Massachusetts Nurse :: January/February 2006

Reconciling medications: whose responsibility is it?

The reconciliation of medications is a new safety standard of the Joint Commission on the Accreditation of Hospital Organizations, but the licenses of nurses are being compromised in the implementation of this new practice by their employers. The reconciliation process is the responsibility of the prescriber.

The nurse caring for the patient in the reconciliation process is not the prescriber. The prescriber or provider is the physician or an advanced practitioner who has prescription authority. The prescriber is the responsible party for the reconciliation of the patient’s medication list throughout the patient's continuum of care, which includes admission and transitions in care (transfers and discharge).

In some hospitals, nurses are being requested to obtain a list of patient medications upon their admission and inappropriately asked to verify this list with the patient's pharmacy for accuracy. At fault with this practice is the reality that patients often use more than one pharmacy for their prescriptive needs and this may be unknown in the reconciliation process. Upon receipt of the information from the pharmacy, the nurse can be required to reconcile the list from the patient and the pharmacy with new medications ordered by the physician upon admission. This is a process that must be completed by the physician/prescriber. Signing medication orders is not within the scope of the RN who is not a prescriber.

This example occurred recently at a local hospital. The admitting physician who was responsible for the admission reconciliation did not reconcile all the medications with his signature before the mediations were ordered from the pharmacy. The nurse tried to contact the physician. He was not available and a covering physician approved the reconciliation via telephone. The nurse signed the reconciliation form which was then transmitted to the pharmacy. The attending physician, in reviewing the patient’s orders the next day, questioned the appropriateness of the ordered medications for this patient.

1. What was the nurse’s liability in this situation?
2. Why is this issue so important to the safety of your practice and license?

Once again, it is important to remember that a registered nurse is not authorized or approved to sign orders that must be reconciled with patient preadmission medication or orders written before transfer or discharge.

There are many variations to this new practice and nurses need to be aware of what the medication reconciliation process is and what it isn’t according to the regulatory requirements of their practice. Taking a medication history on admission has always been part of the nursing assessment, but the nurse is practicing beyond her scope if she reconciles these medications without the prescriber’s signature either in the computer or in the chart before sending these orders to the pharmacy or administering the medications.

The Massachusetts Board of Nursing is definitive in its definition of the registered nurse:

Registered Nurse is the designation given to an individual who is licensed to practice professional nursing, holds ultimate responsibility for direct and indirect nursing care, is a graduate of an approved school for professional nursing, and is currently licensed as a Registered Nurse pursuant to M.G.L. c. 112. Included in such responsibility is providing nursing care, health maintenance, teaching, counseling, planning and restoration for optimal functioning and comfort of those they serve. (244CMR Board of Registration in Nursing Section 3:01)

There is no mention in the definition that the registered nurse can approve prescriptive orders or reconcile these orders with medications that the patient is receiving before admission, transfer and/or discharge. This is the role of the physician, a physician assistant or a nurse in the expanded role. 244CMR 4.05 defines the authority of a nurse in an expanded role:

A nurse engaged in prescriptive practice is a nurse with:

1. Authorization to practice in the expanded role
2. A minimum of 24 contact hours in pharmacotherapeutics which are beyond those acquired through a generic nursing education
3. Valid registration(s) to issue written or oral prescriptions or medication orders for controlled substances from the Massachusetts Department of Public Health in accordance with M.G.L. c. 94C #7(g) and, where required , by the U.S. Drug Enforcement Administration

In reviewing the reconciliation process in Massachusetts hospitals, many are attempting to comply with the following regulations published in 2006 by the JCAHO:

JCAHO Requirement 8A requires organizations to: “Implement a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization and with the involvement of the patient. This process includes a comparison of the medications the organization provides to those on the patient’s list.” (JCAHO Comprehensive Accreditation Manual for Hospitals 2006, Page 11.)

JCAHO Requirement 8B states: “A complete list of the patient’s medications is communicated to the next provider of service when a patient is referred or transferred to another setting, service, practitioner, or level of care within or outside the organization.” (Ibid, Page 11.)

“In the context of Goal 8B, we consider the provider to be another health care organization or an independent practitioner (LIP),” explained Rick Croteau, MD and executive director for patient safety initiatives at the JCIC for Patient Safety. “In general, the ‘provider’ would not be a nurse although it could be an advanced practice nurse. APRs can function as independent practitioners within a defined scope of practice in most states. Whether an organization, physician, APR, or other LIP, the information could be received by an “agent” of the organization or practitioner, who could be a nurse.”

The rationale for this measurement by JCAHO is stated as follows: “Patients are most at risk during transitions in care (handoffs) across settings, services, providers or levels of care. The development, reconciliation and communication of an accurate medication list throughout the continuum of care are essential in the reduction of transition-related adverse drug events.” (Ibid, Page 11.)

As hospitals attempt to develop systems that meet the JCAHO criteria, nurses are being asked to take on additional responsibilities for clarifying the medications the patient took before admission or treatment at a hospital, and reconcile these medications upon transfer and or discharge. Many Massachusetts hospitals are in various stages of compliance with the above standards. Some are beginning the reconciliation process, while others are in the testing phase.

The nurse needs to be aware of her/his responsibilities in relation to the nurse practice act and have an awareness of the following:

1. The medication history assessment can be an order sheet if each medication listed is verified and signed by the prescriber.
2. The medication history assessment, if computerized, must be reconciled by the prescriber before logging off before medication orders can be processed.
3. Obtaining patient information from a pharmacy can be incomplete; it is not recommended to participate in this step of the process.
4. The prescriber must reconcile all orders before transferring the patient within the institution.
5. The prescriber must reconcile all orders before discharge or transfer to another institution.

Many hospitals are struggling to comply with these new criteria. What may be a simple process to many can become complex as each hospital orients staff to its new systems. Hospitals with computerized patient systems will need to program these systems with checks to ensure that the prescribing provider completes the reconciliation process before exiting the system.

Hospitals with paper patient-record systems may need to have several forms for reconciling (i.e. admission, transfer and discharge to reduce error that could occur with an overlapping form).

Nurses must be aware that their availability at the bedside 24 hours a day can target them for requests to practice beyond their scope (i.e., authoring the admission patient history medication list as a medication order sheet for the pharmacy). This same process could be replicated on transfer and discharge.
During 2006, every RN will have a role in medication reconciliation. It is imperative that in your role you follow the regulations of the nurse practice act to protect your patients and yourself.