Medication errors are among the most prevalent patient safety incidents in the U.S., with more than 40% attributed to inadequate medication reconciliation during the hospital admission, transfer, and discharge processes. The consequences of medication error for patients can range from mild to severe to lethal. Fortunately, with proper medication reconciliation across the continuum of patient care, many of these errors can be avoided.
Best Practices
Medication reconciliation is an integral part of the Transitions of Care HEDIS measure and a Joint Commission National Patient Safety Goal since 2005. Defined by the National Institutes of Health as the process of comparing a patient’s medication orders to all the medications that the patient has been taking, medication reconciliation should be performed during every transition of patient care, when new medications are ordered, or existing orders are modified. Because the process often involves multiple health care professionals in multiple settings, it’s essential for your practice to establish a standard medication reconciliation procedure, with clearly defined roles for physicians, nurses, pharmacists, and other members of the care team.
It’s also important to include your patients in the medication reconciliation process so that when called upon, they can address questions about their medication history. Engaging patients in the process also provides the opportunity for you to gauge their level of knowledge about their medications and treatment and identify discrepancies that could lead to harmful medication errors.
When you have conducted a medication reconciliation, be sure to bill CPT code 1111F, which indicates that a medication reconciliation has been completed; a face-to-face visit is not necessary when performing medication reconciliation. Doing so creates greater efficiency and reduces burden on you and your office staff by decreasing medical records requests.
Tufts Health Plan Senior Care Options (SCO) Providers
If you are a Tufts Health Plan SCO provider, we’d like to remind you that when your SCO patient is discharged from a hospital or inpatient facility, a Point32Health nurse care manager will outreach to them within seven days of discharge to perform a medication reconciliation, if a medication reconciliation has not already been noted in the patient’s medical record. Once complete, we will send the medication reconciliation to you by fax, along with next steps. Please be sure to input the medical reconciliation into the patient’s outpatient medical record, in addition to the patient’s discharge summary and the discharge medication list that you received from the hospital or inpatient facility.
We encourage you to schedule your patient for a follow-up appointment within 30 days of their discharge date. Subsequent to the patient’s visit with you, be sure to reference “hospitalization”, “inpatient stay”, or “admission”, along with the patient’s admission or discharge date in your notes. Your documentation should also include the patient’s current medication list as well as indication that the medications were reviewed and reconciled by a Tufts Health Plan SCO registered nurse care manager.
When implemented consistently, medication reconciliation can help prevent errors of omission, duplication, and dosing, as well as adverse drug reactions and interactions that could lead to hospital readmission. We are grateful for the attention you provide to this critical process and look forward to our continued collaboration.