AUTHOR: P.P.PUSHPALATHA
ABSTRACT :
The medication Review process is the process of communication between the patient and the pharmacist to promote the safe and effective use of medications. Medication review services are mostly recommended for patients who are taking several medications at the same time. There are different types of medication reviews namely medication standard, medication pharmacist consultation, and medication follow-up. The medication review process mainly focuses on Medication reconciliation and medication discrepancy. Medication reconciliation targets preventing adverse drug events and it remains a top patient safety priority and also an effective strategy for preventing ADE’S. Reconciliation aims to eliminate undocumented intentional discrepancies and unintentional discrepancies by reconciling all medications at all interfaces of care. In this, mostly a discharge medication discrepancy shows a very significant role and during the discharge process, an electronic discharge medications list is prepared and printed from the electronic health record. The electronic medication administration record and the medication list from the patient history were obtained on admissions. Finally, the detected discrepancies were documented for each patient with the patient’s demographic details and clinical data. The study mainly confirms that medication reconciliation is a critical component for the safe and effective patient care of hospitalized patients. Medication discrepancies at hospital discharge are common and in most cases of major potential harm. Having qualified clinical pharmacists review the medication process, reconciliation and discrepancies help to improve medication use safety and reduce medication errors.
KEYWORDS: Medication reconciliation, Medication discrepancy, adverse drug events, medication errors.
The medication review’s overall aim is to improve the quality, safety, and appropriate use of medicines and prevent any medication-related problems, and optimize medication use in collaboration with GPs, medical practitioners, other healthcare professionals, and patients. the process is patient-centered. Medication reviews form the foundation of national policies and guidelines associated with medication optimization strategies and intervention studies. These remunerated services include Medication Therapy Management and Medication Regimen Review in the United States of America (USA), Residential Medication Management Review (RMMR) and Home Medicines Review (HMR) in Australia, Medicines Use Review in the United Kingdom, and MedsCheck in Canada.
Future of medication use reviews
The use of technology is being implemented in healthcare in various ways. The use of mobile devices and apps for healthcare professionals that have provided many benefits, including increased access to point-of-care tools which are proven to support improved clinical decision-making and patient outcomes. Telepharmacy” is defined as using communication technology and electronic information for the provision and support of comprehensive pharmacy services particularly when distance separates participants. Medication reviews could be ‘integrated’ with other clinical information systems such as electronic health records, rather than being ‘stand-alone manual processes’
Fig-1:Â A general overview of the medication review process in Australia (adapted from the Guidelines for comprehensive medication management reviews 2020)
Systematic medication reviews have been introduced as a procedure to optimize medication use and reduce Medication-related problems. There are different types of medication reviews, they are :
Compliance in medicine refers to the ability of an organ to distend in response to applied pressure. In physics, compliance refers to the property of a material undergoing elastic deformation or (of a gas) changing in volume when subjected to an applied force. Compliance is a restrictive, authoritarian term that implies obedience to doctors’ orders.
The term refers to the deep knowledge of the relationship and to the achievability of examining crucial questions regarding the patient’s lifestyle. The concept of medication concordance entails all practicing family physicians who interact with the patients in their day-to-day clinical practice. The entire concept revolves around patient–doctor relationship. Concordance takes into account and gives due importance to the health beliefs of the patient. It seeks to establish a collaborative “therapeutic alliance” aimed at fulfilling the aspirations and expectations of both patient and doctor. Concordance is a dynamic process, achievable but requiring a set of approaches to patient therapy and management different from the ones currently being practiced in medicine. There is prevailing incoherence between attempts to align individualized care with a predetermined outcome-based clinical practice. Concordance, in contrast, is an end in itself, more coherent with shared care than adherence or compliance, but rejected by many guideline developers of various nations because of its complexity.
Clinical medication reviews are comprehensive,
confidential checks held by doctors on the medication used by patients. These reviews have several objectives. These reviews are best for patients taking multiple medications for long-term chronic conditions. Medication reviews are also crucial for people to withstand various illnesses, whether related or unrelated to each other. To perform the check, the doctor will ask the patient to come in with all current prescriptions. From there, the doctor will ask a series of questions, including:
A final review of the medication helps the doctor determine if anything needs to be changed.
Clinical Pharmacists also have the sovereignty to discuss and perform medication reviews. A community or hospital pharmacist has extensive knowledge of medication and each drug’s effectiveness. Medication reviews have now become a key task for pharmacists, particularly in the community. Since pharmacists are easily accessible, a patient with multiple prescriptions can have a review with little hassle. Relying on a pharmacist has a range of other benefits
The implementation of the medication reconciliation process to improve patient safety by identifying unintended medication discrepancies, especially at transitions of care. medication reconciliation remains a critical patient safety activity that is supported by different international organizations to optimize patient medication safety at transitions of care.
Various medication reconciliation interventions have been evaluated to identify medication reconciliation best practices.
The cornerstone for successful medication reconciliation is creating the best possible accurate medication list by using a systematic approach based on a patient/carer interview and a variety of other medication sources such as prescription bottles, discharge medication orders, or pharmacy records.
Medication reconciliation is an important component of the care of hospitalized patients and their safe transition.
An extensive list of medications should include all prescription medications, herbals, vitamins, nutritional supplements, over-the-counter drugs, vaccines, diagnostic and contrast agents, radioactive medications, parenteral nutrition, blood derivatives, and intravenous solutions. All medications and supplements should be part of a patient’s medication history and included in the reconciliation process.
In simplified terms, six steps—which are remarkably similar at all three IDSs studied—are used to gather, organize, and communicate clinical information at admission and discharge.
At admission—
At discharge—
Research evidence:
Medication reconciliation studies have focused on the accuracy of the medication history during various transitions: ambulatory to an acute care inpatient setting, skilled nursing facility to an acute care inpatient setting, inpatient acute care setting to the skilled nursing facility, inpatient acute care setting to discharge, inpatient floor to the intensive care unit (ICU), and ICU to discharge. Little research has focused on outcomes related to the prevalence of errors resulting from a lack of or incomplete patient medication lists.
Medication reconciliation is the process of comparing a patient’s medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten. Transitions in care include changes in setting, service, practitioner, or level of care. This process comprises five steps:
Errors prevented by medication reconciliation include inadvertent omission of therapy, prescribing a previously ceased medicine, the wrong drug, dose, or frequency, failure to recommence withheld medicines, and duplication of therapy after discharge. Implementing formalized medication reconciliation at admission, transfer, and discharge reduces medication errors by 50–94%and reduces those with the potential to cause harm by over 50%. The process is also associated with improved patient outcomes and a tendency for reduced readmissions.
The first step is perhaps not only the most important but also the most challenging of the medication reconciliation steps: documenting all a patient’s current medications. If even a single medication or critical detail about a medication (e.g., dosage, frequency, route of administration) is omitted from this list, the risk of an adverse drug event increases, and the ability to effectively and appropriately complete the remaining medication reconciliation steps decreases.
Here are just some of the reasons why developing a current medication list can prove so difficult:
This step may seem easy, but that brings with it a potential for mistakes. A false sense of confidence can encourage the rushed completion of responsibilities and corner-cutting. As an Academy of Managed Care Pharmacy article notes, these are just some of the ways preventable prescribing errors occur:
This is essentially the “reconciliation step” in the medication reconciliation process. The comparison of the lists helps ensure discrepancies can be avoided and red flags can be identified, such as omitted medications, therapeutic duplications, dosing errors, drug-drug interactions, and drug-disease interactions.
Considering that any of these issues can put a patient’s health and wellness at risk, why is this step sometimes missed or not completed appropriately? Some of the top reasons include the following:
This is another one of the medication reconciliation steps that can suffer due to time issues. When those performing medication reconciliation lack the adequate time and resources to effectively complete the process, decision-making is likely to be rushed or cut short.
One aspect of medication management that can be negatively affected concerns efforts around deprescribing, which, as we previously noted, “… has become one of the most effective ways to safely decrease inappropriate and unnecessary polypharmacy.”
Unfortunately, as a Health Affairs article states, “In many cases, medication reconciliation has devolved into a box-checking exercise to comprehensively catalog all medications a patient is taking, but the process may not make efforts to decrease the number of medications or stop potentially harmful drugs.”
If the preceding four medication reconciliation steps are completed, this final step is typically completed in some fashion. At a minimum, a patient is usually provided with the revised medication list. But even this can experience problems. They include the following:
MEDICATION DISCREPANCY:
 The terms intentional and unintentional were often used in the literature to describe types of medication discrepancies. More than 50% of hospitalized patients experience one or more unintentional medication discrepancies (UMDs), defined as unexplained differences in medication regimens across different sites of care, with some having the potential for significant harm. Medication reconciliation (MedRec) reduces the risk of UMDs and harmful adverse drug events that increase hospitalization costs and length of stay. MedRec is the process of “creating the most accurate list possible of all medications a patient is taking and comparing that list against the physician’s admission, transfer, and/or discharge orders, intending to provide correct medications to the patient at all transition points within the hospital”
Medication discrepancy at discharge :
A discharge medication discrepancy was defined as any difference identified between the medications listed on the discharge prescription and the medications list from the patient history, Medication Administration Record (MAR), or home medications list.
REFERENCES :Â
Guidelines for comprehensive medication management reviews
accessed on https://www.ppaonline.com.au/wp-content/uploads/2020/04/PSA-Guidelines-for-Comprehensive-Medication-Management-Reviews.pdf (2020), Accessed 10th Jun 2021 Google Scholar
  4. Xu, F., Yin, J., & Zeng, S. (2020). The practice of prescription review mode based on data mining in hospitals. Annals of Translational Medicine, 8(14). https://doi.org/10.21037/atm-20-3933
  5.Almanasreh, E., Moles, R., & Chen, T. F. (2016). The medication reconciliation process and classification of discrepancies: a systematic review. British Journal of Clinical Pharmacology, 82(3), 645-658. https://doi.org/10.1111/bcp.13017
  6.Kreckman, J., Wasey, W., Wise, S., Stevens, T., Millburg, L., & Jaeger, C. (2017). Improving medication reconciliation at hospital admission, discharge, and ambulatory care through a transition of the care team. BMJ Open Quality, 7(2). https://doi.org/10.1136/bmjoq-2017-000281
  7. Barriers Associated with Medication Information Handoffs
 11.Kansagara D, Englander H, Salanitro A, et al. Risk prediction models for hospital readmission: a systematic review. JAMA. 2011;306:1688-1698. doi:10.1001/jama.2011.1515
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