Medication Reconciliation: A Survey of Community Pharmacies and Emergency Departments
May / June 2010
Medication Reconciliation:
A Survey of Community Pharmacies and Emergency Departments
One important aspect of medication reconciliation’s success depends on emergency department and other hospital personnel accessing the patient’s most up-to-date medication history from the outpatient setting. To do this, effective communication between community pharmacies and EDs is critical.
In any given week, 4 out of every 5 U.S. adults will use prescription medicines, over-the-counter (OTC) drugs, or dietary supplements (Aspden et al., 2006). Poor communication of a patient’s medication-use history between community practitioners and emergency department personnel contributes to many adverse drug events (ADEs) and can be a potential source of harm to patients (Pippins et al., 2008). For 2004 and 2005, it is estimated that more than 700,000 patients each year were treated in U.S. emergency departments for ADEs (Budnitz et al., 2006). One out of every 6 of these patients required further care (e.g., hospital admission, transfer to another facility, and emergency department observation admission). During an 11-month period from September 2004 through July 2005, more than 2,000 medication error reports involving a reconciliation issue were submitted to MEDMARX (USP, Rockville, MD) (Santell, 2006). Approximately 22% of these reconciliation-related errors occurred during the hospital admission process. Cornish et al. (2005) found that roughly 54% (81 of 151) patients had at least one unintended medication discrepancy at the time of hospital admission. In another study, discrepancies among documented regimens from different sites of care were found to be highly prevalent, with up to 67% of inpatients in the study having at least one error in their medication history at the time of hospital admission (Pippins et al., 2008). Other studies support that at least 50% of all patients have had at least one unintentional medication discrepancy (Gleason et al., 2004; Lau et al., 2000).
Medication reconciliation is a process that aims to improve patient safety and reduce the risk of medical error by ensuring that healthcare providers have an up-to-date list of the medications a patient is taking. A recent study of hospitalists involved in design and implementation of medication reconciliation processes felt that medication reconciliation would likely have a positive impact on patient safety (Clay et al, 2008). This information, which can reduce therapeutic duplication and adverse drug interactions, must include the drug name, dose, and frequency. ADEs are frequent and often preventable patient safety incidents. Patients are most at risk for ADEs during transitions in care (hand-offs) across settings, services, providers, or levels of care, including community pharmacy services. The goal of “medication reconciliation” is to prevent these ADEs.
The medication reconciliation process has been demonstrated to be a powerful method for reducing ADEs and medication errors (Provonost et al., 2003; Rozich et al., 2004). However, one important aspect of medication reconciliation’s success depends on emergency department (ED) and other hospital personnel accessing the patient’s most up-to-date medication history from the outpatient setting. To do this, effective communication between community pharmacies and EDs is critical.
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Since the NPSG 8 on medication reconciliation was instituted in 2005, many organizations have struggled to develop and implement effective and efficient processes to meet the intent. The Joint Commission (JC) Accreditation Committee determined that effective January 1, 2009, survey findings on the goal to “accurately and completely reconcile medications across the continuum of care” will continue to be evaluated during the on-site survey. However, the JC is in the process of evaluating and refining the expectations for accredited organizations. Expect the revised NPSG 8, which both supports quality and safety of care and can be more readily implemented by the field, in January 2011. The ISMP survey was conducted in 2008 before this decision by the JC Accreditation Committee was made to refine NPSG 8. The results of the survey were based on the respondents’ opinions from the NPSG 8 as defined in 2005. For more information see http://www.jointcommission.org/PatientSafety/National PatientSafetyGoals/npsg8_review.htm |
The Joint Commission (TJC) has implemented medication reconciliation as a National Patient Safety Goal (NPSG 8) for its accredited organizations. This NPSG, active since 2005, requires accredited organizations to completely and accurately reconcile medications across the continuum of care or, in other words, to develop a process for medication reconciliation. This process has several component parts. Initially, the organization must create a complete list of the patient’s current medications upon entry to the healthcare organization. During the reconciliation phase, a provider compares any medication ordered or re-ordered for the patient to those on the list. Any discrepancies are resolved. Communication of the up-to-date reconciled medication list is to take place when a patient is transferred to a different level of care (e.g., transfer from surgical floor to ICU). Upon discharge, the patient’s profile and reconciled list of medications is then sent to the patient’s next provider of healthcare services. This has put pressure on acute care healthcare professionals to obtain a detailed list of each patient’s current medications, including over-the-counter medications, vitamins, herbals, etc. However, facilities are not required or directed to use community pharmacies as a source for current medication information.
Objective
The Institute for Safe Medication Practices (ISMP), a not-for-profit medication safety organization, conducted a survey in a large metropolitan area to gauge the awareness of medication reconciliation in the community pharmacy setting, the degree of communication between community pharmacies and EDs, and to identify barriers that prevent EDs from obtaining medication information from community pharmacies.
Design
ISMP developed two surveys seeking information on the understanding of medication reconciliation, how it is being conducted, and any barriers to the process that are experienced for ED personnel and pharmacy managers of community pharmacies. The survey questions were reviewed by practitioners in each setting including representatives from the National Community Pharmacy Association (NCPA) and the National Association of Chain Drug Stores (NACDS). Online versions of each final survey were constructed using ASP to build the survey and a Microsoft Access database for the results. One survey was sent to chain and independent community pharmacies in the Philadelphia metropolitan area to assess their awareness and understanding of the medication reconciliation process and the Joint Commission’s NPSG. Questions were also asked on how they may be assisting EDs in achieving this goal and any barriers they may perceive in sharing information. The other survey was sent to EDs in the same metropolitan area to determine any barriers they are experiencing in obtaining medication information from community pharmacies and if the EDs are fully utilizing the community pharmacies in their service area to assist in obtaining information. The surveys appear at the end of the article.
In the first quarter of 2008, the surveys were distributed via email and fax to independent, mass merchandise, supermarket, chain, and outpatient pharmacies. NCPA and NACDS assisted in supplying addresses for member organizations. The community pharmacy survey was distributed to 191 practice sites. At the same time, the ED survey was distributed via email by the Health Care Improvement Foundation (HCIF), an independent, non-profit organization with a multi-dimensional focus on healthcare safety, to ED personnel in the Philadelphia metropolitan area. Approximately 70 EDs were emailed the surveys.
A letter explaining the rationale for the survey and survey goals, a copy of the survey tool, and a URL to a secure website were distributed with each email request. A staff person (e.g., pharmacist, physician, nurse) at each site completed and submitted the survey online via a secure website, or transmitted completed surveys to ISMP via secure fax. Faxed surveys were entered into the online portal by personnel from ISMP.
Final completed surveys were reviewed and categorized by ISMP personnel using Microsoft Access.
Results
The ED survey was completed by 19% (13 of 70) emergency departments, ranging in size from fewer than 100 beds (1 of 13) to more than 500 beds (3 of 13). The majority (7 of 13) were hospitals with 100 to 299 beds. All of the responding EDs indicated that their hospitals are accredited by the Joint Commission. Sixty-two percent (8 of 13) of EDs responding to the survey estimate having 25,000 to 50,000 patient visits per year and 31% (4 of 13) have greater than 50,000 patient visits per year. Seven of the ED respondents specified that 21% to 30% of these visits result in hospital admissions. A part-time or full-time pharmacist is employed in the ED of five of the respondents. Pharmacist coverage in the ED for respondents is 8 to 12 hours per day in two of the hospitals, 13 to 16 hours per day in one hospital, and two have pharmacist coverage for less than 8 hours per day. Six of the 13 respondents have an outpatient or retail pharmacy on their campus. However, in more than 85% (11 of 13) of the responding hospitals, a nurse is responsible for obtaining a current list of medications for patients seen in the ED.
Table 1 shows what percentage of patients has a current and complete list of medications when they arrive in the ED. All ED respondents reported that they contact community pharmacies less than 10% of the time to obtain current medication information. Table 2 lists ratings of the understanding of medication reconciliation for primary care physicians, physician practice personnel, and community pharmacies as perceived by ED respondents. The majority of ED respondents (69%, 9 of 13) reported that the quality of information communicated by community pharmacies was good to excellent. Only three of the respondents said they have electronic connectivity in order to obtain a listing of patients’ medications.
| Percentage of Patients | Number of Respondents (n = 13) |
| Less than 10% | 3 (23.08%) |
| 11% to 20% | 4 (30.77%) |
| 21% to 30% | 3 (23.08%) |
| 31% to 50% | 1 (7.69%) |
| Greater than 50% | 2 (15.38%) |
| Rating of Understanding | Number of Respondents (n = 13) |
| Primary Physicians | |
| Total understanding | 0 (0%) |
| Partial understanding | 12 (92.31%) |
| Not familiar with medication reconciliation | 1 (7.69%) |
| Physician Practice Personnel | |
| Total understanding | 0 (0%) |
| Partial understanding | 13 (100%) |
| Not familiar with medication reconciliation | 0 (0%) |
| Community Pharmacies | |
| Total understanding | 1 (7.69%) |
| Partial understanding | 11 (84.62%) |
| Not familiar with medication reconciliation | 1 (7.69%) |
Table 2. Rating, by Emergency Department respondents, of practitioner understanding of the medication reconciliation process.
Of the major barriers to performing medication reconciliation, 85% (11 of 13) of ED respondents cited that patients do not keep a record of all medications, patients use more than one pharmacy, reconciliation with providers is difficult, and staff lacks the time to complete a review of the patient’s medications. None of the ED respondents consider Health Insurance Portability and Accountability Act (HIPAA) violations as an issue for sharing information. Seven respondents said they provide a list of current medications upon discharge from the ED, with 3 reporting that the list was computer generated.
Forty-two percent (80 of 191) of pharmacies, including independent, mass merchandise, supermarket and chain operations, submitted responses for the community pharmacy survey. Fifty-nine percent (47 of 80) described themselves as retail chain pharmacies and 19% (15 of 80) responded as independent pharmacies. Sixty percent (48 of 80) reported that they had more than 500 pharmacies in their organization. Weekday hours of operation ranged from up to 12 hours per day for 41 stores, to 24 hours per day for 10 locations.
Sixty-five percent (51 of 79) of the respondents stated they were familiar with the term “medication reconciliation” yet 46% (37 of 80) said they rarely ask patients for a current list of medications when they arrive in the pharmacy (see Table 3). Seventy-five percent (60 of 80) of respondents said they were aware of the NPSG for hospitals to obtain a list of current medications for each patient entering the ED or hospital. Seventy percent (56 of 80) of the respondents said that less than 10% of patients have a current and complete list of their medications when they visit the pharmacy and 46% (36 of 79) of respondents said they routinely will provide a list to patients. Table 4 lists responses of the 77 participants who answered the question asking if medication reconciliation is performed for patients by community pharmacies.
| Frequency | Number of Respondents (n = 80) |
| Never | 8 (10%) |
| Rarely | 37 (46.25%) |
| Yes, but only for select patients | 23 (28.75%) |
| Yes, for all patients | 12 (15%) |
| Frequency | Number of Respondents (n = 77) |
| Never | 14 (18.18%) |
| Only when requested by patient or prescriber | 36 (46.75%) |
| Rarely | 11 (14.29%) |
| Yes, for select patients | 8 (10.39%) |
| Yes, for all patients | 8 (10.39%) |
Regarding the capabilities of their computer systems, 85% (68 of 80) reported their system is capable of printing a list for patients; 59% (47 of 80) reported that the list includes dosage, route, frequency, and time of last refill. Also, 33% (26 of 80) said they have the ability to document on the list OTCs, herbals, and prescription medications dispensed at other pharmacies. Only 19% (5 of 26) of those reporting the ability to document other medications said that their system prints the information directly on the computer-generated list. Thirty-four percent (27 of 80) of respondents confirmed the capability of electronic connectivity for their computer systems to obtain and share medication information while 54% (43 of 80) answered no and 12% (10 of 80) said they did not know.
Of the major barriers in sharing information with EDs on a multiple answer item, 16 pharmacies reported that their staff perceives sharing of information with EDs as a HIPAA violation, 49 stated the inability of their computer system to obtain medication information from other sources (e.g., other pharmacies), and 26 said staff is reluctant to share with ED unless personnel can be verified. Ninety-five percent (74 of 78) of respondents personally did not consider it a violation of HIPAA to share information with hospital personnel, although 28% (22 of 80) stated they did not know if it was considered a violation by their district or corporate personnel. The majority of respondents reported they did not encounter difficulties with ED personnel (78%, 62 of 80) or physician practice personnel (76%, 61 of 80) sharing medication information on patients due to HIPAA concerns.
Thirty-four percent (26 of 76) of respondents said they have experienced an increase in patients requesting an up-to-date listing of their medications, 21% (16 of 75) experienced an increase from physician practices requesting a list, and 17% (13 of 76) are experiencing an increase from EDs requesting this information. Sixty-four percent (51 of 80) of respondents said they are never or rarely contacted by ED personnel to provide a list of current medications for patients. Sixty-six percent (53 of 80) stated that the quality of communication (open and informative) between EDs and their personnel is good to excellent.
On a multiple answer question item asking what pharmacies may be planning to do to help patients with maintaining an up-to-date list of their medications, 19 said they would provide a medication card to record all medications, 39 said they would review the patient’s medication profile with the patient, 35 said they would provide a listing of medications they have in their pharmacy computer system, 43 said they would provide education on the importance of maintaining and sharing a list, and 14 said they are not aware of or planning any changes in their current practice.
Discussion
The main goals of the survey were to assess the awareness of the topic, barriers preventing medication reconciliation, and communication between community pharmacies and EDs in the same metropolitan area in performing medication reconciliation. Although the response rate (19% for EDs and 42% for community pharmacies) was limited and the community pharmacy responses were skewed toward larger chain pharmacies, important information can be gleaned from these results.
Awareness of the term and definition of medication reconciliation by EDs and community pharmacies appears to be well established. Both settings, however, reported a lack of patient involvement in providing a list of current medications at the time of the patient visit. The majority of patients presenting to EDs and community pharmacies do not supply a current list of medications. This seems to correlate with other findings that patients’ lack of medication knowledge and absence of preadmission medication information are frequently barriers to implementation of medication reconciliation (Clay, 2008). This is particularly discouraging given other research that has shown ADEs are more often caused by errors of medication history-taking rather than reconciliation errors at discharge (Pippins, 2008). Even relying on family members for medication information appears to be a risk factor for error (Pippins, 2008). It is therefore critical to engage patients in the medication reconciliation process. While not all patients may have the health literacy skills necessary to maintain or communicate a list of current drugs (Kutner et al., 2006), hospitals, community pharmacies, and other stakeholders (e.g., healthcare insurers, government advocacy groups, healthcare professional organizations) must make patient education about the importance of medication reconciliation a priority. Explaining to patients and their caregivers the importance of having a current and complete listing of medications, along with how hospitals and community pharmacies are working together to share and provide this information may help. This is especially important today as a single, common database of patient information is not available to all practitioners across practice settings.
Community pharmacy and ED personnel cannot merely ask for a list of current medications if the communication of information is to be complete—they must supply a list to patients as well. However, many EDs and community pharmacies do not provide a list of current medications to a patient. More effort needs to take place in the ED and community pharmacy to provide a current list of medications to patients at each encounter.
The frequency of communication between EDs and community pharmacies for the purpose of medication reconciliation is low. Every ED that responded to the survey reported that they contact community pharmacies for fewer than 10% of their patients to obtain information on a patient’s medication. Sixty-four percent (51 of 80) of community pharmacies reported they receive 3 or fewer calls a month from ED personnel requesting this information. While the exact reason for the low frequency of communication is not known, one potential contributing factor may be that, compared to hospital EDs, community pharmacies typically are not open 24 hours a day. As a result, there is significant time overnight when an ED practitioner cannot reach a community pharmacist. It should be noted, though, that only 1 ED cited this as a major barrier. It is not known if this is because the ED doesn’t routinely call on community pharmacies for medication lists or because the community pharmacies called are usually open. Hospitals can proactively address limited access to community pharmacies, at least at large chain pharmacies, after-hours by identifying stores that are open 24 hours. Large chain pharmacies typically have a common patient database. This means that even though a patient may purchase their medications at a chain store next to the hospital, a healthcare practitioner in the ED can call a 24-hour store that is located across town or even in another state and still access current medication information.
The HIPAA privacy rule does not prohibit the sharing of patient medication information between healthcare practitioners for treatment purposes (“Uses and disclosures,” 2002). Healthcare providers can freely share information for treatment purposes without obtaining a signed patient consent. However, the survey authors had learned anecdotally that some healthcare practitioners may be hesitant to share a patient’s medication history out of misplaced fear of violating HIPAA. To measure the extent of this, the survey questioned if perceptions of HIPAA requirements may inhibit sharing of information between EDs and community pharmacies. All of the EDs who responded said that their personnel do not perceive HIPAA as a barrier to sharing information regarding a patient’s medications with a community pharmacy, but some EDs did report unwillingness on the part of the community pharmacies to share patient information due to perceived HIPAA violations. Additionally, 16 community pharmacies and 2 EDs reported interacting with physician practice personnel who were unwilling to share patient information because of HIPAA. While it is disruptive to the flow of patient information to have some individuals unwilling to share data due to perceived HIPAA restrictions, a potentially larger barrier is the unclear message that district and corporate leaders are sending front-line hospital and pharmacy staff. A number of EDs and pharmacies responded they did not know whether or not the organization allowed sharing of information from a HIPAA perspective. In the absence of clear support to share patient information between EDs and pharmacies, practitioners may be fearful or refuse to communicate critical medication-use information from one level of care to another. Unwillingness of organization leadership or the perception by corporate personnel of a potential violation may also limit internal development of technological processes to enable the sharing of information.
Strategies to make the medication reconciliation process more efficient are needed. Both community pharmacies and EDs reported that a lack of time and personnel limited their ability to perform a complete review of a patient’s medication profile. Responsibility for medication reconciliation has predominantly been added to the existing duties of inpatient physicians and nurses, with limited involvement of pharmacists (Clay, 2008). Adding to the inefficiency is the lack of a single source of patient medication-use information. Specifically, pharmacies cannot provide information on prescription medications dispensed at other pharmacies (not part of a common database), OTC drugs, and herbal products; the pharmacy computer system only tracks medications dispensed by the pharmacy computer system within the store or common database. Likewise, EDs struggle to find and verify medication information, especially when a patient uses multiple pharmacies. A common shared database of patient information accessible by all providers has the potential to provide the needed information more efficiently and completely than the current fragmented system. This shared database would also better enable hospital and pharmacy computer systems to generate a list of current medications that would include products dispensed from more than one pharmacy.
However, hospital and pharmacy computer systems need improved functionality. It has been shown that a computerized medication reconciliation tool and process redesign were associated with a decrease in unintentional medication discrepancies associated with potential for patient harm (Schnipper, 2009). In order to take full advantage of such a system though, hospital and pharmacy computer systems must be designed so that the non-prescription products a patient is taking (e.g., OTC drugs, dietary supplements, herbal products) can be captured and printed as part of a patient’s current medication profile. Likewise the improved IT based medication reconciliation system would need to have the ability to use existing electronic sources of ambulatory medication information. Otherwise, these products must be added manually, increasing the risk that they will be missed or not updated.
It is interesting to note that, according to survey results, both EDs and community pharmacies reported the act of obtaining correct and complete information on a patients’ regimen from the other to be a barrier, yet neither EDs nor community pharmacies cited a major difficulty in communicating with each other.
This suggests that EDs and community pharmacies are able to communicate but that complete patient medication information is not readily available to either of them to share with one another. The establishment of a common database that can be shared among all healthcare providers is surely needed. Although several electronic portals of medication sharing are available between insurers and healthcare providers, the completeness of the information in one common database is not yet available.
Limitations
A major limitation of this study was that it was conducted in a non-controlled setting. A scientific sampling of EDs and community pharmacies in the Philadelphia area could have been added to increase validity of results. The response rate of EDs was low (19%, 13 of 70). While the response rate for the community pharmacy survey was better (42%, 80 of 191), the majority (58%, 47 of 80) of respondents were stores that were part of large chain pharmacies. This may have introduced bias toward the workflow and communication advantages and limitations chain pharmacies may have as compared to independent pharmacies. While participants who entered their responses online were required to answer each question, respondents who completed the survey on paper and then faxed their responses were able to skip questions. As a result, some questions were not answered by all respondents.
Conclusion
The concept of medication reconciliation is of vital importance in medication safety, yet information about the interactions between community pharmacies and hospital EDs in assisting each other and patients with medication reconciliation has been lacking to date. This survey demonstrates that while the quality of communication between EDs and community pharmacies—when it occurs—seems to be good overall, healthcare practitioners still face a number of barriers that make it difficult and inefficient to access and share complete and accurate medication information. Given the existence of these barriers, tools and strategies that EDs and community pharmacies can implement to improve the sharing of critical patient information need to be developed. This survey of community pharmacies and EDs could stimulate others to use the survey instruments, to assess the level of awareness, and to identify the barriers to and communication needs for performing medication reconciliation in their practice settings and geographic areas.
Donna Horn is the director of patient safety – community pharmacy for the Institute for Safe Medication Practices. She may be contacted at dhorn@ismp.org.
Michael Gaunt is a medication safety analyst for the Institute for Safe Medication Practices and the editor of ISMP’s Medication Safety Alert! Community/Ambulatory Care Edition.
Allen Vaida is the executive vice president of the Institute for Safe Medication Practices.
References
Budnitz, B. S., Pollock, D. A., Weidenbach, K. N., et al. (2006). National surveillance of emergency department visits for outpatient adverse events. JAMA, 296, 1858-1866.
Clay, B, Halasyamani, L., Stucky, E., et al. (2008). Results of a medication reconciliation survey from the 2006 Society of Hospital Medicine national meeting. Journal of Hospital Medicine, 3(6), 465–472.
Cornish, P. L., Knowles, S. R., Marchesano, R., et al. (2005). Unintended medication discrepancies at the time of hospital admission. Archives of Internal Medicine, 165, 424-429.
Gleason, K. M., Groszek, J. M., Sulivan, C., et al. (2004). Reconciliation of discrepancies in medication histories and admission orders of newly hospitalized patients. American Journal of Health System Pharmacists, 61, 1689-1695.
Institute of Medicine. Committee on Identifying and Preventing Medication Errors. (2006). Preventing medication errors: Quality chasm series. P. Aspden, J. A. Wolcott, J. L. Bootman (Eds.). Washington, DC: The National Academies Press.
The Joint Commission. 2009 National Patient Safety Goals manual chapter. 2008. Available from Internet: http://www.jointcommission.org/NR/rdonlyres/31666E86-E7F4-423E-9BE8-F05BD1CB0AA8/0/HAP_NPSG.pdf. Accessed 14 September 2009.
Kutner, M., Greenberg, E., Jin, Y., et al. (2006, September). The health literacy of America’s adults: Results from the 2003 national assessment of adult literacy (NCES 2006–483). US Dept of Education. Washington, DC: National Center for Education Statistics. Available at: http://nces.ed.gov/pubs2006/2006483_1.pdf. Accessed March 11, 2009.
Lau, H. S., Florax, C., Porsius, A. J., et al. (2000). The completeness of medication histories in hospital medical records of patients admitted to general internal medicine wards. British Journal of Clinical Pharmacology, 49: 597-603.
Pippins, J., Gandhi, T., Hamann, C., et al. (2008). Classifying and predicting errors of inpatient medication reconciliation. J Gen Intern Med., 23(9), 1414-1422.
Provonost, P., Weast, B., Schwarz, M., et al. (2003). Medication reconciliation: A practical tool to reduce the risk of medication errors. J Crit Care, 18, 201-205.
Rozich, J. D., Howard, R. J., Justeson, J. M., et al. (2004). Standardization as a mechanism to improve safety in health care. Joint Commission Journal of Quality and Patient Safety, 30, 5-14.
Santell, J. P. Reconciliation failures lead to medication errors. (2006). Joint Commission Journal of Quality and Patient Safety, 32, 225-229.
Schnipper, J., Hamann, C., Ndumele, C., et al. (2009). Effect of an electronic medication reconciliation application and process redesign on potential adverse drug events. Archives of Internal Medicine, 169(8): 771-780.
Uses and disclosures for treatment, payment, and health care operations. 45 CFR § 164.506 (2002). Available at: http://edocket.access.gpo.gov/cfr_2002/octqtr/45cfr164.506.htm. Accessed September 15, 2009.
Acknowledgments
The authors wish to acknowledge the National Community Pharmacy Association; the National Association of Chain Drug Stores; the Health Care Improvement Foundation; and Lena Medvinsky IT, a programmer from ISMP, for their assistance in this project.
This project was funded through a grant by the Aetna Foundation.
The following surveys are for reference only.
Medication Reconciliation in Emergency Departments
Medication reconciliation is the process of obtaining a complete list of a patient’s current medications, updating that list throughout the patient’s transition of care, and then communicating any changes to the next healthcare provider of services and to the patient or the patient’s caregiver in order to avoid duplications, omissions and errors.
We thank you for your participation.
Please check the one category that best describes the number of inpatient beds currently set up and staffed for use in your hospital.
___ Fewer than 100 beds
___ 100 to 299 beds
___ 300 to 499 beds
___ 500 beds and over
Please check the one category that best describes the type of organization that is responsible for establishing policy for the overall operation of your hospital.
___ State or local government
___ Non-government, not-for-profit
___ Investor-owned, for-profit
___ Military
To what branch of the service does your hospital belong?
___ Army
___ Navy
___ Air Force
___ Veterans’ Affairs
___ US Public Health Service
___ Other: ____________________
Is your hospital one of several hospitals in a larger healthcare system with common ownership and/or governance?
___ Yes
How many hospitals comprise your health system?
___ 2 – 5
___ 6 – 10
___ Greater than 10
___ No
Please check the one category that best describes the number of annual Emergency Department (ED) visits for your department.
___ Fewer than 7,500
___ 7,500 to 15,000
___ 15,000 to 25,000
___ 25,000 to 50,000
___ Greater than 50,000
What percentage of ED visits result in an admission to your hospital.
___ Less than 10 %
___ 10 to 15 %
___ 16 to 20 %
___ 21 to 30 %
___ Greater than 30 %
Please indicate the percentage of patients served by your hospital that do not speak English as their primary language.
___ 0 to 10%
___ 11 to 30%
___ 31 to 50%
___ 51 to 80%
___ greater than 80%
Please indicate by percentage the approximate payer mix of patients for your hospital? (Percentages should add to 100 %)
___ % Private insurance
___ % Medicare
___ % Medicaid
___ % Managed Care
___ % Cash
___ % Free Care
Does your hospital have a PHYSICIAN residency-training program that has been approved by the Accreditation Council for Graduate Medical Education and/or the American Osteopathic Association?
___ Yes
In what setting is the physician residency-training program carried out?
___ Community teaching hospital
___ Academic medical center
___ No
Does your ED have a pharmacist assigned on a full- or part-time basis to the department?
___ Yes
How many hours per day?
___ Less than 8 hours
___ 8 to 12 hours
___ 13 to 16 hours
___ 24 hours
___ No
Does you hospital have an outpatient or retail pharmacy on campus?
___ Yes
___ No
Is your organization accredited by The Joint Commission?
___ Yes
___ No
Survey
What percentage of patients has a CURRENT and COMPLETE list of their medications when they arrive in the ED?
___ Less than 10 %
___ 11 to 20 %
___ 21 to 30 %
___ 31 to 50 %
___ Greater than 50 %
What personnel are primarily responsible for obtaining a CURRENT list of medications on patients seen in the ED?
___ Registration staff
___ Nurses
___ Physicians
___ Medical Residents
___ Pharmacists
___ Combination of personnel
___ Other (please list) _______________________
Are different personnel (from question #13) responsible for reconciling the current list of medications on patients seen in the ED?
___ Yes (Please check from list below)
___ Registration staff
___ Nurses
___ Physicians
___ Medical Residents
___ Pharmacists
___ Combination of personnel
___ Other (please list) ____________________
___ No
Are different personnel (from question #14) responsible for reconciling the current list of medications if an ED patient is admitted to the hospital?
___ Yes (Please check from list below)
___ Registration staff
___ Nurses
___ Physicians
___ Medical Residents
___ Pharmacists
___ Combination of personnel
___ Other (please list) _______________________
___ No
For what percentage of patients do ED personnel contact community pharmacies to obtain a patient’s CURRENT medication information (e.g., drug, dose, frequency)?
___ Less than 10 %
___ 11 to 20 %
___ 21 to 30 %
___ 31 to 50 %
___ Greater than 50 %
How would you rate the understanding of primary physicians, physician practice personnel, and community pharmacists on the process of medication reconciliation? (Use the following key: 1 = total understanding; 2 = partial understanding; 3 = not familiar with medication reconciliation)
___ Primary Physicians
___ Physician Practice Personnel
___ Community Pharmacists
How would you rate the quality of communication with local community pharmacies when ED personnel contact them for a patient’s CURRENT medication information (e.g., drug, dose, frequency)?
___ Excellent open communication and able to obtain information needed if available.
___ Very good communication and usually able to obtain information needed if available.
___ Good communication and often times able to obtain information needed if available.
___ Poor communication and seldom able to obtain information needed if available.
Does your ED have electronic connectivity in order to obtain a listing of a patient’s medications?
___ Yes (please check all that apply)
___ With physician owned practices of the healthcare organization.
___ With the outpatient clinics and pharmacies of the healthcare organization.
___ With a vendor connected with insurers and local community pharmacies.
___ No
___ Do not know
What are the MAJOR barriers to performing medication reconciliation in the ED? Please check only those you perceive to be a major barrier.
___ Patients do not keep a record of all the medications (Prescription and OTC) they are receiving.
___ Handwritten or community pharmacy generated medication lists that patients or their caregivers supply are incomplete, difficult to read or not current.
___ Difficult to obtain needed information from physician practices.
___ Patient uses more than one pharmacy (may include mail order service) to obtain prescription and other medications; difficult to reach all of them for verification.
___ Difficult to obtain information from community pharmacies.
___ Community pharmacy is usually closed.
___ Community pharmacy is unable to locate patient in the pharmacy computer system.
___ Lack of time or staff to perform a complete review of the patient’s medications.
___ ED does not have sufficient communication technology to receive outside information (fax or e-connectivity).
___ Other (please list)_____________________________
Have ED personnel experienced community pharmacies unwilling to share information regarding a patient due to perceived HIPAA violations?
___ Yes
___ No
Have ED personnel experienced physician practice personnel unwilling to share information on a patient due to perceived HIPAA violations?
___ Yes
___ No
Do you and personnel in your ED consider it a violation of HIPAA regulations to share a patient’s medication profile with community pharmacies or physician practices for the purpose of medication reconciliation?
___ Yes
___ No
Does your hospital leadership or corporate personnel consider it a violation of HIPAA to share a patient’s medication profile with community pharmacies or physician practices for the purpose of medication reconciliation?
___ Yes
___ No
___ Do not know
Does your ED provide a list of CURRENT medications to patients when they are discharged from the ED?
___ Yes
___ Handwritten
___ Computer generated
___ No
Does the computer-generated medication list provided to patients include the dosage, route, frequency and time of last administration for each medication listed?
___ Yes
___ No
___ Not applicable
What is your ED/hospital planning to do to address the barriers to medication reconciliation? Please check all that apply
___ Incorporate electronic connectivity with an outside vendor
___ Add personnel within the ED
___ Assign the process to personnel outside the ED
___ Proactive communication with area community pharmacies to include up-to-date 24-hour store listings
___ Not aware of or not planning to implement anything at this time
___ Other:___________________________________
If you have any additional comments, suggestions or plans to make changes to your practice in regards to Medication Reconciliation, please record them here:
Horn D, et al. Med Reconciliation: Community Pharmacies and EDs
Appendix 1 – Emergency Department Survey
Medication Reconciliation in Community Pharmacy
Medication reconciliation is the process of obtaining a complete list of a patient’s current medications, updating that list throughout the patient’s transition of care, and then communicating any changes to the next healthcare provider of services and to the patient or the patient’s caregiver in order to avoid duplications, omissions and errors.
We thank you for your participation.
Please check the one category that best describes your pharmacy.
___ Independent pharmacy
___ Retail chain pharmacy
___ Supermarket pharmacy
___ Mass merchandise pharmacy
___ Other (explain) _____________
Please check the one category that best describes how many pharmacies are in your company.
___ 1 to 3 pharmacies
___ 4 to 9 pharmacies
___ 10 to 49 pharmacies
___ 50 to 99 pharmacies
___ 100 to 499 pharmacies
___ 500 or more pharmacies
What is the approximate number of prescriptions dispensed per week in your pharmacy?
___ 700 or less
___ 701 – 1,500
___ 1,501 – 3,000
___ 3,001 – 6,000
___ 6,000 or more
What are the normal weekday hours of operation for your pharmacy?
___ Up to 12 hours
___ 13 to 23 hours
___ 24 hours
What are the normal weekend hours of operation for your pharmacy?
___ Up to 12 hours
___ 13 to 23 hours
___ 24 hours
Is your pharmacy owned by a healthcare system?
___ Yes
___ No
Please indicate the percentage of patients served by your pharmacy that do not speak English as their primary language.
___ 0 to 10 %
___ 11 to 30 %
___ 31 to 50 %
___ 51 to 80 %
___ Greater than 80 %
Please indicate by percentage the approximate payer mix of patients for your pharmacy. (Percentages should add to 100 %)
___ % Private insurance
___ % Medicare
___ % Medicaid
___ % Managed care
___ % Cash
___ % Free care
Are you and your staff familiar with the term medication reconciliation?
___ Yes
___ No
Do you routinely ask patients for a CURRENT list of medications when they arrive in your pharmacy?
___ Yes, for all patients
___ Yes, but only for select patients
___ Rarely
___ Never
What percentage of patients has a CURRENT and COMPLETE list of their medications when they arrive in your pharmacy?
___ Less than 10 %
___ 11 % to 20 %
___ 21 % to 30 %
___ 31 % to 50 %
___ Greater than 50 %
Is your pharmacy computer system capable of printing a list of CURRENT prescription medications for patients on demand?
___ Yes
___ No
___ Do not know
Does your pharmacy routinely provide a list of CURRENT medications to patients?
___ Yes (please check all that apply)
___ Handwritten
___ Computer generated
___ No
Does the computer-generated medication list provided to patients include the dosage, route, frequency, and time of last refill for each medication listed?
___ Yes
___ No
___ Not applicable
Does your pharmacy computer system have the ability to document, as part of the patient’s current medication profile/list, OTC drugs, herbal products, and prescription medications dispensed at other pharmacies (not part of a common data base)?
___ Yes, and they print on the list of the patient’s current medications.
___ Yes, but they do not print on the list of the patient’s current medications.
___ No
___ Do not know
Does your pharmacy computer system have electronic connectivity in order to obtain and share a listing of a patient’s medications?
___ Yes (please check all that apply)
___ With local physician practices.
___ With area hospitals and emergency departments.
___ With other pharmacies sharing a common database/owner.
___ With other pharmacies NOT sharing a common database/owner.
___ No
___ Do not know
Does your pharmacy perform medication reconciliation for patients at your practice site?
___ Yes, for all patients
___ Yes, but only for select patients
___ Only when requested by patient or prescriber
___ Rarely
___ Never
What are the MAJOR barriers to performing medication reconciliation at your practice site? Please check only those you perceive to be major barriers.
___ Patients not aware of all the medications they are receiving.
___ Handwritten or printed medication lists that patients or their caregivers supply are incomplete.
___ Difficult to obtain needed information from physician practices.
___ Difficult to obtain information from hospitals and Emergency Departments after patients are discharged.
___ Hospital discharge forms are confusing, difficult to read, or incomplete.
___ Inability to locate and contact appropriate Emergency Department personnel to obtain information regarding a patient’s medications.
___ Lack of time to perform a complete review of the patient’s medications.
___ Other (please list)_____________________________
Are you and your staff familiar with the requirement of hospitals to obtain a current list of medications for each patient that enters the Emergency Department or is admitted?
___ Yes
___ No
How often do Emergency Department personnel contact your pharmacy to obtain current medication information (e.g., drug, dose, frequency) for a patient they are treating?
___ Very often (several calls per day)
___ Often (more than 5 calls per week)
___ Somewhat Often (more than 5 calls per month)
___ Rarely (less than 2 to 3 calls per month)
___ Never
What pharmacy personnel typically provide requested patient medication information to Emergency Department personnel? (please check all that apply)
___ Pharmacist
___ Pharmacy Student
___ Pharmacy Technician
___ Other personnel (please list) _______________________
___ Do not provide information to Emergency Department personnel
How would you rate the quality of communication with local Emergency Departments when Emergency Department personnel contact you for current medication information (e.g., drug, dose, frequency) for a patient they are treating?
___ Excellent open communication and able to give information needed if available.
___ Very good communication and usually able to give information needed if available.
___ Good communication and often times able to give information needed if available.
___ Poor communication and seldom able to give information needed if available.
___ Not applicable
What are the MAJOR barriers to sharing information with Emergency Department personnel so that they can perform medication reconciliation? Please check only those you perceive to be major barriers.
___ Pharmacy staff perceives sharing information with Emergency Department personnel may violate HIPAA.
___ Pharmacy staff is reluctant to share information unless the identity of Emergency Department personnel can be verified.
___ Pharmacy cannot provide information on prescription medications dispensed at other pharmacies (not part of a common database), OTC drugs, and herbal products as the pharmacy computer system only tracks medications dispensed within the store or common database.
___ Pharmacy cannot locate patient in the pharmacy computer system.
___ Lack of time to perform a complete review of the patient’s medications.
___ Unable to print a patient’s current medication profile, including quantity, directions for use, and date of last fill, and transmit it electronically or by fax to the Emergency Department.
___ Other (please list)_____________________________
Has your pharmacy experienced hospital Emergency Department personnel who are unwilling to share information regarding a patient due to perceived HIPAA violations?
___ Yes
___ No
___ Not applicable
Has your pharmacy experienced physician practice personnel who are unwilling to share information regarding a patient due to perceived HIPAA violations?
___ Yes
___ No
___ Not applicable
Do you and personnel in your pharmacy consider it a violation of HIPAA to share a patient’s medication profile with hospitals for the purpose of medication reconciliation?
___ Yes
___ No
Does your district or corporate personnel consider it a violation of HIPAA to share a patient’s medication profile with hospitals for the purpose of medication reconciliation?
___ Yes
___ No
___ Do not know
___ Not applicable
In the last 12 to 18 months has your pharmacy experienced an increase, decrease, or no change in the following: (please use the following key for this question: I = Increase; D = Decrease; N = No change)
___ Patients requesting an up-to-date, printed list of their current medications.
___ Physician practices requesting a current listing of a patient’s medications or information on a specific medication (e.g., dose, frequency) for a patient.
___ Calls from hospital and Emergency Department personnel requesting a current listing of a patient’s medications or information for a specific medication (e.g., dose, frequency) for a patient.
Which of the following do you plan to do to help patients maintain an up-to-date and complete list of their medications? (please check all that apply)
___ Provide the patient a medication card on which prescription and over-the-counter medications as well as herbal products can be recorded.
___ Review a patient’s medication profile with the patient when a medication is dispensed.
___ Provide the patient with a list of medications that appear in their profile.
___ Provide education to patient’s on the importance of maintaining and sharing their medication lists with each healthcare provider they encounter.
___ Not aware of or not planning to implement anything at this time.
If you have any additional comments, suggestions or plans to make changes to your practice in regards to Medication Reconciliation, please record them here:
Horn D, et al. Med Reconciliation: Community Pharmacies and EDs
Appendix 2 – Community Pharmacy Survey