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Joint Commission's Ambulatory Medication Safety Rules


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Joint Commission's Ambulatory Medication Safety Rules

By Tom A. Augello, CRICO

Related to: Ambulatory, Communication, Cures Act: Opening Notes, Emergency Medicine, Primary Care, Medication, Other Specialties, Surgery

Guest Commentators

  • Peter Angood, MD; Joint Commission on the Accreditation of Healthcare Organizations; Oak Brook Terrace, IL
  • Nancy Manchester; Atrius Health; Newton, MA
  • Jeffrey Schnipper, MD, MPH; Brigham and Women's Hospital; Boston, MA


Ambulatory care sites are under new pressure to ensure that, as patients move from setting to setting, everyone knows about what's going on with their medications. The Joint Commission on Accreditation of Healthcare Organizations has released its 2009 Patient Safety Goals for ambulatory care, and medication reconciliation is a strong focus. Although a sizeable portion of office practices and ambulatory sites are not accredited by the Joint Commission, the standards are highly influential.

Dr. Peter Angood is Joint Commission Vice President and Chief Patient Safety Officer.

"Everyone recognizes that the patients have a lot of medications many times, and yet it is confusing as to whose ordering those medications, why are they being ordered, and are the patients even being able to follow and track which medication they are on. Compliance for patients taking medications is well recognized to be only about 50% even if they fill their prescriptions. A lot of patients don't even fill their prescriptions."

Mistakes with medication reconciliation can happen when patients enter a new setting or when they leave. The error might not lead to a health problem, or it may send a patient to the hospital or worse. Liability can attach to facilities and the providers responsible for the patient's care.

Dr. Jeffrey Schnipper is the Director of Clinical Research for the hospitalist service at Brigham and Women's Hospital in Boston. Dr. Schnipper has studied medication error extensively. He acknowledges med errors have not been studied widely in ambulatory care, compared to the in-patient setting.

But his research has found that an average in-patient has 1.5 potentially harmful medication discrepancies between what they were taking when they entered the hospital and what they had in the hospital or upon discharge—which had nothing to do with medical decision-making. Dr. Schnipper says three-quarters of those potential adverse events associated with medication discrepancies are seen after discharge.

In one of his studies, about half of patients reported taking a different list of medications than what their doctors were noting in the record.

"…these are pretty serious errors that two physicians have vetted and said 'that's just not right.' So, the patient has congestive heart failure and doesn't even know they are supposed to be on their Lasix, so isn't taking it at all or they're taking Lasix and furosemide because they don't realize they are the same medication and so they're taking double the dose that they should be and could easily end up dehydrated. It's a patient who's had a heart attack who is not taking a beta blocker at all because they don't know they are supposed to be on it and could easily have another heart attack."

'Omission' is the most common medication discrepancy in Dr. Schnipper's research. He estimates that 75-80 percent of these discrepancies cause symptoms, and about 20 percent are serious enough to cause re-hospitalization or persistent change in the patient's functioning.

Dr. Schnipper says the errors most often occur at admission because the staff doesn't know what the patient was supposed to be taking in the out-patient setting, and neither does the patient. According to Dr. Schnipper, medication list maintenance and documentation is woefully inadequate.

"Far and away the biggest problem is knowing what they were taking before they came into the hospital. So, therefore we write down the wrong orders at admission and we write down the wrong orders at discharge. And then on top of that, about a quarter of the time, even if we knew what they were taking before they came into the hospital we then write the wrong orders at discharge. The patient used to be on an aspirin; we hold that on purpose in the hospital; it can now be restarted, but we forget to restart it."

As patients move from site to site, and doctor to doctor, the potential for error grows. The Joint Commission goals related to reconciling medication lists in the ambulatory setting tend to be fairly broad. They call on out-patient sites to accurately and completely reconcile medications across the continuum of care. The new goal for 2009 gets more specific about what that means.

First, each time a patient moves from one organization or service to another, a complete list of medications is communicated to the next provider. If the patient goes home, the list goes to the primary care or referring physician and to the patients themselves.

Some of what the Joint Commission did with the new standards was reduce the burden and recognize real-world care. For example, if a new medication is given for a short duration, such as an antibiotic in the ED, then a full reconciliation isn't necessary—the list just needs to be checked for allergies or other potential adverse event. Another simplification in the new standard involves who gets the reconciled list when a patient moves on. The Joint Commission says the list can go to just one provider when the patient transfers, not all the known providers. And if the next provider is not known, the patient or family can get the reconciled list.

Dr. Angood says patient involvement is critical.

"It is the patients who are taking the medications, and most of the time patients are aware of what they're taking. They have some idea why they are taking it, but if there are changes going on then it is critically important that patients are aware of those changes, why those changes are occurring, and having those changes explained to them. So, we've got patient involvement all the way through that medication reconciliation process."

Nancy Manchester is Director of Patient Safety and Risk Management for Atrius Health, a multi-site organization of primary care practices in the Boston area. Manchester says medication reconciliation is critical in the out-patient setting. But she explains the challenge of trying to meet important but difficult goals.

"I think closed loop communication is a huge challenge, especially in the ambulatory setting where there are so many moving parts: referrals to specialists, transitions from hospital to outpatient providers. All of those transitions are opportunities to either drop the ball or reconcile medications completely and effectively."

Manchester adds that an obvious problem in primary care is the very short appointment time that providers have with patients. She recommends assigning a knowledgeable persons in a practice the role of reconciling medications for individual patients. Education, self-assessment and data are vital to bringing everyone on board with what can be a tedious task. Atrius is taking advantage of a fairly advanced electronic record system and software that's being piloted to track events and near-misses.

According to Manchester, the objective of getting medication reconciliation onto the radar screen of busy clinicians can be advanced with the help of compelling localized data and a heightened understanding of what can go wrong.

"We really need to stop and look at our work flows and make sure that we've got policies in place and procedures for every step. There are some great tools on the website that they will show you the failure modes and effects analysis in different care settings for the medication reconciliation issue, and some of those lessons learned are applicable and helpful. There is no need to recreate the wheel in some of these situations."

Dr. Schnipper says electronic medical records can help, but technology is not necessary, and system re-design is more critical.

"Everyone is looking for someone else to be in charge of this. As a physician, I would say we as physicians are, at the end of the day, responsible for the accuracy of the process as a whole. That doesn't mean we need to do all the work, but we need to assign responsibility for who is going to do the work in each setting and make sure that it's being done and make sure there is a second person to guarantee sort of the fidelity of the work and make sure that it is being done.

This is a little easier to explain on the inpatient side. On the outpatient side, I think each practice is going to have to decide, is this a nurse who's going to verify the history or a medical assistant? Honestly, those details have not been worked out yet."

More information and guidance on medication reconciliation is available at the Joint Commission web site, which is; Also, the Massachusetts Coalition for the Prevention of Medical Errors provides recommendations and guidance at, and click on "publications."

December 1, 2008
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