Background: Several factors contribute to the potential for patient confusion regarding his or her medication regimen, including multiple names for a single drug and formulary variations when the patient receives medications from more than one pharmacy. Case Study: A 68-year-old woman was discharged from the hospital on a HMG-CoA reductase inhibitor (statin) and resumed her home statin. Eleven days later she returned to the hospital with a diagnosis of severe rhabdomyolysis due to statin overdose. Implementing Solutions: Miami Valley Hospital, Dayton, Ohio, implemented a reconciliation process and order form at admission and discharge to reduce the likelihood that this miscommunication would recur. Initial efforts were trialed on a 44-bed orthopedic unit, with spread of the initiative to the cardiac units and finally to the remaining 22 nursing units. Results: The team successfully implemented initiation of the order sheet, yet audits indicated the need for improvement in reconciling the medications within 24 hours of admission and in reconciling the home medications at the point of discharge. Conclusion: Successful implementation of the order sheet to drive reconciliation takes communication, perseverance, and a multidisciplinary team approach.
Document Type: Research Article
Publication date: July 1, 2005
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Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care. The Joint Commission Journal on Quality and Patient Safety invites original manuscripts on the development, adaptation, and/or implementation of innovative thinking, strategies, and practices in improving quality and safety in health care. Case studies, program or project reports, reports of new methodologies or new applications of methodologies, research studies on the effectiveness of improvement interventions, and commentaries on issues and practices are all considered.
Also known as Joint Commission Journal on Quality Improvement and Joint Commission Journal on Quality and Safety