Med rec: It's not just for inpatients

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Medication reconciliation has been a National Patient Safety Goal for two years and still gives hospitals fits in trying to meet The Joint Commission’s requirements. It’s especially tough in the outpatient setting, where it can be difficult to gauge what should be recorded and transmitted in the reconciliation process.

The Joint Commission’s FAQs about the goals shed some light on the matter, according to Sue Dill, RN, Esq., AD, BA, BSN, MSN, JD, director of hospital risk management/patient safety for OHIC Insurance Company in Dublin, OH. Although the FAQs hold the line in requiring med rec in most cases, they do allow for some breathing room and even ways to avoid the process altogether. “It looks as though they are giving discretion on where this may not apply,” says Dill.

In a nutshell, you must complete the med rec process in the outpatient setting as you would for inpatients. A complete list of home medications must be recorded and then saved. A second list becomes a working document, which should be changed to reflect any changes in the patient’s medications. This becomes the current medication list. If you make changes to the current medication list, discard the old interim list in favor of the one with the latest information. However, the home list should never be changed.

At the end of the patient’s visit, the current medication list must again be reconciled against the home medication list, and a new regimen of home medications must be approved and given to the patient and to any facility to which you transfer the patient. Any change to the patient’s medications, even if it is only for the duration of the outpatient visit, must be reconciled against the patient’s home medication list. 

Minimal medications must be reconciled

Even items such as contrast media must be reconciled against the home medication list, according to the FAQs. The point of the medication reconciliation process is to avoid using contraindicated medications or inadvertently providing repetitive medications to the patient. If you do not reconcile the contrast agent to the patient’s existing medications, you may miss a potential problem.

Short-term topicals, eye drops, radiopharmaceuticals, and other medications may seem innocuous, but they carry the risk of allergic reactions and possible contraindications with a patient’s home medication. The FAQ about the matter says the reconciliation in these situations is checking the home medications and history of allergies to make sure that there are no unintended side effects from the minimal use of a medication. A simple check against the home list is satisfactory, according to the FAQs.

That kind of double-check is a stalwart of good care, according to Dill. “Making that the requirement when it’s a standard of care makes sense,” she says. 

No med rec when:

The Joint Commission’s January FAQs do outline one scenario in which medication reconciliation may not be necessary. The situation would have to satisfy all of the following requirements:

  • It’s a short outpatient event
  • The medication used has a limited, local use and does not affect any of the patient’s major systems (examples listed include topical agents, local anesthetics, and nonabsorbable contrast agents)
  • There are no other medications used during the patient’s appointment
  • No new medications are prescribed for the patient to use after discharge from the outpatient visit
  • No changes were made to the patient’s current list of home medications; the medication was used only during the outpatient visit
  • The care provider receiving a transfer or referral already has the patient’s current medication list

    If you cannot meet all of the above requirements, you must conduct the medication reconciliation process.

    One other such scenario is when you do not give the patient any medication. 

    In that case, there is no new medication that would require a check against the patient’s home medications, and therefore the med rec process is not needed, according to the FAQs.

    “This exception brings a little balance to the requirement,” adds Dill.