurse or doctor; it is a joint responsibility. This is why ensuring compliance with medication reconciliation standards is a task that cannot be performed properly without coordinated error prevention strategies in place. Here are some of the strategies used to ensure healthcare compliance.

Implement Clear Standardization and Policy Enforcement

Healthcare compliance is heavily dependent on consistency. You should follow a single, standardized protocol that also aligns with the hospital safety protocols. This policy should explicitly define the process owner (who is responsible for ensuring reconciliation?), minimum data sources (at least two mandatory sources to obtain the best possible medication history), and specific documentation standards.

Fully Leverage EHR (Electronic Health Record) Capabilities

Manual habits can lead to unwanted medication errors, but technology can help you avoid them. It is highly recommended that you use EHR tools that directly connect with state Prescription Drug Monitoring Programs (PDMPs) and local medical communities to obtain verifiable medical lists electronically.

Establish Continuous, Targeted Education and Competency Checks

One of the main reasons compliance fails is because of inadequately trained staff. It should be a primary responsibility to properly educate pharmacists, nurses, and physicians so that they know how to document a patient’s medication history properly.

Empower Patients as Active Partners in Their Care

Lastly, the best thing you can do is to give patients an active role in their own healthcare program. Educate them about the drugs prescribed to them, along with the recommended dosages. Also, ensure that you follow the nursing best practices and adhere to the national healthcare compliance guidelines.

What are the Benefits of Effective Medication Reconciliation?

Now that we understand what medication reconciliation is and how it is implemented, it is time to learn its significance in ensuring patient safety. As we have discussed earlier, medication reconciliation maps the medication history of a patient so that we, as nurses, can suggest more appropriate and less risky interventions. Here are some of the benefits of effective medication reconciliation.

Maximized Patient Safety and Reduced Mortality

The most noticeable benefit is the direct increase in patient safety. The more a patient and their healthcare providers are aware of their medication patterns, the lower the risk of adverse drug events (ADEs). Naturally, fewer ADEs also contribute to a reduction in patient mortality, as ADEs are responsible for the deaths of several patients each year.

Significant Reduction in Healthcare Costs

Medication errors are incredibly expensive, both for the patient and the clinic. Proper medication reconciliation will directly reduce the costs incurred by ADE treatment, which includes expensive tests, hospital stays, and follow-up care. Also, better healthcare compliance will reduce readmission costs, which is only possible if the patient follows the treatment plans at home precisely.

Improved Quality Metrics and Accreditation Status

Better medication reconciliation is not just good for the patient, but it can also greatly benefit the hospital. Hospitals that are known for remarkable healthcare compliance and documentation are more likely to be accredited by the Joint Commission. Better accreditation will directly lead to better recommendations for the hospital. Naturally, this will boost the hospital’s credibility, trustworthiness, and business.

Enhanced Clinician Communication and Teamwork

The process of reconciliation requires an intricate process of interdisciplinary communication between physicians, pharmacists, and nurses. This causes the medication list accuracy to improve, assuming the communication between each department is transparent. Most importantly, it will also foster teamwork between the different departments of the hospital.

FAQs About Medication Reconciliation

What is the difference between verification and reconciliation?

Although these terms are often used together, they are never used interchangeably. Verification refers to the process of collecting the most accurate and up-to-date information about a patient’s current medications from different sources (medical records, medication history, the patient themselves, family members, etc.). Medication reconciliation, on the other hand, refers to the process of making a comprehensive list of medications that the patient currently takes.

How often should medication reconciliation be performed?

Medication reconciliation should be performed whenever the patient undergoes a transition of care. When a patient goes from a hospital to a specialized care center, or even when he/she go from one unit to another, the medical reconciliation should be updated.

Who is responsible for ensuring healthcare compliance?

Ensuring healthcare compliance is the responsibility of many people, which makes it a shared responsibility. Ultimate accountability usually lies with the hospital’s top administration; however, frontline medical professionals are equally responsible in a technical sense.

Can technology improve medication reconciliation accuracy?

Absolutely. There are tools like Electronic Health Records (EHRs) and Computerized Physician Order Entry (CPOE) that help in precisely tracking the medications taken by a patient to ensure that we can safely avoid medication errors. They can provide automated alerts for drug interactions, flag inconsistencies in medication patterns, and give the nurse a full history of the patient’s medication.

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