Introduction

Medication reconciliation (MedRec) is a vital tool in clinical settings helping to reduce medication errors (MEs) and patient harm.1–3 MedRec is a collaborative process between healthcare providers (HCPs) and patients that involves obtaining the best possible medication history (BPMH) on patient admission and reconciling it with the physicians’ medication orders for ensuring communication of complete and accurate medication information at every point of transition in care, whether admission, transfer or discharge. The intent is to identify, document and discuss discrepancies with the prescribing physician and make appropriate changes if needed to ensure patient safety. MEs occurring at points of transition in care can be caused by discrepancies whether intentional or non-intentional and may include omissions, duplications, dosing errors, different medication and so on, which may jeopardise patient safety and clinical outcomes.1 2

A major reason for implementing MedRec in hospital settings is to prevent errors in patient’s medication regimen from admission to discharge, including points of care transfer within the hospital. Data showed that MEs occurred in up to 67% of patients admitted to hospital and were found to be clinically important in up to 59% of cases.4 There is a large body of data demonstrating the clinical value of MedRec to reduce adverse drug events and MEs, thus improving patient safety and minimising patient harm.5–9 For example, the implementation of a multidisciplinary MedRec process was associated with significant decreases in the number of admission and discharge medication discrepancies and, serious or life threatening errors.10 In a controlled trial where patients were randomised to usual care or MedRec, a total of 327 discrepancies (52.6% unintentional and 47.4% intentional) were identified among patients randomised to the MedRec group, with 64% of patients having one or more discrepancies at admission.6

For MedRec to effectively contribute towards patient safety, it must be an integral part of every institution’s strategic planning and supported by institutional policies that describe processes and workflows, clearly defining responsibilities of all those involved. Furthermore, MedRec implementation must be aligned with accreditation Required Organizational Practices (ROP) and meet required tests for compliance. ROPs are defined by Accreditation Canada as fundamental practices that must be adapted by healthcare institutions to mitigate risk and ensure patient’s safety. For instance, in order to comply with the MedRec ROP, institutions must develop and implement a MedRec policy and process to obtain and use a complete and accurate patient’s medication information at each point of transition in care. An institution policy indicates leadership’s commitment and provides guidance to MedRec implementation. The Institute for Healthcare Improvement, Joint Commission and the Institute for Safe Medication Practices (ISMP), among others, provide guidance for healthcare institutions to develop their policies and procedures and provide tools for implementation, education and monitoring as well as assistance in identifying gaps between current practice and best practice.1–3 The actual process and model of reconciling medicines may differ between various healthcare institutions, and for hospitalised patients, the process may be carried out numerous times when the patient is transferred from one point of care to another or during any point of hospital stay. It is critical to assign the leading responsibility of MedRec to key stakeholders within the organisation, to delegate organisational responsibilities, as well as role of each HCP involved in the process, and to identify and fulfil the ongoing training needs for effective implementation of the MedRec process.2

Data have shown that although HCPs appreciate the value and benefits of MedRec, there is inadequate knowledge and awareness of the MedRec process and policies, lack of clear understanding of the role of each HCP, inconsistencies across hospitals in the MedRec implementation process and underutilisation of pharmacists compared with physicians and nurses in MedRec.11–17 Given that pharmacists are trained as medication experts who may provide direct patient care, it seems counterintuitive that they are underused or not perceived as essential in the MedRec process.11 14 17 Similarly, recent data from Middle Eastern countries showed low awareness of the MedRec concepts and policies among hospital pharmacists in Jordan and a lack of understanding and agreement on the roles and responsibilities of each profession among physicians, pharmacists and nurses working in a tertiary care academic hospital in Oman.11 13 Recent data from Kuwait showed that hospital pharmacists support the implementation of MedRec in their institution but reported several barriers such as the absence of a policy promoting a role for pharmacists in the process. The Ministry of Health (MoH) in Kuwait is working towards obtaining accreditation for their healthcare institutions, and MedRec is an ROP for accreditation. However, it remains to be determined whether HCPs in Kuwait have sufficient knowledge and understanding of the MedRec process, including the roles and responsibilities of each profession. To support the MoH endeavour, and given the paucity of data regarding MedRec in Kuwait, the objective of this study is to assess the knowledge, perception, attitudes and practices of hospital physicians and pharmacists towards MedRec and determine major barriers to implementing a MedRec process in their institution/department.

Methods

Results

Knowledge, training and perceptions about MedRec

Most participants (n=419; 75.2%) reported being familiar with the term ‘medication reconciliation’, with significantly more pharmacists compared with physicians (171/209; 81.8% vs 248/348; 71.3%; p=0.005) (table 2). Less than half of participants received training on MedRec during their university studies (n=224/557; 40.2%) or in the work place (n=240/557; 43.1%). However, in contrast to training in the workplace, significantly more pharmacists compared with physicians were trained at university (n=116/209; 55.5% vs 108/348; 31.0%; p<0.001) (table 2).

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Table 2

Knowledge and training about medication reconciliation among physicians and pharmacists working in governmental hospitals in Kuwait 

When participants were asked to rate their perception of MedRec as a valuable process for patient safety (1=not valuable to 5=very valuable), the majority (n=432/540; 80.0%) perceived it as valuable or very valuable, with significantly more pharmacists perceiving it as very valuable (n=128/190; 67.4% vs n=186/350; 53.1%; p<0.001). The overall mean score was 4.30 (±0.99 SD), significantly higher for pharmacist compared with physicians (4.45±0.92 vs 4.22±1.02; P=0.004).

Participants were asked their perception of which healthcare professional was responsible for various steps involved in MedRec (figure 1); they could select more than one answer option for each step of the process. Overall, participants perceived that physicians are the main healthcare professionals responsible for various steps of the process, followed to a lesser extent by pharmacists and nurses. Significantly more physicians compared with pharmacists believed that physicians were responsible, and in contrast, significantly more pharmacists compared with physicians perceived that pharmacists were responsible.

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Figure 1

In your institution, who (%) is responsible for: 

Discussion

In the context of patient safety initiatives and in-line with international accreditation standards, the MoH is investing significant efforts in meeting these standards and obtaining accreditation for its healthcare institutions. MedRec is an important accreditation requirement, and this study provides data on the current state of MedRec in Kuwait and suggests ways to further implement MedRec in governmental hospitals. In line with data from Oman and Jordan,11 13 our findings indicate that the majority of participants were familiar with MedRec and perceived it as a highly valuable process. These observations were expected given the fact that MoH hospitals are seeking accreditation and MedRec is a ROP, and as such, the quality and accreditation departments have raised awareness and discussed MedRec in the workplace. Overall, participants in this study perceived that physicians were the main healthcare professionals responsible for the various steps of the MedRec process, which is in line with recent findings.11 14 16 These studies showed that physicians, nurses and pharmacists had different perspectives regarding MedRec and were not clear on which profession was responsible for various steps of the process. In Kuwait, these perceptions may be driven by the policies that hold physicians solely responsible for the entire process and do not clearly define each step of the process, including task delegation involving other healthcare professionals in the process workflow, that is, collecting and documenting BPMH, reconciling BPMH to in-hospital/discharge medication orders.21 Currently, the expertise of inpatient pharmacists is not optimised as their role is mainly limited to technical work in the dispensary. In this context, it may prove valuable to revise the current policies and procedures to align them with international standards and ISMP guidelines2 and to develop workflows for points of transition in care to clearly define roles and responsibilities, reallocate tasks and responsibilities, standardise the MedRec process and promote collaboration among HCP, with MedRec being a shared responsibility. The MedRec training received at workplace may have also contributed to familiarity and basic understanding of the MedRec process and its value. Yet, our findings suggest a lack of thorough understanding of the orchestrated roles and responsibilities of each HCP involved in the MedRec process. Even if more pharmacists were taught MedRec at university, additional training, namely for BPMH, both in university and workplace, would be beneficial.

The present study assessed the awareness of participants about the availability of a MedRec policy at their institution. Surprisingly, and despite the fact that the MoH hospitals are in the process of implementing MedRec as a ROP by Accreditation Canada International, our results showed that almost half of the participants were aware about the presence of a MedRec policy; however, that awareness was significantly lower among pharmacists as compared with physicians. This is consistent with similar results reported in Jordan, which have demonstrated low awareness among pharmacists concerning the presence of a MedRec policy at their healthcare institutions.13 Similarly, there was low awareness when participants were specifically asked for how long they believed a MedRec process had been in place at their institution as well as the time frame required for reconciling medications on admission. These findings could be explained by the fact that there was insufficient knowledge dissemination about the ROP policy and procedures to HCP and more specifically to pharmacists, although a MedRec policy was issued in January 2016 by the MoH Quality and Accreditation Directorate and circulated to its individual healthcare institutions.21 Furthermore, the fact that treating physicians are considered as solely responsible for the MedRec process as highlighted in the policy clearly explains higher awareness among physicians.

MedRec is a shared responsibility and a patient-centred process.22 In the present study, and as compared with physicians, a significantly larger proportion of pharmacists rarely or ever asked patients for their current list of medications to verify their medications on admission to a medical service. This might in part be related to the pharmacist’s current practice setting, presence in the wards, job description or lack of clarity about systematic approach involved in obtaining a BPMH and standards of MedRec practice. This finding may also be due to the fact that physicians are the HCPs assigned with the responsibility of collecting and documenting BPMH as per the national MoH policy, thus excluding pharmacists from such a practice. The policy only includes a general statement indicating that pharmacists may participate in the process along with nurses as far as they receive the needed knowledge, skills and behaviour to perform this function; yet, not a single role is assigned to them throughout the whole process.21 This contrasts the concept of an interprofessional MedRec process designed to ensure optimal medication management.10 22 Published literature clearly supports the role of pharmacists as an integral part in the process and that their involvement in collecting and documenting a complete and accurate BPMH has positively impacted patients’ health outcomes and prevented adverse drug events due to identified discrepancies at interfaces of care.9 23 In fact, pharmacists believe that they have the skills required to lead this process but their current role in providing clinical services in Kuwait, including MedRec, is limited and mainly revolves around education, drug information, technical and drug distribution duties.24 Pharmacists should have a significant involvement in the MedRec process, namely by collecting the BPMH. Then, physicians could review the medications list to make a conscientious decision of what to continue, modify or discontinue at the points of transition in care.

Physicians reported that over half of their patients bring their list of medications with them. In contrast, Horn et al18 reported a lack of patient involvement in providing a list of current medications at the time of patient visit to emergency departments and community pharmacies.18 This may be due to a difference in the type of healthcare setting and pace of medical service visited by patients, specifically emergency departments, as well as lack of patient’s awareness. Patient’s involvement in the process and their knowledge about their medications is essential to ensure safe medication practices during transition in care. To increase patients’ awareness and improve communication about their medications with HCPs, an education-based initiative ‘5 questions to ask about your medications’ was developed and launched by ISMP in collaboration with multiple Canadian organisations and could be adapted for MoH hospitals in Kuwait. Multiple hospitals across Canada had endorsed and adapted this initiative with the support of ISMP.25

Participants reported that there are two approaches to document the BPMH/MedRec process in the public hospitals in Kuwait: paper and electronic records base. However, significantly more pharmacists reported that the process was not documented. This may be due to lack of knowledge about the documentation process since they are not actively involved or assigned any role in it. In addition, most participants reported that there was no interinstitutional connectivity or that they did not know about its presence to assist them in obtaining a medications list for the patients to help with the BPMH step of the process. These findings highlight a major caveat that is present in the current medication management workflow that needs to be optimised and addressed as soon as possible. Pharmacists should have access to all patient medication information and should know where to document and/or where to locate such information, even when performing their technical dispensing role in order to ensure safe medication practices. Data from the literature support computerisation in aiding the MedRec process. Studies showed that implementation of MedRec electronically led to better understanding by the patients of their discharge medications and minimised medication discrepancies such as omissions, commissions, wrong dose or frequency, duplications or wrong drug selection that might occur during admission, transfer and discharge and may lead to potential adverse events.26 27 However, this may be limited by how user-friendly the software is and how well trained the users of the interface are. At this time, there is no centralised connectivity, and there is no common health information system to collect and document patient medication histories. This will require intervention of the MoH to standardise interinstitutional connectivity, drug databases and medication order entries. In fact, the technology is available to provide patients with a list to carry with them when moving between healthcare systems, but yet is not optimally used or centrally connected to offer physicians and pharmacists an optimised information exchange when patients move from one healthcare setting to another. More pharmacists reported that their computer system can generate and print a current patient medication list with the required detailed information, but more physicians routinely provide the list to their patients. This may be due to the fact that physicians are the only HCPs assigned a role in the MedRec process; they are the ones making final decision about medication changes for their patients during the patient’s visit to their medical service. Interprofessional collaboration and delegation of the counselling service to pharmacists should be encouraged allowing both physicians and pharmacists to optimise their role and scope of practice. Furthermore, pharmacists may not have received any requests or asked to provide a list, may not be aware of the value due to lack of knowledge about the concept or may not have access or authorisation to print and give the list to patients.

MedRec is not simply a nominal process; instead, it requires a rigorous and efficient strategy to ensure appropriate knowledge dissemination, effective training and process implementation.28 Therefore, standardised education programmes are urgently needed, should be delivered by experienced personnel across all public hospitals and enforced by the MoH Quality and Accreditation Directorate. Furthermore, reallocating tasks and responsibilities to other regulated healthcare professionals besides physicians in the MoH policy may be the most critically needed change in the implementation process.

Conclusion

Overall and in line with international accreditation standards, this study showed that MedRec initiatives have started in Kuwait governmental hospitals and are perceived as a valuable patient safety initiative. Providing onsite training on the MedRec process and its policies and optimising current technologies to draw additional value from the existing computerised systems would provide value to HCPs and support MoH in its accreditation objectives. Recommendations to improve the existing MedRec process based on the ISMP guidelines would include involving other HCPs in the process and revising the policies accordingly. This must be supported by continuous onsite training on the policy, procedures and workflows and on BPMH, which is the cornerstone of MedRec. In the near future, it would be worthwhile to measure and document with more details the practices in every step of the MedRec process in order to enhance and streamline the current practices.