Joint Commission Issues Alert to Improve Medication Safety

OAKBROOK TERRACE, Ill., Jan. 25 /U.S. Newswire/ — The Joint Commission on Accreditation of Healthcare Organizations today issued a new Sentinel Event Alert that urges intensified attention to the accuracy of medications given to patients as they transition from one care setting to another, or one practitioner to another. The failure to reconcile medications during these transitions can cause serious patient injuries and even death.

According to the Alert, medication reconciliation should occur whenever a patient moves from one location to another location in a health care facility (for example, from a critical care unit to a general medical unit); or from one health care facility to another or to home; and/or when there is a change in the caregivers responsible for the patient. When effective medication reconciliation does not occur, patients may receive duplicative medications, incompatible drugs, wrong dosages, or wrong dosage forms among the array of potential errors. The medication reconciliation process also provides an important opportunity to assure that the patient is receiving all medications necessary to his or her care and to eliminate any medications that are no longer needed by the patient.

Last year, United States Pharmacopeia received more than 2,000 voluntary reports of medication reconciliation errors, and a 1999 Institute of Medicine report estimated that more than 7,000 deaths occur each year in hospitals alone due to medication errors. The Joint Commission’s Sentinel Event Database also identifies medication errors as one of the most frequently occurring threats to patient safety. This Database reveals that 63 percent of the reported medication errors resulting in death or serious injury were due to breakdowns in communication, and approximately half of those would have been avoided through effective medication reconciliation.

The fact that medication reconciliation errors continue to occur, despite repeated warnings and rigorous standards, prompted the Joint Commission to issue the Sentinel Event Alert on medication reconciliation to the more than 15,000 health care organizations it accredits.

“A systematic approach to reconciling medications must be the foundation for all efforts to prevent drug errors,” says Dennis S. O’Leary, M.D., president, Joint Commission. “As challenging as this effort may be, it will be well worth the investment for caregivers and patients alike.”

To reduce the risk of errors related to medication reconciliation, the Alert recommends that health care organizations:

— Put the list of medications in a highly visible place in the patient’s chart and include essential information about dosages, drug schedules, immunizations, and drug allergies.

— Reconcile medications at each interface of care, specifically including admission, transfer and discharge. The patient and responsible physicians, nurses and pharmacists should be involved in this process.

— Provide each patient with a complete list of medications that he or she will take after being discharged from the facility, as well as instructions on how and how long to take any new medications. The patient should be encouraged to carry this list and share it with any caregivers who provide any follow-up care.

In addition, as part of its current National Patient Safety Goals, the Joint Commission also specifically requires that each accredited health care organization:

— Implement a process for obtaining and documenting a complete list of the patient’s current medications upon admission. This includes a comparison of the medications the organization provides to those on the list. The patient should be asked to describe or confirm any prescription medications, over-the-counter medications, vitamins, herbs or other supplements that he or she takes.

— Communicate a complete list of the patient’s medications to the next service provider when the patient is referred or transferred to another setting, service, practitioner or level of care within or outside the organization.

The warnings about medication reconciliation are the latest in a continuing series of Sentinel Event Alerts issued by the Joint Commission. Much of the information and guidance provided in these Alerts are drawn from one of the nation’s most comprehensive voluntary reporting systems for serious adverse events in health care. The Sentinel Event Database includes detailed information both about the adverse events and their underlying causes. Previous Alerts have addressed wrong-site surgery, medication mix-ups, health care-associated infections, and patient suicides, among others. The complete list and text of past issues of Sentinel Event Alert can be found on the Joint Commission Web site at http://www.jcaho.org.

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Founded in 1951, the Joint Commission on Accreditation of Healthcare Organizations seeks to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations. The Joint Commission evaluates and accredits more than 15,000 health care organizations and programs in the United States, including more than 8,200 hospitals and home care organizations, and more than 6,800 other health care organizations that provide long term care, assisted living, behavioral health care, laboratory and ambulatory care services. The Joint Commission also accredits health plans, integrated delivery networks, and other managed care entities. In addition, the Joint Commission provides certification of disease- specific care programs, primary stroke centers, and health care staffing services. An independent, not-for-profit organization, the Joint Commission is the nation’s oldest and largest standards- setting and accrediting body in health care. Learn more about the Joint Commission at http://www.jcaho.org.

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