WILLMAR -- It's one of the thorniest challenges in hospital care: ensuring the continuity of patients' medication, from the time they enter the hospital until they go home.
For many patients, especially those on multiple medications, hospitalization can be a vulnerable time. Pills they normally take at home can be overlooked. Dosages might need to be raised or lowered while they're in the hospital. Sometimes new medications are started or older ones dropped.
Getting it right can be critical, says Jessica Vagle, clinical nurse specialist for adult health and intensive care at Rice Memorial Hospital.
That's why Rice Memorial Hospital embarked in late 2005 on a massive project to improve this process.
The project is part of the city-owned hospital's overall focus on care improvement and elevating its performance to the highest level.
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"We're talking about going from good care to perfect. We're setting the bar as high as we can," said Dr. Norris Anderson, medical director for care improvement at Rice.
By this past November, Rice had managed to reach a 96 percent success rate at reconciling each patient's medications when the patient enters and leaves the hospital.
"This is a project that hasn't been easy," Vagle said. "Every organization is grappling with medication reconciliation."
Medication reconciliation has increasingly become a national patient safety priority. It's one of the goals of the Joint Commission, the chief accrediting organization for hospitals and other health care organizations. It's also a priority of the Institute of Medicine.
It's not hard to see why.
"When you look at patient safety literature, medication is the leading error that you find," Vagle said.
It's estimated that a preventable adverse drug event -- wrong dose, wrong medication, wrong patient -- occurs in two out of every 100 hospitalizations.
Some studies have charted a 30 to 70 percent discrepancy between the medications patients take at home and the medications listed on their record when they're admitted to the hospital.
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Transition times -- for instance, when a patient leaves the intensive care unit for a regular bed or when the patient goes home -- are especially vulnerable.
To complicate matters, patients might not know the names of all the drugs they're taking and hence can't give providers an accurate list. If they have multiple prescriptions from several different doctors, their medical record might not completely reflect this.
There have even been cases in which the pills in a bottle brought from home didn't match the label on the outside, Vagle said.
The Rice Hospital team that tackled medication reconciliation knew it had to start small, she said.
"We really had to break this down and go step by step," she said.
"We've been working on this for over a year. We're aiming for accuracy at every step. It encompasses all areas of the hospital -- all physicians, all nurses and every patient."
One of the strategies that were adopted: creating a list of all the medications, including vitamins, herbal supplements and over-the-counter products, that each patient takes at home. The list must be completed within 24 hours after the patient is admitted to the hospital, Vagle said.
A similar list, containing a complete and accurate description of all the patient's current medications, also is drawn up when the patient is ready to leave the hospital.
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"This is really important. Now it is something we do for every patient," Vagle said.
There's still more to accomplish, though. This month the hospital started a three-week trial on reconciling medications for patients who are transferred within the hospital -- for instance, when someone is moved out of the intensive care unit.
The team has a goal of getting an accurate, current list of medications to each patient's doctor in time for the patient's first post-hospital visit.
They're also exploring community medication cards that electronically store the patient's medication history and that could be carried anywhere.
"We have done a lot of things this past year," Anderson said. "Medical issues don't always come in a neat package, so we have to do a lot of strategizing to provide perfect care."
