Documentation of Communication in Medication Safety Practices Article by: Jeannell Mansur, Practice Leader, Medication Safety, Joint Commission Resources
There continues to be a greater focus on the necessity of documented communications in medication safety practices. In fact, many of the changes to the 2009 medication safety NPSGs relate to documentation of communication, which is critical to maintaining safety and mitigating risk.
For example, admission home medication lists are now required to include dose, frequency and route, and there must be documented evidence that communication occurs between the transferring and receiving units. Also, upon discharge, a medication list must be provided to the patient, their family, and the next provider of care, and this communication documented.
Thorough communication helps ensure each patient receives the right medications, in the correct doses, at the right times. An ideal patient experience would be one in which every aspect of patient care—medications as well as other details—-are shared across all involved disciplines, who work collaboratively to guarantee that patient’s right to safe, effective, quality care.
I've been at several hospitals where there was incomplete or unclear transfer of information regarding medications the patient was taking at home. In one case, a patient was admitted, and during the admission process was asked about home medications. He provided a list of medications to the nurse, who completed a hospital-approved medication reconciliation form. The form instructed the user, after listing the medications, doses, and frequencies, to select a "Continue" or "Discontinue" option. With regard to the antihypertensive medication, the box for "Discontinue" was selected, and a note was added to change the dose. This was conflicting information. The drug ended up being discontinued even though the patient was still supposed to be taking the drug in a different strength. Lack of reconciliation resulted in the patient not receiving an intended medication. It would appear that conflicting information contributed, but this should have been resolved by the nurse and the pharmacist.