Medication Reconciliation and History in Psychiatry

This may seem like a boring topic, but it’s a critically important one when it comes to psychiatric care. Medication reconciliation is defined by Centers for Medicare Services (CMS) as “the process of identifying the most accurate list of all medications that the patient is taking, including name, dosage, frequency, and route, by comparing the medical record to an external list of medications obtained from a patient, hospital, or other provider.” A medication history includes a list of recent medication, past medications and dosages a patient may have tried for a particular condition, and relevant responses. Failures in either area may lead to poor decision making and patient harm.

Some potential errors:

1. Failure to order current medication for medical conditions;

2. Placing patients on medications they have trialed in the past and were unsuccessful;

3. Wrong doses of medications that require titration or taper;

4. Wrong doses of current medications.

As someone who once functioned in a role with a primary responsibility of performing medication reconciliation in a psychiatric setting, I can tell you that the process is wonky and error prone. The obtained list is often only as good as the person putting in the effort, and people can be busy with this important task falling to the wayside. The process is also more complicated when electronic health records are not available. In some cases, it is necessary to call other providers, and to call pharmacies to fax over lists of medications a patient has filled in the past several months. Most of the time it is not a problem to get this information, but once in a while you get a HIPAA related objection, which is an objection based on inaccuracy, but nonetheless throws a wrench in a plan to provide the best care in a timely manner.

Some patients are able to provide excellent histories, while others are not. And this is a factor to take into consideration.

The medication reconciliation process should occur at all points of care, but emergency rooms may be more problematic simply because of the limited role they play – they are designed for rapid stabilization and transfer. But one of the frustrating things about psychiatric patients seen in emergency rooms is that they often go without the appropriate medications for days. This is likely because medication reconciliation was not performed adequately. Even if the role of the emergency room is confined to maintenance of safety, waiting for several days with wrong meds or no meds is nonsensical particularly in the light of the costs associated with delayed and insufficient care.

The health care industry has been trying to solve this problem by passing this task between registered nurses, physicians, advanced practice providers, and pharmacists. Thus far, I don’t think there’s been a widely applied or successful solution. However, given the impact accurate medication reconciliation and history has on treatment decisions in psychiatry, I think it very important for all those receiving care or working in the field to pay special attention to this aspect of care.

What have you seen that works well?

T.