|Year : 2022 | Volume
| Issue : 1 | Page : 55-61
Medication reconciliation – Responsibilities and barriers facing physicians, pharmacists, and nurses in Saudi Arabia
Najah Saud Alanazi, Wafa A Alatawi, Kousalya Prabahar
Department of Pharmacy Practice, Faculty of Pharmacy, University of Tabuk, Tabuk, Saudi Arabia
|Date of Submission||03-Jun-2021|
|Date of Acceptance||06-Dec-2021|
|Date of Web Publication||2-May-2022|
Najah Saud Alanazi
Faculty of Pharmacy, University of Tabuk, Tabuk 47914
Source of Support: None, Conflict of Interest: None
Background: Patient safety can be adversely affected by medication errors. The medication reconciliation process plays a critical role in the prevention of medication discrepancies and adverse drug events. Aims: This study aimed to investigate the perceptions of Saudi Arabian physicians, pharmacists, and nurses regarding their functions in the medication reconciliation process and to elucidate the barriers to implementing this process. Materials and Methods: A cross-sectional survey was performed for 4 months targeting pharmacists, physicians, and nurses who work at various hospitals in Saudi Arabia. An online survey was used to collect all data. Data gathered were statistically analyzed using SPSS24. Results: In all, 447 participants completed the survey. Physicians considered their profession to be the primary health-care providers responsible for every step of the medication reconciliation process. Pharmacists believed that their profession was the main one among health-care providers responsible for all steps in the process, apart from interviewing patients during admission and taking a correct medication history. They assigned those tasks to physicians by a margin of 53.3%. Nurses viewed themselves as responsible for more roles than physicians, except for two steps, in which they considered pharmacists to be the responsible person: reconciling medications while transferring a patient to the next level of care (54.1%) and sending the patient's discharge medication list to his or her next provider (56.5%). Conclusions: Participants revealed the insufficiency of a clear understanding of the functions of health-care providers in every step of the medication reconciliation process.
Keywords: Medication reconciliation, nurses, pharmacists, physicians, Saudi Arabia
|How to cite this article:|
Alanazi NS, Alatawi WA, Prabahar K. Medication reconciliation – Responsibilities and barriers facing physicians, pharmacists, and nurses in Saudi Arabia. Saudi J Health Sci 2022;11:55-61
|How to cite this URL:|
Alanazi NS, Alatawi WA, Prabahar K. Medication reconciliation – Responsibilities and barriers facing physicians, pharmacists, and nurses in Saudi Arabia. Saudi J Health Sci [serial online] 2022 [cited 2022 Jun 28];11:55-61. Available from: https://www.saudijhealthsci.org/text.asp?2022/11/1/55/344493
| Introduction|| |
A “medication error” is any preventable event that results from the improper use of, or patient injury by, a medication. These events may be associated with medical products and occur during the process of prescribing, dispensing, administering, and monitoring patients. Adverse drug events (ADE) are patient harms following an intervention, including dispensing of a medication, irrespective of the medication dose. ADEs have been associated with significant morbidity, mortality, increased length of hospital stay, and greater financial costs.,, A review study was conducted to identify drug-related problems in Saudi Arabian hospitals; 46 studies reported that ADEs or reactions were the main reason for the hospitalization of every six patients per 100. Surprisingly, roughly half of all ADEs are believed to be avoidable. Moreover, a prospective cohort study performed to assess the occurrence of ADEs in private and public Saudi hospitals found that 16% of the accepted cases were ADEs, and more than half of these ADEs were significant (52.7%). Medication discrepancies are considered a type of medication error. These can occur at the time of admission, during a patient's transition between hospital wards, or upon discharge; examples include the omission of one of the patient's prescribed medications without a specific reason, the adding of an unnecessary medication with no significant indication, or neglecting to take a proper medication history. One Saudi study examined the types of medication discrepancies that had been identified during medication reconciliation upon patients' admission and found that 48.3% of patients had a minimum of one or more medication discrepancies. Another study conducted in an outpatient geriatric department found more than one discrepancy (an addition, difference in dose, or deletion) between the medication lists of patients, general practitioners, or the pharmacy (86.7%). Another study found more than one discrepancy between medication lists and letters at discharge in nearly half of the participants' cases (47.6%; 95% confidence interval [CI]: 40.5–54.7).
According to the World Health Organization (WHO), ADEs and medication discrepancies can be avoided through the implementation of a medication reconciliation process. The WHO defines medication reconciliation as the action by health-care professionals of generating a precise listing of medications by reconciling medications upon admission, a transition of care, and discharge. This is a multidisciplinary service that involves more than one health-care professional knowing the responsibilities of each participant in this process. According to the Saudi Central Board for Accreditation of Healthcare Institutions, each hospital develops its own local policy and procedures that govern the practice of medication reconciliation. In a majority of these guidelines, checking the patient's current medications and filling out a medication reconciliation form is the responsibility of physicians. Informing the attending physician about the patient's medications that were brought from home or any being transferred from another ward is the responsibility of a charge nurse. Labeling the medications brought from home with full instructions and an expiration date, if the physician chooses to include these medications in the treatment plan, is the responsibility of a pharmacist. According to the American Society of Health-System Pharmacists, pharmacists should play a crucial role in the following important components of medication reconciliation: Establishing policies and procedures, following and improving medication reconciliation process, improving the proficiency of persons involved in medication reconciliation, and aiding their expertise in the development of information systems. The medication reconciliation process takes time and effort in a very busy environment; moreover, it can be implemented by a multidisciplinary team. The role of each health-care provider (physician, pharmacist, or nurse) when applying medication reconciliation is not fully clear due to shortfalls of perceptions of the significance of the process and each person's responsibility for applying the practice.
A study done in Kuwait assessed the knowledge, perceptions, and practices of all health-care providers concerning medication reconciliation. It found that physicians were the health-care providers most entangled in the process. By contrast, a study done in San Francisco reported a lack of understanding concerning who is responsible for the full process of medication reconciliation, which should begin with a patient's admission and continue through to their discharge. To the best of our knowledge, no studies conducted in Saudi Arabia have yet examined the perceptions of physicians, pharmacists, and nurses concerning their responsibilities and functions in medication reconciliation and the barriers to implementing this process. Physicians, pharmacists, and nurses are the first line and most important members of any patient care team; therefore, understanding their perceptions of the responsibilities and functions of health-care providers in the process of medication reconciliation will contribute to good practices, early detection, and the subsequent prevention of medication errors and patient harm. It would be beneficial to know how knowledgeable these professionals are on the medication reconciliation process and the barriers and factors that affect their efforts.
| Materials and Methods|| |
Pharmacists, physicians, and nurses who work at the Ministry of Health hospitals, armed forces hospitals, private hospitals, and university teaching hospitals in Saudi Arabia were included in this study. Hospital workers other than these three subject groups, such as dieticians, physiotherapists, and clinical laboratory specialists, were excluded. The sample size was calculated with a 95% CI, 50% response distribution, and ± 5% margin of error. The desired sample size was calculated using Raosoft sample size calculator software to be 380 participants. Ethical approval was obtained from the Research Ethics Committee in the University of Tabuk (UT-103-09-2020). All involved health-care professionals gave their consent to participate in this study.
Study design and data collection
A cross-sectional survey was performed in Saudi Arabia for 4 months. An online survey was published featuring a questionnaire based on questions developed in a previous study. The questionnaire consisted of three sections. The first section asked for participants' demographic data. The second section had one question about perceived responsibilities in the medication reconciliation process, one question about perceptions and principles behind the medication reconciliation process, and one question about perceptions of the value of the medication reconciliation process. Participants' overall perceptions of medication reconciliation and patient safety were graded on a scale of 1–5, where 5 was the greatest perceived value and 1 was the lowest perceived value. The third section contained one question about barriers to implementing this process. The survey used a variety of question types, including Likert scales, multiple-choice questions, and yes/no answers. Based on the inclusion and exclusion criteria, the questionnaire was distributed to the study participants through social media (e.g., WhatsApp, Twitter). Data were collected from the health-care providers who work in the northern, central, eastern, and southern regions of Saudi Arabia via simple random sampling.
Data were analyzed by the statistical package for the social sciences (SPSS) Armonk, NY: IBM Corp. database version 24. Frequencies, percentages, and Chi-square tests were performed for categorical variables. A correlation test was performed to uncover the relationship between years of practice and perceptions of the medication reconciliation process. The data were considered statistically significant if P < 0.05.
| Results|| |
By the end of the survey period, data had been collected from 155 (34.7%) physicians, 122 (27.3%) pharmacists, and 170 (38.0%) nurses. The majority of participants were Saudi nationals (341, 76.3%). The demographics of the participating health-care professionals are detailed in [Table 1].
Perceived responsibilities in medication reconciliation
Participants expressed a variety of views [Table 2] on the responsibilities of health-care providers using a standardized medication reconciliation process. As evident from [Table 2], statistically significant differences were observed in the providers' perceptions (P ≤ 0.05). A majority of physicians tended to perceive that their profession plays the greatest role in the medication reconciliation process. On providing counseling to patients on medication use prior to discharge, pharmacists were ranked next to the physician and saw a lower role from the nurse, with 60 (38.7%), 67 (43.2%), and 26 (16.8%), respectively. They believed that reconciling medication discrepancies is a responsibility shared equally by pharmacists and nurses (24, 15.5%). In directing the discharge medication list of patients to the health-care provider of patients, nurses were ranked second to physicians with 42 (27.1%) and 90 (58.1%), respectively. Regarding pharmacists' perceptions, they also reported that they play a major role in the medication reconciliation process, apart from conducting patient interviews during admission and getting a correct medication history; pharmacists perceived this as the main role of physicians (65, 53.3%).
|Table 2: Perceived responsibilities of health-care providers in medication reconciliation (n=447)|
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In directing discharge medication list of patients to the health-care provider, physicians, pharmacists, and nurses, each reported that they have the main responsibility, with 90 (58.1%), 44 (36.1%), and 96 (56.5%), respectively.
The nurses felt more responsibility for physicians in every step of the process, except for two: Reconciling medications upon handing over patients to the next level of care and directing discharge medication list to other health-care providers. In these cases, they considered their profession as the principal provider with 92 (54.1%) and 96 (56.5%), respectively. When it comes to providing counseling on medication use during the patient discharge, they considered physicians to be the principal provider, followed by themselves and then pharmacists, with 82 (48.2%), 44 (25.9%), and 42 (24.7%), respectively.
Perceptions of medication reconciliation
[Table 3] depicts health-care providers' agreement levels regarding the principles behind the medication reconciliation process. Most of the physicians, pharmacists, and nurses strongly agreed with the significance of obtaining a correct medication history during admission. They also strongly agreed that the medication reconciliation process decreases instances of patient injury, and that their profession plays a major role in the reconciliation process. They indicated that the proper execution of the medication reconciliation process is of value to them. The plurality of pharmacists (41.8%) and nurses (31.2%) agreed with the amount of time they are given to implement the medication reconciliation process, whereas physicians were neutral in their views (31.0%).
|Table 3: Perceptions and principles behind medication reconciliation process (n=447)|
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[Table 4] shows the mean and standard deviation of the perceptions and principles behind the medication reconciliation process. The significance of obtaining a correct medication history during admission was perceived higher (4.71 ± 0.583).
|Table 4: Mean and standard deviation of the perception and principles behind a medication reconciliation process (n=447)|
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The relationship between years of practice and perceptions of the medication reconciliation process was explored using a correlation test. It showed a statistically significant relationship between a pharmacist's years of practice and the time they are given to implement the medication reconciliation process (P ≤ 0.05). A negative correlation emerged, where an increase in years of practice led to a decrease in the time available for implementing medication reconciliation.
The majority of physicians, pharmacists, and nurses considered the medication reconciliation process to be a very valuable one for overall patient safety, with 67 (43.2%), 68 (55.7%), and 77 (45.3%), respectively.
Perceived barriers to medication reconciliation implementation
The barriers in implementing the medication reconciliation process in practice, as perceived by health-care providers, are presented in [Table 5]. Many participants reported that they have enough time, but they lack the human resources needed to implement the process (131, 29.3%).
|Table 5: Barriers in implementing the medication reconciliation process (n=447)|
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| Discussion|| |
These survey results provide insight into the perceptions of health-care professionals in Saudi Arabia regarding medication reconciliation. Our study results show that physicians and pharmacists regard themselves as the main service provider in many parameters, except for one or two cases. Nurses reported a major role for physicians, compared to their own role and that of pharmacists. This was in accordance with some other study results, yet contrary to the results of other studies., Physicians and nurses perceived the provision of medication counseling for patients upon discharge as the main role of physicians, whereas pharmacists saw it as their main role. This was inconsistent with another study, where all three groups of health-care professionals accepted that this is the principal responsibility of pharmacists. The pharmacists considered their profession to be the main health-care provider in all steps of the medication reconciliation process except one. This was similar to another study, in which pharmacists reported positive feelings toward their functions in the medication reconciliation process.
In our study, physicians and pharmacists see themselves as playing a major role in the patient interview during admission and in getting a correct medication history, but nurses view physicians as those with the chief responsibility for obtaining a medication history. Other studies reported that nurses play a major role in obtaining correct medication histories from patients during admission.,,,, Two other studies reported that pharmacists were the ones who took medication histories during the admission process., In Saudi Arabian hospital settings, pharmacists play a major role in providing clinical services to patients, including the recording of medication histories and providing counseling. According to the physicians' perspective, resolving the differences between the list in a patient's medication history and the medications ordered during admission are a responsibility shared equally by pharmacists and nurses. A study compared the impact of medication histories obtained by pharmacists with those taken by a nurse and their subsequent reconciliation. Pharmacists identified more discrepancies than nurses did. Health-care professionals should collaborate closely to ensure that correct medication lists are obtained for their patients. Further, they should be informed of the rationale behind medication reconciliation, and their roles and responsibilities must be clearly defined.
Local guidelines are available for conducting medicine reconciliation in Saudi hospitals. A lack of human resources was the major barrier to implementing the medication reconciliation process; this finding was in accordance with other studies' results., Another study reported that “patients lack awareness about all the medications they are receiving” and the “lack of communication between healthcare providers” were the major barriers to reconciliation. Previous studies have also demonstrated that a lack of time, lack of patient awareness of medications, and a lack of proper communication among health-care providers were challenges faced by providers in the daily practice of medication reconciliation.,,, Another study reported that the main barrier to medication reconciliation was the ineffective communication among health-care providers. Finally, one study reported barriers such as time constraints and patients who are unaware of their medications.
A majority of participants agreed with the importance and utility of the medication reconciliation process, which was consistent with previous research. A possible explanation for this might be the increasing awareness among health-care providers regarding the cost of ADEs, patient harm, and the possibility of preventing errors through the medication reconciliation process. One implication of low perceptions of the value of medication reconciliation to patient safety is the possibility of poor communication and teamwork among health-care providers. This finding was similar to that noted in another study.
The observed correlation between pharmacists' years of practice and the time they are given to implement the medication reconciliation process might be explained in this way: A greater length of practice might lead to more involvement in administrative work and responsibilities, which, in turn, may lead to a decrease in the time available to implement medication reconciliation.
This study included a wide sample of health-care professionals from all areas of Saudi Arabia, but the sample size does not reflect data suitable for generalization.
| Conclusions|| |
This study has shown that physicians, pharmacists, and nurses lack a clear perspective of their roles in every step of a standardized medication reconciliation process. A majority of participants agreed that medication reconciliation is a valuable process and acknowledged that there are barriers to implementing this process. Appropriate and effective training programs to educate and train health-care providers about their contribution to the medication reconciliation process should be implemented.
The authors wish to acknowledge Eman Hassan Alfayez, Renad Ahmed Alageel, Reeman Salman Alsalman, Mohammed Mousa Alghamdi, Emad Hassan Alfayez, Nada Hussain Alzahrani, and Razan Ali Almuraykhi for their participation in the data collection process. We also acknowledge the physicians, pharmacists, and nurses who participated in the survey.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]