Boockvar KS (James J. Peters VAMC), Kushniruk A
(University of Victoria), Santos S
(VA New Jersey Health Care System), Nebeker J
(VA Salt Lake City Health Care System), Signor D
(James J. Peters VAMC)
Patient transfer between sites of care is associated with medication discrepancies and adverse drug events. The Joint Commission has established medication reconciliation as a patient safety standard, but many VA and non-VA organizations have had difficulty implementing this process. The objective of this study was to explore qualitatively VA providers’ approaches to conducting medication reconciliation, their attitudes toward the process, and barriers to completion.
We recorded interviews with 23 physicians and 12 pharmacists at the VA Medical Center in Bronx, NY. In individual task analysis interviews we asked participants to complete medication reconciliation with real and fictitious cases using a CPRS dialog and to verbalize their thoughts as they worked. We recorded computer screens and mouse clicks, and followed with interview questions to ascertain dialog deficiencies and suggestions for improvement. We subsequently conducted focus groups separately with pharmacists and physicians to elicit their views on medication reconciliation’s purpose and utility, who should perform medication reconciliation, and barriers and facilitators to completing the task. Recordings were transcribed, coded and analyzed by one or more investigators. Prevailing themes were identified.
In task analysis interviews we found two opposing approaches to medication reconciliation. Approach 1, observed in some physicians, was characterized by scant information access and processing, little editing of note, completion times of one minute or less, and a belief that medication reconciliation is a requirement but not beneficial to providers or patients. Approach 2, observed in pharmacists and some physicians, was characterized by extensive information access and processing, editing of the note for readability, completion times of 5-15 minutes, and a belief that medication reconciliation is an important decision support process. In focus groups, participants echoed this finding of low- and high-rigor approaches to medication reconciliation and indicated an association with differing attitudes toward its purpose and prioritization. They also indicated that the dialog facilitated rapid data access but could be difficult to comprehend, and that time limitations and competing tasks were barriers.
Our findings suggest that better dialog readability, better integration of medication reconciliation with other tasks, and formal provider training on purpose and prioritization could improve medication reconciliation adherence and rigor.
These findings are being shared with the VA Medication Reconciliation Workgroup to inform efforts to improve the implementation of medication reconciliation in the VA nationwide.