Improving Medication Reconciliation with Comprehensive Evaluation at a Veterans Affairs Skilled Nursing Facility

Background: Unintentional medication discrepancies due to inadequate medication reconciliation pose a threat to patient safety. Skilled nursing facilities (SNFs) are an important care setting where patients are vulnerable to unintentional medication discrepancies due to increased medical complexity and care transitions. This study describes a quality improvement (QI) approach to improve medication reconciliation in an SNF setting as part of the Multi-Center Medication Reconciliation Quality Improvement Study 2 (MARQUIS2).

Methods: This study was conducted at a 112-bed US Department of Veterans Affairs SNF. The researchers used several QI methods, including data benchmarking, stakeholder surveys, process mapping, and a Healthcare Failure Mode and Effect Analysis (HFMEA) to complete comprehensive baseline assessments.

Results: Baseline assessments revealed that medication reconciliation processes were error-prone, with high rates of medication discrepancies. Provider surveys and process mapping revealed extremely labor-intensive and highly complex processes lacking standardization. Factors contributing were polypharmacy, limited resources, electronic health record limitations, and patient exposure to multiple care transitions. HFMEA enabled a methodical approach to identify and address challenges. The team validated the best possible medication history (BPMH) process for hospital settings as outlined by MARQUIS2 for the SNF setting and found it necessary to use additional medication lists to account for multiple care transitions.

Conclusion: SNFs represent a critical setting for medication reconciliation efforts due to challenges completing the reconciliation process and the concomitant high risk of adverse drug events in this population. Initial baseline assessments effectively identified existing problems and can be used to guide targeted interventions.