Holbrook Anne, Bowen James M, Patel Harsit, O'Brien Chris, You John J, Tahavori Roshan, Doleweerd Jeff, Berezny Tim, Perri Dan, Nieuwstraten Carmine, Troyan Sue, Patel Ameen
Division of Clinical Pharmacology & Toxicology, McMaster University, Hamilton, Ontario, Canada.
Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
BMJ Open. 2016 Dec 30;6(12):e013663. doi: 10.1136/bmjopen-2016-013663.
Medication reconciliation (MedRec) has been a mandated or recommended activity in Canada, the USA and the UK for nearly 10 years. Accreditation bodies in North America will soon require MedRec for every admission, transfer and discharge of every patient. Studies of MedRec have revealed unintentional discrepancies in prescriptions but no clear evidence that clinically important outcomes are improved, leading to widely variable practices. Our objective was to apply process mapping methodology to MedRec to clarify current processes and resource usage, identify potential efficiencies and gaps in care, and make recommendations for improvement in the light of current literature evidence of effectiveness.
Process engineers observed and recorded all MedRec activities at 3 academic teaching hospitals, from initial emergency department triage to patient discharge, for general internal medicine patients. Process maps were validated with frontline staff, then with the study team, managers and patient safety leads to summarise current problems and discuss solutions.
Across all of the 3 hospitals, 5 general problem themes were identified: lack of use of all available medication sources, duplication of effort creating inefficiency, lack of timeliness of completion of the Best Possible Medication History, lack of standardisation of the MedRec process, and suboptimal communication of MedRec issues between physicians, pharmacists and nurses.
MedRec as practised in this environment requires improvements in quality, timeliness, consistency and dissemination. Further research exploring efficient use of resources, in terms of personnel and costs, is required.
近10年来，用药核对（MedRec）在加拿大、美国和英国一直是一项强制或推荐开展的活动。北美认证机构很快将要求对每位患者的每次入院、转院和出院都进行用药核对。用药核对研究揭示了处方中存在无意的差异，但没有明确证据表明临床重要结局得到改善，导致做法差异很大。我们的目标是将流程映射方法应用于用药核对，以阐明当前流程和资源使用情况，识别潜在的效率提升点和护理差距，并根据当前有效性的文献证据提出改进建议。
流程工程师观察并记录了3家学术教学医院中所有内科患者从急诊科初步分诊到患者出院期间的所有用药核对活动。流程地图先由一线工作人员进行验证，然后由研究团队、管理人员和患者安全负责人进行验证，以总结当前问题并讨论解决方案。
在所有3家医院中，确定了5个常见问题主题：未充分利用所有可用的用药信息源、工作重复导致效率低下、最佳用药史的完成缺乏及时性、用药核对流程缺乏标准化以及医生、药剂师和护士之间用药核对问题的沟通欠佳。
在这种环境下开展的用药核对需要在质量、及时性、一致性和传播方面加以改进。需要进一步研究如何在人员和成本方面有效利用资源。
