Abstract

Medication reconciliation has been recognized as an important National Patient Safety Goal by the Joint Commission. Studies have shown that hospitals with medication reconciliation Programs led by pharmacists, as part of the interdisciplinary team, may have improved outcomes in the following areas of assessment: the rates of medication errors, adverse events, and readmissions. This study aims to investigate the factors that influence the compliance to the medication reconciliation process. It is a quantitative analytical Cross-Sectional design undertaken at the specialized hospital, Makkah, Saudi Arabia. The study adopted the following independent variables (knowledge and training about medication reconciliation, Medication reconciliation policy, procedures involved in the medication reconciliation process, and organizational support) and the compliance to the medication reconciliation process in KAMC as dependent variables. Data collected from 90 pharmacists by using a self-administered questionnaire. When proving the hypothesis, the result showed that there is a positive correlation between the study variables including knowledge and training, medication reconciliation policy and procedures, and organizational management support with the compliance of medication reconciliation process. This study concluded that hospital pharmacists should be knowledgeable and have adequate training about medication reconciliation process. Proper implementations of policy and procedures with the organizational management support can contribute to improving the medication reconciliation process. However, further studies are needed to include all physicians and nurses to determine overall institutional factors that influence medication reconciliation process improvement.

1. Introduction

Medication management is a prevalent and critical component of health care delivery and the most common source of error in health care. Medication management is a highly complex cooperative task involving essential clinical roles such as physicians, nurses, and pharmacists to maximize outcomes and minimize error ¹. The information needed to support medication management such as the rationale for a particular drug or dosage choice; drug-drug, drug-disease, and/or drug-lab alerts; and family and patient information about preferences and prior therapeutic and adverse responses is often distributed across professional roles and constitutes what human factors researchers describe as a joint cognitive system ².

Medication discrepancies occur in up to 80% of hospitalized patients during transitions of care, either at admission or discharge. To ensure patients' medication management is not interrupted during these transitions, healthcare professionals are encouraged to document patient’s medication histories, accounting for recent changes, and compare that list against the prescriber’s current medication orders, to ensure no unintentional discrepancies occur. This process is referred to as ‘medication reconciliation’ and has been recognized by numerous organizations as an important process to prevent medication errors and promote patient safety ³.

Medication reconciliation is defined “the process of creating and maintaining the most accurate list possible of all medications a patient is taking (including drug name, dosage, frequency, and route) and using that list to guide therapy ⁴. The goal is to provide correct medications to the patient at all transition points within the hospital. Medication reconciliation can be considered complete when each drug the patient is taking has been actively continued, discontinued, held, or modified at each transition point”. Transitions in care include changes in setting, service, practitioner or level of care ⁵. A structured medication reconciliation process comprises five steps: (1) develop a list of current medications; (2) develop a list of medications to be prescribed; (3) compare the medications on the two lists; (4) make clinical decisions based on the comparison; and (5) communicate the new list to appropriate caregivers and to the patient ⁶.

Medication reconciliation is a vital tool in clinical settings helping to reduce medication errors and patient harm ⁷. Medication reconciliation is a collaborative process between healthcare providers and patients that involves obtaining the best possible medication history 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. Medication reconciliation is mandated by many institutions as a method to provide structure to minimize the complexity of medication management at transitions in care and to decrease error ⁸.

Several patient safety organizations have adopted and promoted Medication Reconciliation as a medication safety strategy in their guidelines and recommendations. Medication reconciliation as a medication safety strategy has been championed by several of healthcare organizations. It was first adopted in 2005 as a National Patient Safety Goal (NPSG) by the Joint Commission 2006 and, later, the WHO and collaborators involved themselves in endorsing this strategy across many countries ⁹.

Despite these efforts, the implementation of a medication reconciliation service is a hospital-wide challenge. This study is aimed to investigate the barriers that influence the performance of medication reconciliation process that can be used by the pharmacists to create a strategic plan for improving the medication reconciliation process in the King Abdullah Medical City (KAMC).

The study aims to investigate the factors influencing the performance of medication reconciliation process. This aim is achieved through

1. Assessing the knowledge, perception, and practice towards the medication reconciliation in KAMC, Makkah, Saudi Arabia.

2. Identifying potential obstacles that prevent successful implementation of medication reconciliation in KAMC, Makkah, Saudi Arabia.

1. There is a significant statistical relationship between knowledge and training about medication reconciliation and compliance to the medication reconciliation process in KAMC.

2. There is a significant statistical relationship between medication reconciliation Policy and compliance to medication reconciliation process in KAMC.

3. There is a significant statistical relationship between procedures involved in the medication reconciliation process and compliance to medication reconciliation process in KAMC.

4. There is a significant statistical relationship between organizational management support and compliance to medication reconciliation process in KAMC.

2. Research Methodology

The design of this study is a quantitative analytical cross-sectional. A simple random sample of 90 professional pharmacists was allocated proportionally from the hospitals that were working in KAMC for more than 6 months.

The sample size included permanent pharmacist was 130. The minimum sample size by the total number of hospital pharmacists is 90 assuming a minimum response rate of 50% and a confidence interval of +/-5%.

The researchers designed a self-made questionnaire which included the most items suitable to measure the barriers influencing the performance of medication reconciliation process from pharmacists’ perspective. The questionnaire was distributed electronically to the study sample through online platform. The survey questions consist of 4 dimensions and 22 items which include the most items suitable to measure the independent variables of the study. The compliance to medication reconciliation process was the dependent variable which was used as secondary data. This data was taken from the annual quality report. The Medication Reconciliation compliance in KAMC was 65% as Average at 2019. It was calculated as the nominator, the total number of reconciled Patient in specified month, and dominator, the total number of admitted patient multiply by 100%. The first part of the questionnaire included socio-demographic characteristics of the pharmacy staff; gender, age, and years of experience in the hospital. The other part includes different items as knowledge and training, policy, procedure, organizational management support. The participant was answering the questionnaire by Likert scale which included as strongly agree, agree, neutral, disagree, and strongly agree, sometimes, and never.

The investigators collected data from the participants by using online survey questionnaires. The survey link was closed when the needed number of respondents is achieved. An invitation part was included in the survey to understand the aim of the study to the participants and to obtain their cooperation.

The total Cronbach’s alpha (α) for the questionnaire was 0.815 and 0.826 for the first and the second round respectively that indicates acceptable and high reliability in the first, and second as shown in Table 1. The correlation coefficients between each statement and the total degree ranged between (0.273-0.695) which are positive and significant at the level of significance (0.01) that indicates high internal consistency for the data of medical staff in KAMC as shown in Table 2.

The researchers were committed to all ethical considerations required to conduct the research. Before data collection, the researchers obtained official permission from IRB to conduct the current study, after that the aim of the study was explained for the hospital pharmacists to obtain their cooperation before sending the online survey. The researchers maintained anonymity and confidentiality for the participants. The researchers assured that all data files are secured and used only for the research, and will be deleted after conducting the research. Participants were not identified on questions.

The researchers used the software Statistical Package for Social Science (SPSS) version (25) for conducting statistical analysis. The participant’s demographics characteristics were described using frequency and percentages. The independent variables were presented in form of the mean and standard deviation. The Cronbach alpha coefficient was applied for reliability testing. Chi square (χ2) test was performed to examine possible differences in means between each item in the dimensions and its significance with compliance of medication reconciliation process. Pearson Correlation Coefficients was to test the relationship between the study variables. P-value < 0.05 is considered significant.

3. Results

The majority of the respondents (65.6%) were male. The 25.6% of the respondents aged (36-40 years), 21.1% in the age group (41-45 years), 20.0% in the age group (20-30 and 31-35 years), and the minimum percentage 13.3% aged between 46-55 years. The majority of the participants (44.4%) had 4-7 experience years, and 32.2% has 8-10 experience years, and the minimum (23.3%) reported 1-3 experience years as shown in Table 3.

The greater mean of knowledge and training dimension was (3.41) for item (training and education about medication reconciliation), but the lowest mean value was (1.44) for item (medication reconciliation is one of the tools to improve patient safety). The p values indicate some statement had association with medication reconciliation process as shown in Table 4.

The policy dimensions shows that the greater mean was (2.49) for item (Medication reconciliation policy is applicable to all settings in patient care), but the lowest mean value was (2.06) for item (Medication reconciliation policy identifies the responsibilities in each steps of reconciliations). P values indicate all the statements in policy dimensions have association with medication reconciliation process. So it is factor influencing medication reconciliation process as shown in Table 5.

The greater mean of procedure involved in the medication reconciliation process was (3.38) for item (If the patient is admitted from an external hospital, it is easy to obtain the medication history), but the lowest mean value was (2.62) for item (Medication reconciliation is an essential part of patient assessment). Also, it is finding that some of the items in procedure dimensions associated with medication reconciliation process. This indicates procedure dimension is one of the factors that influences medication reconciliation process as shown in Table 6.

The greater mean of organizational management support for compliance to medication reconciliation process was (2.71) for item (Your manager always get a feedback from you regarding the process of medication reconciliation), but the lowest mean value were (2.40) for item (Leadership support a learning culture by sharing errors occurred during medication reconciliation process instead of making it personal). Also, all of the procedure dimension items have association with medication reconciliation process. This indicates organizational management support dimension is one of the factors that influence medication reconciliation as shown in Table 6.

The greater mean score (23.1) of the study variables was for Knowledge and training on medication reconciliation process and it is the most influencing independent variables on compliance of medication reconciliation process in KAMC. The second mean score was procedures involved in medication reconciliation process (19.47) and this result also indicates that procedures involved in medication reconciliation process also influencing factor in the compliance of medication reconciliation process. Remaining two variables; Medication reconciliation policy (14.711) and Organizational management support for medication reconciliation process (13.844) also showing influence on compliance of medication reconciliation process. The χ2 value (p<0.001) also shows that all the variables have significant association with medication reconciliation process that indicates all the independent variables are influencing factors on compliance to medication reconciliation process in KAMC as shown in Table 7.

4. Discussion

The aim of the study is to investigate the factors influence the performance of medication reconciliation process in KAMC. This study result reflects the challenges that prevent medication reconciliation process effectively. Despite the potential for pharmacists have a positive impact on medicine reconciliation services ¹⁰. This can be used by the pharmacist to create a strategic plan to improve medication reconciliation process in hospital settings. The results show that medication reconciliation process from pharmacist perspective is perceived as an area of strength whereas those areas in need of improvement were scattered on several levels.

The results reached that the majority (65.6%) of the respondents are male, most of them about 25.6% in the age group (36-40years), (44.4%) with (4-7) years of experience in the hospital. Result regarding the medication reconciliation composite items shows that the knowledge and training, medication reconciliation policies, procedures involved in medication reconciliation process and organizational management support are influences the performance of medication reconciliation process KAMC. This might, in part, be related to the identified lack of awareness identified among those pharmacists regarding this process ¹¹. These results are consistent with a previous report by van Sluisveld et al ¹² demonstrating lack of awareness and insufficient knowledge of different healthcare professionals, including pharmacists, about the concept of medication reconciliation. This requires the execution of educational programs by the hospital management to include all staff pharmacists regarding current hospital policies related to medication reconciliation. One study conducted in Saudi Arabia reported that pharmacists are willing to practice medicine reconciliation if training is received. Providing educational sessions to healthcare providers were actually shown to significantly improve pharmacists’ implementation of reconciliation services ¹³.

The present study assessed the awareness of participants about the medication reconciliation policy and the result shows that policy is one of the influencing factors in medication reconciliation process. This report also supported by another study that pharmacist have good perception on policies ¹⁴. The respondents also given the medication reconciliation procedure also influence medication reconciliation process. In this context, it may prove valuable to revise the current process of medication reconciliation.

When proving the hypothesis, the result show that there is a positive correlation exist between the study variables including knowledge and training, Medication reconciliation policy, procedures involved in the Medication Reconciliation Process and organizational management support with compliance of medication reconciliation process. Result of the correlation indicates that all the above variables higher scores are associated with higher medication reconciliation scores. In addition the previous study also supporting the correlation results that some of the above factors influence the medication reconciliation process ².

5. Conclusion

The present study found the barriers that influence the performance of medication reconciliation process. The final result proved medication reconciliation composite items the respondents agree about the knowledge and training, medication reconciliation policies, procedures involved in medication reconciliation process and organizational management support are the most influences factors in the performance of medication reconciliation process in KAMC. Finally, when proving the hypothesis, the result show that there is a positive correlation exist between the study variables including knowledge and training, Medication reconciliation policy, procedures involved in the Medication Reconciliation Process and organizational management support with compliance of medication reconciliation process. Result of the correlation indicates that all the above variables higher scores are associated with higher medication reconciliation scores.

6. Limitations of the Study

The perceptions of physicians and nurses were not included in the study. So, the result cannot be represented as a whole organizational level. The study relies on self-reported online survey and if using participant’s direct interview may get more ideas and recommendations for improving medication reconciliation process.

7. Recommendations

This study finding will help the hospital leaders to make changes towards medication reconciliation process improvement. The result of the study showing the factors that that influences compliance to medication reconciliation process that will help the leaders to prepare improvement plans. The final result proved medication reconciliation composite items the respondents agree about the knowledge and training, procedures involved in medication reconciliation are the most influencing factor in compliance of medication reconciliation process in KAMC. Finally, when proving the hypothesis, this research recommending the strong relationship between study variables and compliance to medication reconciliation process. We are recommending the health care leaders to create an institutional strategic plan to improve medication reconciliation program in hospital settings.

Direction for Further Research

This study strongly recommending for further research should include physicians, nurses and clinical pharmacist and also as multicenter comparative study to find the medication reconciliation process. That finding can contribute to implement the multilevel health care settings to implement policy regarding medication reconciliation process.

Conflicts of interest

None.

References