Medication reconciliation at nursing home admission

As patients move from one point of care to another, medications that travel with the person need to be reconciled at admission to the new care setting. Amy Vogelsmeier, RN, PhD, conducted an observational study on medication reconciliation (MR) in relation to medication safety. “Medication reconciliation is based on existing evidence that it can reduce medication errors, thus reducing preventable adverse drug events that result from errors,” she explains.

For the past eight years, Vogelsmeier, an assistant professor in the University of Missouri Sinclair School of Nursing, has focused her research on medication safety and the implementation of safety practices such as technology systems and medication error identification.

AVOIDING PREVENTABLE ERRORS

Medication reconciliation is a safety process in which a patient transitions from points of care (e.g., home to hospital to nursing home). The goal of the MR process is to identify and resolve discrepancies. “For example,” says Vogelsmeier, “perhaps a person was on an antidepressant or diuretic at home. Upon admission, those meds were eliminated for various reasons. Should those medications be restarted as the patient transfers to a skilled nursing facility?” Or perhaps a medication is started during a pre-op evaluation—should it be discontinued upon discharge to home?

Vogelsmeier observes that there are some common problems, or barriers in the nursing home, to performing MR at the points of transition that might relate to fragmented care and miscommunication between settings. “Fragmented care means that the physician (or group of physicians) managing a patient’s hospital stay is different than the physician following the person when he or she transfers to the nursing home setting,” she explains. This is where nursing home RNs become invaluable allies in the MR process.           

“Because physicians don’t always communicate with each other directly, it is up to the nurses to coordinate the process and inform the physicians if they discover any potential discrepancies,” explains Vogelsmeier. Ideally, she say, MR should be an interdisciplinary process. “However, this was one area of concern in the study because nurses identified these potential discrepancies differently which, in turn, influenced their communications with the physicians and pharmacists,” notes Vogelsmeier. 

CLOSING THE DISCONNECTION

In some nursing homes RNs and LPNs are used interchangeably. In her study, Vogelsmeier found that the MR was done by whoever was present when the resident arrived. Whether an RN or an LPN, it was that person’s responsibility to communicate with the physician. Although LPNs do receive training in medications and their effects, Vogelsmeier stresses that RNs are the clinical leaders. 

Traditionally, RNs function as supervisors and administrators. They oversee the staff who look after resident care. “That’s where I see a disconnect,” says Vogelsmeier. “There are fewer RNs in nursing homes today than there were ten years ago, but higher-acuity residents are being admitted,” she explains. Sicker residents mean that RNs have to be more hands-on than in the past. “RNs need to see residents daily to assess and understand their clinical conditions,” she says. In addition, RNs should ensure that medications are being monitored by checking lab values, vital signs and pain assessments, for example. 

To close the disconnection, it is important for these nurse leaders—the RNs—to bring LPNs into the fold. “They need to educate their LPNs and aides in how to deliver clinical care and they need to be in constant communication with them,” adds Vogelsmeier. After all, LPNs are the extension of the RN because they, too, have an educational background and training in medications and how they work. If medication is not reconciled properly, preventable adverse events such as falls, allergic reactions and more severe consequences can occur. 

LPNs interface directly with the residents and their families. Vogelsmeier stresses that they play an important role in letting the RN know what medication concerns they or the resident and/or family might have. It is this hands-on role that contributes to medication safety. 

The RN should take time, go on the floor and ask the LPNs and aides about their residents. Of all staff, aides are the closest to the residents. They see the subtle changes and can tell you who isn’t eating, who is a bit more combative today and who isn’t taking their meds. This healthy communication is a result of the aides knowing that the RN is receptive and appreciative of the information given. As Vogelsmeier states, “That’s a healthy relationship among staff.” 

SUMMARY                 

From her observations, Vogelsmeier believes that RNs must be recognized as the nurse leaders that they were educated to be. However, because of the higher resident acuity, these nurse leaders must also be hands-on participants in providing clinical care. The RN must take charge of communicating with the physician about his or her concerns about a resident’s clinical condition, their medication therapy needs and, most importantly, ensuring that medication monitoring is ongoing so that problems can be identified and managed early and appropriately. 

Sandra Hoban

Sandra Hoban was on I Advance Senior Care / Long-Term Living’s editorial staff for 17 years. She is one of the country’s longest-serving senior care journalists. Before joining Long-Term Living, she was a member of the promotions department at Advanstar Communications. In addition to her editorial experience, Sandi has served past roles in print and broadcast advertising as a traffic and talent coordinator.