Journal of Nursing Management, 2014, 22, 362–372
Identifying medication order discrepancies during medication reconciliation: perceptions of nursing home leaders and staff AMY VOGELSMEIER
PhD, RN
Assistant Professor and John A. Hartford Claire M. Fagin Fellow, Sinclair School of Nursing, University of Missouri, Columbia, MO, USA
Correspondence Amy Vogelsmeier S314 Sinclair School of Nursing University of Missouri Columbia MO 65211 USA E-mail: vogelsmeiera@missouri. edu
(2014) Journal of Nursing Management 22, 362–372. Identifying medication order discrepancies during medication reconciliation: perceptions of nursing home leaders and staff
VOGELSMEIER A.
Aim The purpose of this qualitative study was to explore nursing home leader and staff nurse perceptions about the process of medication reconciliation, with a specific focus on identifying medication order discrepancies. Background Medication order discrepancies and harmful discrepancy-related adverse drug events can occur when residents make the transition to nursing homes, yet little is known about how discrepancies are identified in this setting. Method Interviews of 18 leaders and focus groups of 13 registered nurses and 28 licensed practical nurses from eight mid-western United States nursing homes were conducted. Result Three themes emerged from the data: (1) nurses believe nursing home physicians rely on them to know, (2) active vs. passive information-seeking, and (3) nurses making sense of medication orders to identify discrepancies. Conclusion This study provides evidence about the role of nursing home nurses in medication reconciliation and how nurses engage in cognitive processes, such as ‘sensemaking’, when identifying discrepancies. Implications for nursing management Nursing leaders and managers must acknowledge that medication reconciliation is a complex cognitive process that requires the right nurse be assigned to the role, taking into account education and experience. Additionally, systems to support collaboration between physicians, nurses and pharmacists should be in place to ensure that potentially harmful discrepancies are identified and resolved. Keywords: medication order discrepancies, medication reconciliation, medication safety, nursing homes Accepted for publication: 3 July 2013
Background Medication safety in nursing homes Adverse drug events (ADEs), defined as harm resulting from the use of a drug, are a leading cause of morbidity and mortality among the elderly and are among the most serious medication use concerns in nursing 362
homes (Hajjar et al. 2003, Nebeker et al. 2004, Gurwitz et al. 2005, Handler et al. 2006, Institute of Medicine 2007). Many ADEs are considered preventable when they result from medication order discrepancies (errors), such as unintentional drug omissions, drug additions and dosage changes, that occur when patients make transitions between health care settings DOI: 10.1111/jonm.12165 ª 2013 John Wiley & Sons Ltd
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(Boockvar et al. 2011, Feldman et al. 2012); 40–70% of medication order discrepancies have the potential to cause some level of harm (Cornish et al. 2005, Boockvar et al. 2009, Feldman et al. 2012). Evidence suggests that as many as 70% of nursing home residents may have at least one medication order discrepancy when transitioning from acute care (Tija et al. 2009). Medication order discrepancies occur during transitions in care in part because communication between clinical providers such as physicians, pharmacists and nurses is often inconsistent and unclear (Vogelsmeier et al. 2013). Nursing homes are further challenged because residents frequently have different medical providers between their hospital and nursing home stay, thus impacting continuity of care (Boockvar & Burack 2007). Moreover, physicians and pharmacists are typically not available in the nursing home at times of resident transition to identify medication order discrepancies that could cause harm (Vogelsmeier et al. 2007).
Medication reconciliation as a nursing home safety practice Safety practices such as medication reconciliation are designed to identify and resolve potentially harmful medication order discrepancies that can occur during patient transitions between health-care settings. The Joint Commission, an independent, not-for-profit organisation recognised in the USA as setting standards of health-care quality, defines medication reconciliation as a systematic process whereby a clinician compares medications a patient is currently taking and intended to be taking to medications ordered for the new setting, in order to resolve any discrepancies (Joint Commission 2013). Discrepancies include such things as drug omissions, drug duplications, contraindications for ordered medications, unclear information and changes to medications that require clarification. The goal of medication reconciliation is to minimise error and mitigate harm by detecting and resolving potentially harmful discrepancies when transitions between health-care settings occur. Despite national attention on medication reconciliation as a safety practice, little is known about the effectiveness of this process in nursing homes (Chhabra et al. 2012). Intervention studies in nursing homes most often include a pharmacist performing the process (Crotty et al. 2004, Boockvar et al. 2006, Delate et al. 2008). While pharmacists can be effective in detecting discrepancies and preventing discrepancy-related adverse events that result in harm, in the ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 362–372
current nursing home environment, pharmacists are rarely on site at resident transition. In reality, medication reconciliation is most often performed by nurses, including both registered nurses (RNs) and licensed practical nurses (LPNs) (Vogelsmeier et al. 2011). Because little is known about how medication reconciliation is currently practised in nursing homes, the purpose of this article is to explore the perceptions of nursing home leaders and direct care nurses about their current role in the process.
Method Setting, sample and procedures This was a qualitative study conducted to explore perceptions of nursing home leaders and direct-care nursing staff about the process of medication reconciliation, with a specific focus on how medication order discrepancies are identified at resident transitions to the nursing home. Data collection was conducted between 2010 and 2011 and included interviews and focus groups held on site in eight mid-western US nursing homes that self-reported implementing medication reconciliation processes. The nursing homes were a mix of urban (n = 4) and rural (n = 4), ranging in size from 60 to 180 resident beds. Further details about the setting have not been included, due to the sensitive nature of participants sharing examples of medication order discrepancies and potential resident harm. The sample consisted of nursing home leaders and nursing home RN and LPN staff who reported performing medication reconciliation at resident admission. RNs and LPNs often have similar responsibilities in nursing homes, therefore both groups were included in the sample (Vogelsmeier et al. 2011, Mueller et al. 2012, Corazzini et al. 2013). To clarify, in the USA RNs and LPNs differ in their education and scope of practice (NCSBN 2011); RNs attend 2–4 years of an accredited nursing programme and are eligible to provide comprehensive nursing care, including assessing, planning, implementing and evaluating patient care. In comparison, LPNs typically attend a 12 month programme and have a limited, more technical scope of practice. Individual interviews were conducted with 18 nursing home leaders and focus groups were conducted with 13 RN and 28 LPN staff. The nursing home leaders included six licensed administrators, eight directors of nursing and four assistant directors of nursing and/or nurse managers. Of the six nursing home administrators, three were RNs and three had no clinical background. The remaining leaders were 363
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Table 1 Nursing home participant demographics Demographic
Leaders (n = 18)
Credential RN 15 LPN 0 Non-clinical 3 Education level No formal education 1 Technical 0 Associate degree 6 Diploma 3 Bachelor degree 6 Master degree 2 Experience at current nursing home >1 year 4 1–5 years 5 6–9 years 3 >10 years 6
Table 2 Nursing home leader interview guide Staff nurses (n = 41)
13 28 0 0 28 10 0 2 1 12 18 8 3
all RNs. Nearly one-half of all nursing home leaders had a bachelor’s degree or higher (44%). One-half of nursing home leaders had 6 or more years of experience in their current nursing home (50%). Among the direct-care staff, the majority of RNs had an associate’s degree (66%) and all LPNs had completed a practical nursing programme required for licensure (100%). Regarding experience, the majority of all staff nurses had less than 5 years of experience in their nursing home (75%) (Table 1). Interviews and focus groups were selected because these forums provide important insight from the participant’s perceptive about a relatively unknown area of study (Stewart & Shamdasani 1990). Nursing home leaders were intentionally interviewed separately, so as not to influence discussion generated by front-line staff. According to Stewart and Shamdasani (1990), focus group participation can be influenced by dynamics such as perceived power within the group. All interviews and focus groups were conducted by the principal investigator. Separate semi-structured interview guides were used for the leader interviews and for the staff nurse focus groups. The leader groups varied in size between two or three participants/site and focus groups varied in size from five to 10 participants/site. Each interview/focus group lasted 60–90 minute. All interviews and focus groups were audio-recorded and transcribed verbatim for analysis (Tables 2 and 3). This study was approved by the University of Missouri Health Sciences Institutional Review Board (MU HSIRB). In accordance with the MU HSIRB requirements, a waiver of documentation of consent was obtained. A waiver of documentation of consent is appropriate when the research presents no more than 364
Why was medication reconciliation implemented at this nursing home? Please describe how the process of medication reconciliation is performed here What is the role of nurses in this process? What concerns (if any) do you have about how medication reconciliation is currently performed here? What are the challenges to successfully identifying medication order discrepancies at this nursing home? Is there anything else about medication reconciliation that we have not discussed that you would like to discuss?
Table 3 Focus group interview guide Describe how medication reconciliation is currently performed at this nursing home Why do you think medication reconciliation is being done here? What is your responsibility in this process? What types of challenges or barriers do you encounter when trying to identify medication order discrepancies? Describe what you do when you encounter these challenges Can you share examples of when medication reconciliation did not occur? What do you think can happen when medication order discrepancies are not identified? Is there anything else that you would like to discuss about medication reconciliation?
minimal risk of harm to subjects and involves no procedures for which written consent is normally required outside of the research context. Prior to any data collection activities, the investigator provided participants with a written statement regarding the study goals and procedures to ensure that they were adequately informed about study activities.
Data analysis Based on recommendations by Saldana (2009), a thematic analysis approach called ‘theming the data’ was used. According to DeSantis and Ugarriza (2000), ‘a theme is an abstract entity that brings meaning and identify to a recurrent experience and its variant manifestations. As such a theme captures and unifies the nature or basis of the experience into a meaningful whole’ (p. 362). The process of analysis consisted of a series of iterative reviews of the transcribed text by two researchers, including the principal investigator and an expert nursing home and medication safety nurse researcher. Texts from the transcripts were reviewed in depth for concepts or phrases that leaders and nurses described about performing medication reconciliation and/or identifying medication order discrepancies. Each selected text was labelled, according to nursing home site (e.g. NH1, NH2, NH3), as either a leader quote or a staff nurse quote. Salient concepts ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 362–372
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or phrases from the text were highlighted, coded and grouped into a Word table, based on similarities. All groups of coded texts were reviewed a second time by the research team and collapsed into 11 categories. Text within the 11 categories was reviewed a third time by the two researchers and merged into three primary themes. Three analytical strategies were used to ensure that the findings were credible, dependable and confirmable (Crabtree & Miller 1992). Strategies included: (1) member checking during the interviews and focus groups to ensure a valid reflection of participant perceptions, (2) maintenance of a detailed audit trail to ensure data dependability and stability, and (3) participation of two expert nursing home and medication safety researchers to ensure that the findings were consistent and objective. These strategies reflect efforts to ensure the rigour and trustworthiness of the analysis approach.
Results Three primary themes emerged representing leader and staff nurse perceptions about nurses’ role in medication reconciliation and how they identify medication order discrepancies during the process. These themes included: (1) nurses think that nursing home physicians rely on them to know, (2) active vs. passive information seeking, and (3) making sense of medication order discrepancies. Salient quotes are included below to represent participant perceptions across the eight nursing homes, according to the three primary themes.
Nurses think that nursing home physicians rely on them to know When initially talking about medication reconciliation, the majority of leaders and staff spoke about the nurse’s responsibility in the process. Many believe that nursing home physicians rely on nurses to know what medications the resident is supposed to be taking and why. Participants spoke about the reality that many physicians care for residents solely in the nursing home and are therefore unfamiliar with their medical care prior to transfer. Moreover, nursing home physicians and other medical providers rarely communicate with each other, therefore they rely on nurses to be the liaison between them: ‘The [nursing home] physician expects the nurses to be the hub of the communication and get that information gathered from all the physicians and try to, you know, piece it together’. (Leader) ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 362–372
‘The [nursing home] physician is asking us, “What’s this medicine? Why are they on this?”, and we don’t know. We have no history yet’. (Staff nurse) ‘And then our [nursing home] doctors know less than we know. So it’s up to me to get all the information together and get with the doctor and say, “Here’s, you know, this is why they’re on that [medication]”’. (Staff nurse) Leaders and staff spoke about nursing home physicians not being on site at the time of transfer, which they believe increases the nurses’ responsibility to know the resident. Because of the physician’s absence, both leaders and staff shared how nursing home physicians often seek their opinions and follow their recommendations when making decisions about residents’ medication orders: ‘The physicians don’t come around every day so they’re pretty dependent on us to, you know, do their assessments and [review] lab values, too. So, I mean, a lot of times they’ll ask, or they’ve asked us before, “Do you think that they need to be on the Lasix [furosemide]?”’ (Staff nurse) ‘The majority of the time [physician] takes what we say verbatim. If we have a recommendation, they’re gonna go, “Okay”. They may discuss previous labs with us, you know, go over their med [sic] list with us, instead of making the visit from there to here’. (Staff nurse) ‘But it’s the nurse relaying to the physician, “Let’s keep this medication that has been recommended by an outside physician, at least to attempt to trial it”. Well, and the doctors go with the nurse’s recommendation. I feel like we can lead the doctors’. (Leader) ‘Some of our docs [sic] are overly cautious, don’t really listen to our nurses and what their opinions are, but Dr [name omitted] and others are wonderful. They’ll pretty much do whatever we ask … but there’s probably a fine line between being wonderful and being so lax that you’ll let anything go through’. (Leader)
Active vs. passive information seeking During discussions about physicians’ reliance on nurses to know, participants described differing approaches to knowing the residents and their medi-
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cation history. Some shared stories of searching through transfer documents and talking with residents, families and providers, while others spoke about making assumptions and relying on others to share information with them. This dichotomy in approach is described as ‘active vs. passive information seeking’. Active information seeking Some participants described a detailed and often tedious process of reviewing transfer records, with the goal of assimilating clinical information about the resident. They shared examples of sorting through volumes of paper and reading document after document to understand the resident’s history and to know what medications were ordered and why. When leaders and staff spoke about reviewing and assimilating transfer documents, they often shared frustrations about inconsistent, unclear or unavailable information, and medication orders written that simply did not ‘make sense’. ‘But the [medication] orders won’t make sense the way they’re written, here’s what they’re saying they were given and here’s the transfer orders. And these are different’. (Leader) ‘It’s like they [hospital staff] printed some list out of the computer … it’s probably on their checklist of forms to print out, but there’s not a real, true reconciliation because the orders don’t make sense to us’. (Leader) ‘The H&Ps [physician-documented history and physical of the resident] are not always accurate; sometimes it will say under home meds, see med [sic] list, and that list is buried in another note, so we have to look there … and sometimes it’s not there, so we have no way to know what they were on at home and then we have to ask the family’. (Staff nurse) ‘Sometimes it’ll be in progress notes or order notes and I’ll see where maybe that order was [discontinued] and it didn’t show up on the hospital [record] but it showed up on the transfer sheet’. (Staff nurse) Because written transfer information is often inconsistent, unclear or unavailable, some nurses spoke about strategies in which they engage to fill in the gaps. In particular, they spoke about communicating with families, hospital staff and clinic staff to piece information together. Many staff cited barriers, such as families 366
who have ‘little to no knowledge of the resident’s medications’, hospital staff who cite ‘HIPAA’ (Health Information Portability and Accountability Act, a federal US law enacted to protect private health information) violations if information is shared, and office staff who consistently put a ‘wall around’ the physician. The most frustrating stories related to communicating directly with transferring physicians. ‘You’ll find a discrepancy but then when you try to question the discrepancy you get resistance, you’re kind of caught in the middle of it. And all I’m trying to do is – what am I to give them’. (Staff nurse) ‘You call the doctor, and then that’s when you and the doctor have a disagreement. He’s saying, “No, this [medication]”. And I go, “But, sir, I have this [transfer] paper here”, and they are different. You don’t want to argue, but then in the same sense you’ve got the patient you’ve gotta concern yourself with more’. (Staff nurse) ‘I had an on-call doctor that had no clue of who the patient was, and I had questions and they were like, “Just give them whatever’s on the [transfer] list and then call their doctor Monday”. Well, if it’s Friday night, we could go 3 days, almost into 4, and that can’t happen, we can’t let that happen’. (Staff nurse) Passive information seeking Discussions about assimilating clinical information during medication reconciliation led others to share how they were encumbered by vast amounts of transfer documents to review, among competing demands of the overall admission process. Both leaders and staff acknowledged that too much information and not enough time leaves staff feeling overwhelmed and overworked. As a result, deciphering clinical information to look for medication order discrepancies is not a priority: ‘Nurses are so pressed to get so many things done, and it is a huge time commitment to do a good job at medication reconciliation’. (Leader) ‘I just don’t have time to sit and decipher; if it’s not on the H&P, then am I supposed to do a review, or like flip through and look for labs? It is very time consuming’. (Staff nurse) ‘This lady got 40 pills, and I kid you not, and you’ve got a list here and you’ve got 50 directions ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 362–372
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you’re going in, by the time you sit down again or look at it, you’re going, “Ah, whatever”’.
with absolutely nothing. She just didn’t voice it, and I guess we didn’t ask?’ (Staff nurse)
(Staff nurse)
‘Then the daughter comes in later, and her mom is worse, and says, “Well, wait a minute. Where’s the Lasix [furosemide], she was on it at home?” Well, what Lasix [furosemide]? They weren’t on it in the hospital’. (Staff nurse)
‘[Residents] have all this information and sometimes you just skip right over that part because you’re worried about getting the orders in, getting them faxed to the pharmacy, making sure they’re comfortable, you know, all at 5.00 p.m’. (Staff nurse) During discussions about information overload and time challenges, some leaders and staff spoke confidently about their belief that medication orders at transfer are typically correct, therefore questioning the presence of discrepancies is not necessary: ‘We don’t really question if orders are intentional or not, we just assume the orders are the way the hospital physician wanted it’. (Leader) ‘I usually just assume that the hospital orders [at transfer] were what they intended to be continued and would continue those medications. Gosh, if not, we’d have a lot to do’. (Staff nurse) ‘I don’t know that we ever questioned if [any order] was accurate or not. We don’t really question if there was a discrepancy or not. I mean, that would be too much to think about’. (Staff nurse) When discussions turned to residents and families as a source of information, leaders and staff who assume orders are accurate later shared how they actually rely on families to initiate questions or raise concerns about the resident’s medication regimen. However, these same leaders and staff shared stories about families and residents raising questions after an adverse event had occurred; adverse events they describe as happening all too often: ‘After the fact, I’ll see that they were never on this [medication] before and frequently that’s a psych med [sic] that they were put on. And we’re continuing that and they’re drowsier and drowsier and the family said, “What the heck, they weren’t on this before”. I’ve seen this happen way often’. (Leader) ‘Now, when she came from home she was, remember, after a few days just coughing, but then I went and talked to her, “Well, I was on breathing treatments at home”, and she came ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 362–372
Nurses making sense of medication order discrepancies Discussions about assimilating clinical information evolved into discussions about how nurses ‘make sense’ of the information they encounter. Many nurses spoke about ‘red flags’, such as specific medications, nursing home rules/regulations and experience with harmful past events, that create cues when considering potential discrepancies. One staff member also spoke about physician expectations as her cue to question the presence of discrepancies. ‘If they were on Lasix or something like that, Neurontin or whatever for a seizure or whatever, I definitely don’t want that to be missed. I don’t want the Tylenol [acetaminophen] either, per se, but I focus more so on the major medications before I focus on the others’. (Staff nurse) ‘[There’s a] red flag with all psych meds [sic] … we have to have an appropriate diagnosis for our psychotropics because of regs [sic]’. (Staff nurse) ‘My issue is a certain resident who was on a blood thinner. She was supposed to continue this for another week and that did not get passed over. She died from a blood clot [nurse crying]’. (Staff nurse) ‘I look for stop dates. I remember seeing an antibiotic that was given for months because there was no stop date, and we realised it when the resident got C. diff. [Clostridium difficile]’. (Staff nurse) ‘For me, it depends on the doctor. We have some doctors who say, “Whatever the hospital orders say”, so we never question [medication orders]. And then there are others who will say, “No, I had them on this and this is what I want them on”. So then we always know to question those orders’. (Staff nurse) 367
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Whereas some nurses make sense of discrepancies based on specific cues or ‘red flags’, a few described other types of cues, such as considering medication order discrepancies within the context of medication safety and the resident’s overall mediation therapy plan. Examples, such as linking current and past medications to the resident’s medical condition, assuring laboratory monitoring is in place and collaborating with physicians about medication appropriateness, were viewed by some nurses as important opportunities to prevent resident harm: ‘When they’d stopped the Lasix [furosemide], and the dehydration resolved, I would want to look at it to see, you know, with the CHF will they eventually need to have the Lasix [furosemide] back? I’d ask [the physician] about that’. (Staff nurse) ‘I would want to know, why did they put them on Ativan [lorazepam]? Are they agitated or something, you know. Is that resolved, the agitation? I try to look out for these guys, so I would ask [the physician], you know, does she even need that now?’ (Staff nurse) ‘If they’re on a lot of medications that indicate they’ve got congestive heart failure or diabetes, for example, then are there labs or other clinical parameters that need to be looked at because of their recent change in condition, to get baselines, that sort of thing? It’s something you’ve just gotta kind of ask’. (Staff nurse) ‘You review them; dosages, are they out of the norm; medications, are they appropriate to the diagnoses, you know. As an RN I should know something that requires lab levels, monitoring, that we have recent results in that and the appropriate orders to go with it’. (Staff nurse) Despite the process nurses describe to make sense of medication orders, only two leaders explicitly acknowledged medication reconciliation as a cognitive process. Within discussions about cognitive complexity, these same leaders cited concerns about some staffs’ inability to think critically and raise questions to identify discrepancies with the goal to prevent harm, concerns that are validated by these staff nurse quotes: ‘We don’t [usually] get diagnoses listed on the medication order, so we have to guess why they are on a certain medication and we just have to go 368
by what we think they are on it for; if its Neurontin [gabapentin], we just assume it if for “X” reason. We have to use our best judgement’. (Staff nurse) ‘When [residents] come in and there’s a discrepancy between the old med [sic] list and the new list, then we have to decide what to put on hold … I’ll think, well, let’s try it for 2 weeks, you know, placing this med [sic] on hold to see how they do, then I’ll let the doctor know’. (Staff nurse) These same leaders further acknowledged that limited education and experience likely result in variation in their staffs’ ability to identify and subsequently resolve discrepancies; higher-level cognitive skills they perceive necessary to assure resident safety: ‘I think the population of nurses that we have here are very task-oriented, don’t have the critical thinking capabilities to really raise questions and identify discrepancies, you know, that someone else who’s an RN or who has even been a nurse for a long time usually has’. (Leader) ‘It’s scary sometimes. There are so many opportunities for the processes to fail. The nurses’ individual judgement, they think, “Oh, this wasn’t a big deal so we’re not gonna follow up on this and then boom”, a poor outcome. I see this with many of my LPNs and even some of my RNs’. (Leader) When discussing staff limitations, these same leaders shared examples of systems or safeguards they employ to help staff identify discrepancies that might otherwise go undetected. Examples such as RN oversight, pharmacist support and technology systems are perceived by some leaders to be effective in ensuring that discrepancies are identified: ‘I would say 95% of the time an LPN is doing that admission. That’s why [RN name omitted] takes that chart when she’s here, combs through all those things and says, “Hey, let’s check on this, let’s follow up on this”’. (Leader) ‘We have [staff] working with the pharmacist and for example, and he’s usually going through and going, “Okay, do they really need three different orders for Tylenol [acetaminophen]?”’ (Leader) ‘[Technology] does have some safeguards because you can actually print off a transfer list that gives [staff] so much information at the ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 362–372
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hospital side. It will list all of their medications, any treatments that they’ve been receiving, their history. Of course, that is if they use it’. (Leader)
Discussion This study provides a foundational understanding about leader and staff perceptions of nurses’ role in medication reconciliation in nursing homes. Specifically, this study expands our knowledge of how nursing home nurses identify medication order discrepancies during medication reconciliation. These findings also contribute to our knowledge about the cognitive process of ‘sensemaking’, in which nursing home nurses engage to detect discrepancies during the process.
Nurses’ role in medication reconciliation In this study, nurses describe their role in medication reconciliation when residents make the transition to the nursing home. Some nurses perform medication reconciliation by reviewing and assimilating clinical information and collaborating with residents, families and providers about information that is inconsistent or unclear. In contrast, other nurses are seemingly passive by working in isolation, making assumptions and relying on others to raise questions and concerns. At the surface, the passive approach relates to time constraints and information overload. However, as some leaders surmise, the underlying reason may be individual nurses’ limited ability to interpret clinical information and to know when further inquiry is necessary. As leaders in this study acknowledge, nurses of different education and experience are responsible for performing medication reconciliation, yet some, perhaps more often LPNs, may not have the education and experience to do the process effectively. This finding is supported by Boblin et al. (2008), who found differences in nurses’ clinical decision-making based on their education and credentials. Despite differences in RN and LPN education and scopes of practice (National Council State Boards of Nursing 2011), the current nursing home paradigm is to interchange RN and LPN staff roles, where both RNs and LPNs are assessing, planning, implementing and evaluating resident care (Mueller et al. 2012, Corazzini et al. 2013). Perhaps these differences in education and credentials underlie the variability described by nurse leaders. This study also supports existing evidence that physicians rely on nurses to provide information necessary to prescribe medications and to monitor relevant sysª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 362–372
tems to prevent ADEs (Longo et al. 2004, Vogelsmeier et al. 2007). Gabe et al. (2011) suggest that nurses play an important role in medication monitoring, perhaps in part because of their front-line proximity to patients, families and providers. Nurses’ front-line proximity is particularly important at times of resident transition, when information about medication orders may be inconsistent or unclear.
Nurses’ ‘sensemaking’ to identify discrepancies Findings from this study suggest that nurses engage in a cognitive process called ‘sensemaking’ to identify discrepancies. Sensemaking, which literally means to make sense, is a cognitive process in which individuals interpret and assign meaning to unexpected events, which in turn directs their actions. In sensemaking, people construct mental models of unexpected events based in part on past events, social relationships and organisational structures/rules and can be influenced by education and experience (Weick 1995). In this study, nurses described significant past events, physician expectations, nursing home regulations as well as their clinical knowledge and experience as influencing the discrepancies they identified. Moreover, this study highlights how nurses vary in their sensemaking. For example, some nurses describe potential discrepancies within the context of specific medications, nursing home regulations or significant past events, while others considered discrepancies within the broader context of medication safety and the resident’s overall medication therapy plan. The variability in nurses’ sensemaking is concerning, because potentially harmful discrepancies may go undetected and unresolved. Sensemaking can influence resident safety by either promoting or hindering safety actions. Effective sensemaking can result when individuals challenge assumptions, raise questions and work with others. In contrast, ineffective sensemaking can result when individuals make assumptions, adhere to strict rules and work in isolation (Powers et al. 2010). Whereas this study provides an initial understanding of nursing home nurses’ sensemaking, understanding differences between nurses is important and warrants further study.
Limitations In qualitative research, transferability refers to the extent that findings can be transferred to other settings (Polit & Beck 2004). There are limitations with this study worthy of acknowledgment that may affect the 369
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transferability of findings. First, the nursing homes for this study were selected because leaders self-reported performing medication reconciliation at resident transitions. Because little is known about the widespread implementation of medication reconciliation within this setting, it is possible that processes within these nursing homes are unique. Second, because data collection was completed nearly 2 years ago, it is possible that medication reconciliation as a safety practice in nursing homes has changed. However, due to the sensitive nature of the data, analysis was extensive and therefore publication has been delayed. Third, the relatively low number of participants from each setting may not reflect the perception of other nurses within those same settings. Finally, focus groups included both RN and LPN staff. Because the two credentials of staff were combined, it is difficult to ascertain whether differences between the two groups exist. Future investigators should explore the distinct differences between RNs and LPNs, particularly when considering the cognitive process of sensemaking.
performing medication reconciliation. Working in isolation leaves opportunities for nurses to make unsafe assumptions that may translate to unsafe actions. Unsafe assumptions are particularly concerning, given the blind reliance on nurses that physicians may have when communicating about residents’ medication therapy needs. Leaders and managers must acknowledge that medication reconciliation requires a shared approach across roles involving physicians, nurses and pharmacists (Boockvar et al. 2011, Feldman et al. 2012, Vogelsmeier et al. 2013). To ensure a shared approach, leaders and managers must facilitate nurse– physician collaboration by resolving current communication barriers and clarifying the expectations of each role (Vogelsmeier et al. 2013). Moreover, formalising systems that support RN oversight, pharmacist and physician collaboration and access to electronic health records between settings can provide important safeguards to ensure that medication order discrepancies are appropriately identified and resolved. Addressing these challenges can go a long way to improving medication safety for nursing home residents.
Implications for nursing management There are important nursing management implications identified from this study. First, leaders and managers must acknowledge that medication reconciliation is a complex cognitive process. Because of the complexity of medication reconciliation, the challenge for nursing home leaders is to ensure that nurses assigned to the process have the necessary cognitive skills to do so. Evidence supports the influence of RNs to improved nursing home outcomes (Horn et al. 2005, Corazzini et al. 2011), yet there are fewer RNs in nursing homes today than a decade ago (Seblega et al. 2010). Because RNs are a limited resource in many nursing homes, rather than interchanging RN and LPN roles, leaders and managers must assign the right nurse to the right role to maximise their contribution to resident safety. Second, medication reconciliation is gaining recognition as an integral component in the broader context of medication management (American Society of Health-System Pharmacist 2012). As such, nurses’ sensemaking within the context of the resident’s overall medication therapy plan is important to identify discrepancies that could be in conflict with that plan. The focus on medication management, however, requires an active collaboration, including input from the physician to assure medication appropriateness. Finally, this study provides important insight into the often isolated approach nursing home nurses take when
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Conclusion Medication order discrepancies and related ADEs are a serious concern for nursing home safety. Although medication reconciliation is a safety practice designed to identify and resolve potentially harmful discrepancies, little is known about the process in nursing homes. Findings from this study expand our knowledge by providing insight into the process of medication reconciliation and how medication order discrepancies are identified when residents make the transition to the nursing home. Specifically, this study provides evidence about the integral role nursing home nurses play in the process and how nurses engage in important cognitive processes, such as sensemaking, when detecting discrepancies.
Acknowledgements The author would like to acknowledge Jill Scott-Cawiezell PhD, RN, FAAN, University of Iowa College of Nursing, for her assistance with the data analysis portion of this study.
Source of funding This project was funded by the John A. Hartford Foundation and the University of Iowa Gerontological Nursing Intervention Research Center.
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Identifying medication order discrepancies in nursing homes
Ethical approval Ethical approval was obtained from the University of Missouri Health Sciences Institutional Review Board IRB # 1139999.
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Delate T., Chester E.A., Stubbings T.W. & Barnes C.A. (2008) Clinical outcomes of a home-based medication reconciliation program after discharge from a skilled nursing facility. Pharmacotherapy 28, 444–452. DeSantis L. & Ugarriza D.N. (2000) The concept of theme as used in qualitative nursing research. Western Journal of Nursing Research 22 (3), 351–372. Feldman L.S., Costa L.L., Feroli E.R., Nelson T., Poe S.S., Frick K.D., et al. (2012) Nurse–pharmacist collaboration on medication reconciliation prevents potential harm. Journal of Hospital Medicine 7, 396–401. Gabe M.E., Davies G.A., Murphy F., Davies M., Johnstone L. & Jordan S. (2011) Adverse drug reactions: treatment burdens and nurse-led medication monitoring. Journal of Nursing Management 19, 377–392. Gurwitz J.H., Field T.S., Judge J., Rochon P., Harrold L.R., Cadoret C., et al. (2005) The incidence of adverse drug events in two large academic long-term care facilities. American Journal of Medicine 118, 251–258. Hajjar E.R., Hanlon J.T., Artz M.B., Lindblad C.I., Pieper C.F., Sloane R.J., et al. (2003) Adverse drug reaction risk factors in older outpatients. American Journal of Geriatric Pharmacotherapy 1, 82–89. Handler S.M., Wright R.M., Ruby C.M. & Hanlon J.T. (2006) Epidemiology of medication related adverse events in nursing homes. American Journal of Geriatric Pharmacotherapy 4, 264–272. Horn S., Buerhaus P., Berstrom N. & Smout R.J. (2005) RN staffing time and outcomes of long-stay nursing home residents. American Journal of Nursing 105, 58–70. Institute of Medicine. (2007) Preventing Medication Errors. Available at: National Academies Press website: http://books. nap.edu/openbook.php?record_id=11623, accessed 10 January 2013. Joint Commission. (2013) National Patient Safety Goals Effective January 1, 2013. Available at: http://www.jointcommission.org/assets/1/18/NPSG_Chapter_Jan2013_LTC.pdf, accessed 30 January 2013. Longo D.R., Young J., Mehr D., Lindbloom E. & Salerno L.D. (2004) Barriers to timely care of acute infections in nursing homes: a preliminary qualitative study. Journal of the American Medical Directors Association 5, S5–S10. Mueller C., Anderson R.A., McConnell E.S. & Corazzini K. (2012) Licensed nurses responsibilities in nursing homes: a scope of practice issue? Journal of Nursing Regulation 3, 1–8. National Council State Boards of Nursing. (2011) NCSBN Model Nursing Practice Act and Model Nursing Administrative Rule. Available at: https://www.ncsbn.org/ Model_Nursing_Practice_Act_March2011.pdf, accessed 1 May 2013. Nebeker J.R., Barach P. & Samore M.H. (2004) Clarifying adverse drug events: a clinician’s guide to terminology, documentation, and reporting. Annals of Internal Medicine 140, 795–801. Polit D.F. & Beck C.T. (2004) Nursing Research: Principles and Methods, 7th edn. Lippincott Williams & Wilkins, Philadelphia, PA. Powers E., Stech F. & Burns K. (2010) A behavioral model of team sensemaking. International C2 Journal 4(1).Available at:
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http://www.dodccrp.org/files/IC2J_v4n1_04_Powers.pdf, accessed 25 October 2012. Saldana J. (2009) The Coding Manual for Qualitative Analysis. Sage, Thousand Oaks, CA. Seblega B.K., Zhang N.J., Unruh L.Y., Breen G.M., Paek S.C. & Wan T.H. (2010) Changes in nursing home staff staffing levels, 1997–2007. Medical Care Research Review 67, 232– 246. Stewart D.W. & Shamdasani P.N. (1990) Focus Groups: Theory and Practice. Sage, Newbury Park, CA. Tija J., Bonner A., Briesacher B.A., McGee S., Terrill E. & Miller K. (2009) Medication order discrepancies upon hospital to skilled nursing facility transitions. Journal of General Internal Medicine 24, 630–635.
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Identifying medication order discrepancies during medication reconciliation: perceptions of nursing home leaders and staff AMY VOGELSMEIER
PhD, RN
Assistant Professor and John A. Hartford Claire M. Fagin Fellow, Sinclair School of Nursing, University of Missouri, Columbia, MO, USA
Correspondence Amy Vogelsmeier S314 Sinclair School of Nursing University of Missouri Columbia MO 65211 USA E-mail: vogelsmeiera@missouri. edu
(2014) Journal of Nursing Management 22, 362–372. Identifying medication order discrepancies during medication reconciliation: perceptions of nursing home leaders and staff
VOGELSMEIER A.
Aim The purpose of this qualitative study was to explore nursing home leader and staff nurse perceptions about the process of medication reconciliation, with a specific focus on identifying medication order discrepancies. Background Medication order discrepancies and harmful discrepancy-related adverse drug events can occur when residents make the transition to nursing homes, yet little is known about how discrepancies are identified in this setting. Method Interviews of 18 leaders and focus groups of 13 registered nurses and 28 licensed practical nurses from eight mid-western United States nursing homes were conducted. Result Three themes emerged from the data: (1) nurses believe nursing home physicians rely on them to know, (2) active vs. passive information-seeking, and (3) nurses making sense of medication orders to identify discrepancies. Conclusion This study provides evidence about the role of nursing home nurses in medication reconciliation and how nurses engage in cognitive processes, such as ‘sensemaking’, when identifying discrepancies. Implications for nursing management Nursing leaders and managers must acknowledge that medication reconciliation is a complex cognitive process that requires the right nurse be assigned to the role, taking into account education and experience. Additionally, systems to support collaboration between physicians, nurses and pharmacists should be in place to ensure that potentially harmful discrepancies are identified and resolved. Keywords: medication order discrepancies, medication reconciliation, medication safety, nursing homes Accepted for publication: 3 July 2013
Background Medication safety in nursing homes Adverse drug events (ADEs), defined as harm resulting from the use of a drug, are a leading cause of morbidity and mortality among the elderly and are among the most serious medication use concerns in nursing 362
homes (Hajjar et al. 2003, Nebeker et al. 2004, Gurwitz et al. 2005, Handler et al. 2006, Institute of Medicine 2007). Many ADEs are considered preventable when they result from medication order discrepancies (errors), such as unintentional drug omissions, drug additions and dosage changes, that occur when patients make transitions between health care settings DOI: 10.1111/jonm.12165 ª 2013 John Wiley & Sons Ltd
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(Boockvar et al. 2011, Feldman et al. 2012); 40–70% of medication order discrepancies have the potential to cause some level of harm (Cornish et al. 2005, Boockvar et al. 2009, Feldman et al. 2012). Evidence suggests that as many as 70% of nursing home residents may have at least one medication order discrepancy when transitioning from acute care (Tija et al. 2009). Medication order discrepancies occur during transitions in care in part because communication between clinical providers such as physicians, pharmacists and nurses is often inconsistent and unclear (Vogelsmeier et al. 2013). Nursing homes are further challenged because residents frequently have different medical providers between their hospital and nursing home stay, thus impacting continuity of care (Boockvar & Burack 2007). Moreover, physicians and pharmacists are typically not available in the nursing home at times of resident transition to identify medication order discrepancies that could cause harm (Vogelsmeier et al. 2007).
Medication reconciliation as a nursing home safety practice Safety practices such as medication reconciliation are designed to identify and resolve potentially harmful medication order discrepancies that can occur during patient transitions between health-care settings. The Joint Commission, an independent, not-for-profit organisation recognised in the USA as setting standards of health-care quality, defines medication reconciliation as a systematic process whereby a clinician compares medications a patient is currently taking and intended to be taking to medications ordered for the new setting, in order to resolve any discrepancies (Joint Commission 2013). Discrepancies include such things as drug omissions, drug duplications, contraindications for ordered medications, unclear information and changes to medications that require clarification. The goal of medication reconciliation is to minimise error and mitigate harm by detecting and resolving potentially harmful discrepancies when transitions between health-care settings occur. Despite national attention on medication reconciliation as a safety practice, little is known about the effectiveness of this process in nursing homes (Chhabra et al. 2012). Intervention studies in nursing homes most often include a pharmacist performing the process (Crotty et al. 2004, Boockvar et al. 2006, Delate et al. 2008). While pharmacists can be effective in detecting discrepancies and preventing discrepancy-related adverse events that result in harm, in the ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 362–372
current nursing home environment, pharmacists are rarely on site at resident transition. In reality, medication reconciliation is most often performed by nurses, including both registered nurses (RNs) and licensed practical nurses (LPNs) (Vogelsmeier et al. 2011). Because little is known about how medication reconciliation is currently practised in nursing homes, the purpose of this article is to explore the perceptions of nursing home leaders and direct care nurses about their current role in the process.
Method Setting, sample and procedures This was a qualitative study conducted to explore perceptions of nursing home leaders and direct-care nursing staff about the process of medication reconciliation, with a specific focus on how medication order discrepancies are identified at resident transitions to the nursing home. Data collection was conducted between 2010 and 2011 and included interviews and focus groups held on site in eight mid-western US nursing homes that self-reported implementing medication reconciliation processes. The nursing homes were a mix of urban (n = 4) and rural (n = 4), ranging in size from 60 to 180 resident beds. Further details about the setting have not been included, due to the sensitive nature of participants sharing examples of medication order discrepancies and potential resident harm. The sample consisted of nursing home leaders and nursing home RN and LPN staff who reported performing medication reconciliation at resident admission. RNs and LPNs often have similar responsibilities in nursing homes, therefore both groups were included in the sample (Vogelsmeier et al. 2011, Mueller et al. 2012, Corazzini et al. 2013). To clarify, in the USA RNs and LPNs differ in their education and scope of practice (NCSBN 2011); RNs attend 2–4 years of an accredited nursing programme and are eligible to provide comprehensive nursing care, including assessing, planning, implementing and evaluating patient care. In comparison, LPNs typically attend a 12 month programme and have a limited, more technical scope of practice. Individual interviews were conducted with 18 nursing home leaders and focus groups were conducted with 13 RN and 28 LPN staff. The nursing home leaders included six licensed administrators, eight directors of nursing and four assistant directors of nursing and/or nurse managers. Of the six nursing home administrators, three were RNs and three had no clinical background. The remaining leaders were 363
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Table 1 Nursing home participant demographics Demographic
Leaders (n = 18)
Credential RN 15 LPN 0 Non-clinical 3 Education level No formal education 1 Technical 0 Associate degree 6 Diploma 3 Bachelor degree 6 Master degree 2 Experience at current nursing home >1 year 4 1–5 years 5 6–9 years 3 >10 years 6
Table 2 Nursing home leader interview guide Staff nurses (n = 41)
13 28 0 0 28 10 0 2 1 12 18 8 3
all RNs. Nearly one-half of all nursing home leaders had a bachelor’s degree or higher (44%). One-half of nursing home leaders had 6 or more years of experience in their current nursing home (50%). Among the direct-care staff, the majority of RNs had an associate’s degree (66%) and all LPNs had completed a practical nursing programme required for licensure (100%). Regarding experience, the majority of all staff nurses had less than 5 years of experience in their nursing home (75%) (Table 1). Interviews and focus groups were selected because these forums provide important insight from the participant’s perceptive about a relatively unknown area of study (Stewart & Shamdasani 1990). Nursing home leaders were intentionally interviewed separately, so as not to influence discussion generated by front-line staff. According to Stewart and Shamdasani (1990), focus group participation can be influenced by dynamics such as perceived power within the group. All interviews and focus groups were conducted by the principal investigator. Separate semi-structured interview guides were used for the leader interviews and for the staff nurse focus groups. The leader groups varied in size between two or three participants/site and focus groups varied in size from five to 10 participants/site. Each interview/focus group lasted 60–90 minute. All interviews and focus groups were audio-recorded and transcribed verbatim for analysis (Tables 2 and 3). This study was approved by the University of Missouri Health Sciences Institutional Review Board (MU HSIRB). In accordance with the MU HSIRB requirements, a waiver of documentation of consent was obtained. A waiver of documentation of consent is appropriate when the research presents no more than 364
Why was medication reconciliation implemented at this nursing home? Please describe how the process of medication reconciliation is performed here What is the role of nurses in this process? What concerns (if any) do you have about how medication reconciliation is currently performed here? What are the challenges to successfully identifying medication order discrepancies at this nursing home? Is there anything else about medication reconciliation that we have not discussed that you would like to discuss?
Table 3 Focus group interview guide Describe how medication reconciliation is currently performed at this nursing home Why do you think medication reconciliation is being done here? What is your responsibility in this process? What types of challenges or barriers do you encounter when trying to identify medication order discrepancies? Describe what you do when you encounter these challenges Can you share examples of when medication reconciliation did not occur? What do you think can happen when medication order discrepancies are not identified? Is there anything else that you would like to discuss about medication reconciliation?
minimal risk of harm to subjects and involves no procedures for which written consent is normally required outside of the research context. Prior to any data collection activities, the investigator provided participants with a written statement regarding the study goals and procedures to ensure that they were adequately informed about study activities.
Data analysis Based on recommendations by Saldana (2009), a thematic analysis approach called ‘theming the data’ was used. According to DeSantis and Ugarriza (2000), ‘a theme is an abstract entity that brings meaning and identify to a recurrent experience and its variant manifestations. As such a theme captures and unifies the nature or basis of the experience into a meaningful whole’ (p. 362). The process of analysis consisted of a series of iterative reviews of the transcribed text by two researchers, including the principal investigator and an expert nursing home and medication safety nurse researcher. Texts from the transcripts were reviewed in depth for concepts or phrases that leaders and nurses described about performing medication reconciliation and/or identifying medication order discrepancies. Each selected text was labelled, according to nursing home site (e.g. NH1, NH2, NH3), as either a leader quote or a staff nurse quote. Salient concepts ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 362–372
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or phrases from the text were highlighted, coded and grouped into a Word table, based on similarities. All groups of coded texts were reviewed a second time by the research team and collapsed into 11 categories. Text within the 11 categories was reviewed a third time by the two researchers and merged into three primary themes. Three analytical strategies were used to ensure that the findings were credible, dependable and confirmable (Crabtree & Miller 1992). Strategies included: (1) member checking during the interviews and focus groups to ensure a valid reflection of participant perceptions, (2) maintenance of a detailed audit trail to ensure data dependability and stability, and (3) participation of two expert nursing home and medication safety researchers to ensure that the findings were consistent and objective. These strategies reflect efforts to ensure the rigour and trustworthiness of the analysis approach.
Results Three primary themes emerged representing leader and staff nurse perceptions about nurses’ role in medication reconciliation and how they identify medication order discrepancies during the process. These themes included: (1) nurses think that nursing home physicians rely on them to know, (2) active vs. passive information seeking, and (3) making sense of medication order discrepancies. Salient quotes are included below to represent participant perceptions across the eight nursing homes, according to the three primary themes.
Nurses think that nursing home physicians rely on them to know When initially talking about medication reconciliation, the majority of leaders and staff spoke about the nurse’s responsibility in the process. Many believe that nursing home physicians rely on nurses to know what medications the resident is supposed to be taking and why. Participants spoke about the reality that many physicians care for residents solely in the nursing home and are therefore unfamiliar with their medical care prior to transfer. Moreover, nursing home physicians and other medical providers rarely communicate with each other, therefore they rely on nurses to be the liaison between them: ‘The [nursing home] physician expects the nurses to be the hub of the communication and get that information gathered from all the physicians and try to, you know, piece it together’. (Leader) ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 362–372
‘The [nursing home] physician is asking us, “What’s this medicine? Why are they on this?”, and we don’t know. We have no history yet’. (Staff nurse) ‘And then our [nursing home] doctors know less than we know. So it’s up to me to get all the information together and get with the doctor and say, “Here’s, you know, this is why they’re on that [medication]”’. (Staff nurse) Leaders and staff spoke about nursing home physicians not being on site at the time of transfer, which they believe increases the nurses’ responsibility to know the resident. Because of the physician’s absence, both leaders and staff shared how nursing home physicians often seek their opinions and follow their recommendations when making decisions about residents’ medication orders: ‘The physicians don’t come around every day so they’re pretty dependent on us to, you know, do their assessments and [review] lab values, too. So, I mean, a lot of times they’ll ask, or they’ve asked us before, “Do you think that they need to be on the Lasix [furosemide]?”’ (Staff nurse) ‘The majority of the time [physician] takes what we say verbatim. If we have a recommendation, they’re gonna go, “Okay”. They may discuss previous labs with us, you know, go over their med [sic] list with us, instead of making the visit from there to here’. (Staff nurse) ‘But it’s the nurse relaying to the physician, “Let’s keep this medication that has been recommended by an outside physician, at least to attempt to trial it”. Well, and the doctors go with the nurse’s recommendation. I feel like we can lead the doctors’. (Leader) ‘Some of our docs [sic] are overly cautious, don’t really listen to our nurses and what their opinions are, but Dr [name omitted] and others are wonderful. They’ll pretty much do whatever we ask … but there’s probably a fine line between being wonderful and being so lax that you’ll let anything go through’. (Leader)
Active vs. passive information seeking During discussions about physicians’ reliance on nurses to know, participants described differing approaches to knowing the residents and their medi-
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cation history. Some shared stories of searching through transfer documents and talking with residents, families and providers, while others spoke about making assumptions and relying on others to share information with them. This dichotomy in approach is described as ‘active vs. passive information seeking’. Active information seeking Some participants described a detailed and often tedious process of reviewing transfer records, with the goal of assimilating clinical information about the resident. They shared examples of sorting through volumes of paper and reading document after document to understand the resident’s history and to know what medications were ordered and why. When leaders and staff spoke about reviewing and assimilating transfer documents, they often shared frustrations about inconsistent, unclear or unavailable information, and medication orders written that simply did not ‘make sense’. ‘But the [medication] orders won’t make sense the way they’re written, here’s what they’re saying they were given and here’s the transfer orders. And these are different’. (Leader) ‘It’s like they [hospital staff] printed some list out of the computer … it’s probably on their checklist of forms to print out, but there’s not a real, true reconciliation because the orders don’t make sense to us’. (Leader) ‘The H&Ps [physician-documented history and physical of the resident] are not always accurate; sometimes it will say under home meds, see med [sic] list, and that list is buried in another note, so we have to look there … and sometimes it’s not there, so we have no way to know what they were on at home and then we have to ask the family’. (Staff nurse) ‘Sometimes it’ll be in progress notes or order notes and I’ll see where maybe that order was [discontinued] and it didn’t show up on the hospital [record] but it showed up on the transfer sheet’. (Staff nurse) Because written transfer information is often inconsistent, unclear or unavailable, some nurses spoke about strategies in which they engage to fill in the gaps. In particular, they spoke about communicating with families, hospital staff and clinic staff to piece information together. Many staff cited barriers, such as families 366
who have ‘little to no knowledge of the resident’s medications’, hospital staff who cite ‘HIPAA’ (Health Information Portability and Accountability Act, a federal US law enacted to protect private health information) violations if information is shared, and office staff who consistently put a ‘wall around’ the physician. The most frustrating stories related to communicating directly with transferring physicians. ‘You’ll find a discrepancy but then when you try to question the discrepancy you get resistance, you’re kind of caught in the middle of it. And all I’m trying to do is – what am I to give them’. (Staff nurse) ‘You call the doctor, and then that’s when you and the doctor have a disagreement. He’s saying, “No, this [medication]”. And I go, “But, sir, I have this [transfer] paper here”, and they are different. You don’t want to argue, but then in the same sense you’ve got the patient you’ve gotta concern yourself with more’. (Staff nurse) ‘I had an on-call doctor that had no clue of who the patient was, and I had questions and they were like, “Just give them whatever’s on the [transfer] list and then call their doctor Monday”. Well, if it’s Friday night, we could go 3 days, almost into 4, and that can’t happen, we can’t let that happen’. (Staff nurse) Passive information seeking Discussions about assimilating clinical information during medication reconciliation led others to share how they were encumbered by vast amounts of transfer documents to review, among competing demands of the overall admission process. Both leaders and staff acknowledged that too much information and not enough time leaves staff feeling overwhelmed and overworked. As a result, deciphering clinical information to look for medication order discrepancies is not a priority: ‘Nurses are so pressed to get so many things done, and it is a huge time commitment to do a good job at medication reconciliation’. (Leader) ‘I just don’t have time to sit and decipher; if it’s not on the H&P, then am I supposed to do a review, or like flip through and look for labs? It is very time consuming’. (Staff nurse) ‘This lady got 40 pills, and I kid you not, and you’ve got a list here and you’ve got 50 directions ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 362–372
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you’re going in, by the time you sit down again or look at it, you’re going, “Ah, whatever”’.
with absolutely nothing. She just didn’t voice it, and I guess we didn’t ask?’ (Staff nurse)
(Staff nurse)
‘Then the daughter comes in later, and her mom is worse, and says, “Well, wait a minute. Where’s the Lasix [furosemide], she was on it at home?” Well, what Lasix [furosemide]? They weren’t on it in the hospital’. (Staff nurse)
‘[Residents] have all this information and sometimes you just skip right over that part because you’re worried about getting the orders in, getting them faxed to the pharmacy, making sure they’re comfortable, you know, all at 5.00 p.m’. (Staff nurse) During discussions about information overload and time challenges, some leaders and staff spoke confidently about their belief that medication orders at transfer are typically correct, therefore questioning the presence of discrepancies is not necessary: ‘We don’t really question if orders are intentional or not, we just assume the orders are the way the hospital physician wanted it’. (Leader) ‘I usually just assume that the hospital orders [at transfer] were what they intended to be continued and would continue those medications. Gosh, if not, we’d have a lot to do’. (Staff nurse) ‘I don’t know that we ever questioned if [any order] was accurate or not. We don’t really question if there was a discrepancy or not. I mean, that would be too much to think about’. (Staff nurse) When discussions turned to residents and families as a source of information, leaders and staff who assume orders are accurate later shared how they actually rely on families to initiate questions or raise concerns about the resident’s medication regimen. However, these same leaders and staff shared stories about families and residents raising questions after an adverse event had occurred; adverse events they describe as happening all too often: ‘After the fact, I’ll see that they were never on this [medication] before and frequently that’s a psych med [sic] that they were put on. And we’re continuing that and they’re drowsier and drowsier and the family said, “What the heck, they weren’t on this before”. I’ve seen this happen way often’. (Leader) ‘Now, when she came from home she was, remember, after a few days just coughing, but then I went and talked to her, “Well, I was on breathing treatments at home”, and she came ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 362–372
Nurses making sense of medication order discrepancies Discussions about assimilating clinical information evolved into discussions about how nurses ‘make sense’ of the information they encounter. Many nurses spoke about ‘red flags’, such as specific medications, nursing home rules/regulations and experience with harmful past events, that create cues when considering potential discrepancies. One staff member also spoke about physician expectations as her cue to question the presence of discrepancies. ‘If they were on Lasix or something like that, Neurontin or whatever for a seizure or whatever, I definitely don’t want that to be missed. I don’t want the Tylenol [acetaminophen] either, per se, but I focus more so on the major medications before I focus on the others’. (Staff nurse) ‘[There’s a] red flag with all psych meds [sic] … we have to have an appropriate diagnosis for our psychotropics because of regs [sic]’. (Staff nurse) ‘My issue is a certain resident who was on a blood thinner. She was supposed to continue this for another week and that did not get passed over. She died from a blood clot [nurse crying]’. (Staff nurse) ‘I look for stop dates. I remember seeing an antibiotic that was given for months because there was no stop date, and we realised it when the resident got C. diff. [Clostridium difficile]’. (Staff nurse) ‘For me, it depends on the doctor. We have some doctors who say, “Whatever the hospital orders say”, so we never question [medication orders]. And then there are others who will say, “No, I had them on this and this is what I want them on”. So then we always know to question those orders’. (Staff nurse) 367
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Whereas some nurses make sense of discrepancies based on specific cues or ‘red flags’, a few described other types of cues, such as considering medication order discrepancies within the context of medication safety and the resident’s overall mediation therapy plan. Examples, such as linking current and past medications to the resident’s medical condition, assuring laboratory monitoring is in place and collaborating with physicians about medication appropriateness, were viewed by some nurses as important opportunities to prevent resident harm: ‘When they’d stopped the Lasix [furosemide], and the dehydration resolved, I would want to look at it to see, you know, with the CHF will they eventually need to have the Lasix [furosemide] back? I’d ask [the physician] about that’. (Staff nurse) ‘I would want to know, why did they put them on Ativan [lorazepam]? Are they agitated or something, you know. Is that resolved, the agitation? I try to look out for these guys, so I would ask [the physician], you know, does she even need that now?’ (Staff nurse) ‘If they’re on a lot of medications that indicate they’ve got congestive heart failure or diabetes, for example, then are there labs or other clinical parameters that need to be looked at because of their recent change in condition, to get baselines, that sort of thing? It’s something you’ve just gotta kind of ask’. (Staff nurse) ‘You review them; dosages, are they out of the norm; medications, are they appropriate to the diagnoses, you know. As an RN I should know something that requires lab levels, monitoring, that we have recent results in that and the appropriate orders to go with it’. (Staff nurse) Despite the process nurses describe to make sense of medication orders, only two leaders explicitly acknowledged medication reconciliation as a cognitive process. Within discussions about cognitive complexity, these same leaders cited concerns about some staffs’ inability to think critically and raise questions to identify discrepancies with the goal to prevent harm, concerns that are validated by these staff nurse quotes: ‘We don’t [usually] get diagnoses listed on the medication order, so we have to guess why they are on a certain medication and we just have to go 368
by what we think they are on it for; if its Neurontin [gabapentin], we just assume it if for “X” reason. We have to use our best judgement’. (Staff nurse) ‘When [residents] come in and there’s a discrepancy between the old med [sic] list and the new list, then we have to decide what to put on hold … I’ll think, well, let’s try it for 2 weeks, you know, placing this med [sic] on hold to see how they do, then I’ll let the doctor know’. (Staff nurse) These same leaders further acknowledged that limited education and experience likely result in variation in their staffs’ ability to identify and subsequently resolve discrepancies; higher-level cognitive skills they perceive necessary to assure resident safety: ‘I think the population of nurses that we have here are very task-oriented, don’t have the critical thinking capabilities to really raise questions and identify discrepancies, you know, that someone else who’s an RN or who has even been a nurse for a long time usually has’. (Leader) ‘It’s scary sometimes. There are so many opportunities for the processes to fail. The nurses’ individual judgement, they think, “Oh, this wasn’t a big deal so we’re not gonna follow up on this and then boom”, a poor outcome. I see this with many of my LPNs and even some of my RNs’. (Leader) When discussing staff limitations, these same leaders shared examples of systems or safeguards they employ to help staff identify discrepancies that might otherwise go undetected. Examples such as RN oversight, pharmacist support and technology systems are perceived by some leaders to be effective in ensuring that discrepancies are identified: ‘I would say 95% of the time an LPN is doing that admission. That’s why [RN name omitted] takes that chart when she’s here, combs through all those things and says, “Hey, let’s check on this, let’s follow up on this”’. (Leader) ‘We have [staff] working with the pharmacist and for example, and he’s usually going through and going, “Okay, do they really need three different orders for Tylenol [acetaminophen]?”’ (Leader) ‘[Technology] does have some safeguards because you can actually print off a transfer list that gives [staff] so much information at the ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 362–372
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hospital side. It will list all of their medications, any treatments that they’ve been receiving, their history. Of course, that is if they use it’. (Leader)
Discussion This study provides a foundational understanding about leader and staff perceptions of nurses’ role in medication reconciliation in nursing homes. Specifically, this study expands our knowledge of how nursing home nurses identify medication order discrepancies during medication reconciliation. These findings also contribute to our knowledge about the cognitive process of ‘sensemaking’, in which nursing home nurses engage to detect discrepancies during the process.
Nurses’ role in medication reconciliation In this study, nurses describe their role in medication reconciliation when residents make the transition to the nursing home. Some nurses perform medication reconciliation by reviewing and assimilating clinical information and collaborating with residents, families and providers about information that is inconsistent or unclear. In contrast, other nurses are seemingly passive by working in isolation, making assumptions and relying on others to raise questions and concerns. At the surface, the passive approach relates to time constraints and information overload. However, as some leaders surmise, the underlying reason may be individual nurses’ limited ability to interpret clinical information and to know when further inquiry is necessary. As leaders in this study acknowledge, nurses of different education and experience are responsible for performing medication reconciliation, yet some, perhaps more often LPNs, may not have the education and experience to do the process effectively. This finding is supported by Boblin et al. (2008), who found differences in nurses’ clinical decision-making based on their education and credentials. Despite differences in RN and LPN education and scopes of practice (National Council State Boards of Nursing 2011), the current nursing home paradigm is to interchange RN and LPN staff roles, where both RNs and LPNs are assessing, planning, implementing and evaluating resident care (Mueller et al. 2012, Corazzini et al. 2013). Perhaps these differences in education and credentials underlie the variability described by nurse leaders. This study also supports existing evidence that physicians rely on nurses to provide information necessary to prescribe medications and to monitor relevant sysª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2014, 22, 362–372
tems to prevent ADEs (Longo et al. 2004, Vogelsmeier et al. 2007). Gabe et al. (2011) suggest that nurses play an important role in medication monitoring, perhaps in part because of their front-line proximity to patients, families and providers. Nurses’ front-line proximity is particularly important at times of resident transition, when information about medication orders may be inconsistent or unclear.
Nurses’ ‘sensemaking’ to identify discrepancies Findings from this study suggest that nurses engage in a cognitive process called ‘sensemaking’ to identify discrepancies. Sensemaking, which literally means to make sense, is a cognitive process in which individuals interpret and assign meaning to unexpected events, which in turn directs their actions. In sensemaking, people construct mental models of unexpected events based in part on past events, social relationships and organisational structures/rules and can be influenced by education and experience (Weick 1995). In this study, nurses described significant past events, physician expectations, nursing home regulations as well as their clinical knowledge and experience as influencing the discrepancies they identified. Moreover, this study highlights how nurses vary in their sensemaking. For example, some nurses describe potential discrepancies within the context of specific medications, nursing home regulations or significant past events, while others considered discrepancies within the broader context of medication safety and the resident’s overall medication therapy plan. The variability in nurses’ sensemaking is concerning, because potentially harmful discrepancies may go undetected and unresolved. Sensemaking can influence resident safety by either promoting or hindering safety actions. Effective sensemaking can result when individuals challenge assumptions, raise questions and work with others. In contrast, ineffective sensemaking can result when individuals make assumptions, adhere to strict rules and work in isolation (Powers et al. 2010). Whereas this study provides an initial understanding of nursing home nurses’ sensemaking, understanding differences between nurses is important and warrants further study.
Limitations In qualitative research, transferability refers to the extent that findings can be transferred to other settings (Polit & Beck 2004). There are limitations with this study worthy of acknowledgment that may affect the 369
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transferability of findings. First, the nursing homes for this study were selected because leaders self-reported performing medication reconciliation at resident transitions. Because little is known about the widespread implementation of medication reconciliation within this setting, it is possible that processes within these nursing homes are unique. Second, because data collection was completed nearly 2 years ago, it is possible that medication reconciliation as a safety practice in nursing homes has changed. However, due to the sensitive nature of the data, analysis was extensive and therefore publication has been delayed. Third, the relatively low number of participants from each setting may not reflect the perception of other nurses within those same settings. Finally, focus groups included both RN and LPN staff. Because the two credentials of staff were combined, it is difficult to ascertain whether differences between the two groups exist. Future investigators should explore the distinct differences between RNs and LPNs, particularly when considering the cognitive process of sensemaking.
performing medication reconciliation. Working in isolation leaves opportunities for nurses to make unsafe assumptions that may translate to unsafe actions. Unsafe assumptions are particularly concerning, given the blind reliance on nurses that physicians may have when communicating about residents’ medication therapy needs. Leaders and managers must acknowledge that medication reconciliation requires a shared approach across roles involving physicians, nurses and pharmacists (Boockvar et al. 2011, Feldman et al. 2012, Vogelsmeier et al. 2013). To ensure a shared approach, leaders and managers must facilitate nurse– physician collaboration by resolving current communication barriers and clarifying the expectations of each role (Vogelsmeier et al. 2013). Moreover, formalising systems that support RN oversight, pharmacist and physician collaboration and access to electronic health records between settings can provide important safeguards to ensure that medication order discrepancies are appropriately identified and resolved. Addressing these challenges can go a long way to improving medication safety for nursing home residents.
Implications for nursing management There are important nursing management implications identified from this study. First, leaders and managers must acknowledge that medication reconciliation is a complex cognitive process. Because of the complexity of medication reconciliation, the challenge for nursing home leaders is to ensure that nurses assigned to the process have the necessary cognitive skills to do so. Evidence supports the influence of RNs to improved nursing home outcomes (Horn et al. 2005, Corazzini et al. 2011), yet there are fewer RNs in nursing homes today than a decade ago (Seblega et al. 2010). Because RNs are a limited resource in many nursing homes, rather than interchanging RN and LPN roles, leaders and managers must assign the right nurse to the right role to maximise their contribution to resident safety. Second, medication reconciliation is gaining recognition as an integral component in the broader context of medication management (American Society of Health-System Pharmacist 2012). As such, nurses’ sensemaking within the context of the resident’s overall medication therapy plan is important to identify discrepancies that could be in conflict with that plan. The focus on medication management, however, requires an active collaboration, including input from the physician to assure medication appropriateness. Finally, this study provides important insight into the often isolated approach nursing home nurses take when
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Conclusion Medication order discrepancies and related ADEs are a serious concern for nursing home safety. Although medication reconciliation is a safety practice designed to identify and resolve potentially harmful discrepancies, little is known about the process in nursing homes. Findings from this study expand our knowledge by providing insight into the process of medication reconciliation and how medication order discrepancies are identified when residents make the transition to the nursing home. Specifically, this study provides evidence about the integral role nursing home nurses play in the process and how nurses engage in important cognitive processes, such as sensemaking, when detecting discrepancies.
Acknowledgements The author would like to acknowledge Jill Scott-Cawiezell PhD, RN, FAAN, University of Iowa College of Nursing, for her assistance with the data analysis portion of this study.
Source of funding This project was funded by the John A. Hartford Foundation and the University of Iowa Gerontological Nursing Intervention Research Center.
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Ethical approval Ethical approval was obtained from the University of Missouri Health Sciences Institutional Review Board IRB # 1139999.
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