Nurse-Driven Process to Improve Ambulatory Care Medication Reconciliation

Purpose: The purpose of this quality improvement project was to improve outpatient medication review and reconciliation through the introduction of nursing. It is understood that active health professional medication management assists patients in maintaining complete and correct medication lists. This in turn helps improve the patient’s medication awareness, sustains overall health, and promotes long-term wellness. Despite the benefit of medication review and reconciliation, fragmented outpatient visit processes result in medication lists not being reconciled between what is prescribed and what the patient is self-administering. Multi-factorial reasons have been outlined as to why the licensed prescriber may not resolve these discrepancies; however, the lack of action taken has resulted in compliance rates as low as 60% within the studied practice settings. Published evidence notes that many adults often partially or completely omit prescribed medications. Non-adherence has been estimated to contribute $290 billion annually to national health system spending. Shared effort towards improved medication management inclusive of nursing has demonstrated an increase in complete and correct improved problem anticipation and a potential reduction in adverse medication events.

Description: Two outpatient clinical areas were selected for a 15-week intervention. One caring for primary care/infectious disease patients and the other a surgical otolaryngology practice. Between the practices, 17 nurses are employed. The reviewed encounters were primarily made up of prescriber appointments but also included nurse exclusive visits. Further, nursing telephone triage encounters were included in the intervention. Workflow changes included nurse education on proper medication review and reconciliation, establishment and instruction on the preferred workflow, and EHR workflow enhancement. Nurses during in-person clinic visits and during appropriate telephone encounters were directed to review and reconcile current EHR records. Medication reconciliation compliance was measured through the recorded completion of the activity. Those patients engaging in an in-person encounter were provided a paper version or directed to the e-version after-visit summary for an updated and valid medication list. Press Ganey© CG-CAHPs rates, specific to medication management, were also reviewed.

Evaluation/outcome: Overall compliance and specifically nursing compliance contribution was measured. Reconciliation compliance data at baseline was 81.5% for the primary care and 74.7% for the otolaryngology setting. Overall reconciliation slightly improved to a high of 90.4% within the primary care and 86.2% within the specialty setting. The primary care overall nurse attributed compliance rate was 2.9% with a high of 4.4% at week 4. The otolaryngology practice recorded an overall rate of 22.8% with a high of 30.8% at week 6. Nursing exclusive encounters demonstrated a 30-40% reconciliation improvement. Medication review and reconciliation management during telephone encounters was minimal with a high of 2.5% during week 7 of the intervention. Patient satisfaction data was unchanged in the primary care practice setting and demonstrated a 13% positive change from baseline in the otolaryngology.