Medication Reconciliation Simulation
|Case||9275||1||November 28, 2012|
This teaching case has been used with 3rd and 4th year medical students to teach topics pertaining to medication reconciliation including safe and effective medication use.
A standardized patient, 3 faculty members, and an administrative assistant were used to accomplish the goals of this case. Specifically, a standardized patient interrupts a classroom session and asks for assistance in figuring out which medications she is taking. Furthermore, the patient wishes to know if her medications are responsible for the side effects she is experiencing. The standardized patient has some prescription vials, some drug samples, an incomplete medication list, a telephone number for her pharmacy, and a telephone number for her doctors’ office.
Students are tasked with telephoning the “pharmacy” and the “doctors’ office” and interviewing the patient, in conjunction with using the resources provided by the patient (incomplete medication list, prescription vials, and drug samples), to synthesize the patient’s medication list. By completing this exercise, students will simultaneously encounter patient- and systems- related difficulties that lead to medication-related problems (e.g. lack of communication between healthcare providers, poor communication between patient and provider, etc.), and they will evaluate the signs and symptoms with which a patient presents in the context of the medications she has been taking. Moreover, students will discuss whether the medications are appropriate for the medical conditions that the patient has. Furthermore, during the debriefing session, students will discuss each medication with the patient to educate and empower her to take a more active role in her own medication management.
Karpa K. Medication Reconciliation Simulation. MedEdPORTAL; 2012. Available from: www.mededportal.org/publication/9275
Contains Information Suitable for Patient Education
- To gather a medication history for a patient using available resources and synthesize an accurate medication list for a patient.
- To identify a patient’s chief complaint in the context of medication-related adverse effects.
- To discuss patient-specific and system factors that impact accurate medication utilization.
- To provide patient education for each drug on the medication list to empower patient’s involvement in care.
- Medication Reconciliation (MeSH)
- Family Medicine
- Internal Medicine
- Critical Thinking
- Interpersonal & Communication Skills
- Medical Knowledge
- Patient Care
- Basic Sciences
- Communication Skills
- Evaluation of Clinical Performance
- Patient Safety/Medical Errors
- Professional School
- Medical Student
- Problem-based Learning
- Standardized Patient
Authors & Co-Authors
Kelly Karpa, PhD
Pennsylvania State University College of Medicine
Sponsorship or Funding Source
Woodward Endowment for Medical Sciences Education, Penn State University College of Medicine
Health Resources and Services Administration
Effectiveness and Significance
Although we teach medical students the basic mechanisms of drugs in the early years of medical school, we must do a better job instructing students about safe and effective prescribing practices (AAMC, Report X) and the complexities of pharmacotherapy in actual patients.
Medication reconciliation has been a priority with the Institute of Medicine, Institute for Healthcare Improvement, and Joint Commission on Accreditation of Healthcare Organizations, but it is not just an “institutional” problem. Medication reconciliation is not simply about copying medications from one list to another; it is not a “computer” problem. Instead, medication reconciliation offers opportunities to assess appropriateness of each medication for individual patients by taking into account patient-specific parameters (e.g. comorbidities, diagnoses, financial considerations, etc). Even in outpatient settings, medication reconciliation can decrease medication errors, improve patient outcomes, and save healthcare costs.
This case illustrates complexities associated with medication reconciliation as students must use resources available to “solve the puzzle” of the medication regimen the patient is taking. In addition, students encounter patient- and systems- factors that impact appropriate medication utilization and safety. They also begin thinking about patients’ problem lists in terms of potential medication adverse events. Students begin to critically analyze the appropriateness of each medication that a patient is taking and develop a dialog with the patient to education him/her about the reason for each medication, common adverse effects, how to avoid problems, etc.
Students have rated this simulation session highly (>4 on a 5 point scale) in most areas assessed, and the majority of students (14 of 15; 93%) have indicated that the session is worth their time (additional details of effectiveness provided in Instructors’ Guide).
Special Implementation Guidelines or Requirements
Prerequisites for implementation: Learners must have a firm knowledge of basic pharmacology prior to completing this simulation session. The following props or classroom situations are needed:
Classroom: The tables and chairs in the classroom have deliberately been set up to separate the students into small groups.
Makeup: Moulage is applied to the patient’s arms to simulate ecchymoses. Briefly, 30 minutes prior to the session, bruising is applied sporadically to both hands and the volar aspect of the forearms, including the anticubital fossa. This is accomplished by: (a) Using a wet stippled sponge which is rounded and a small amount of maroon makeup tapped onto the sponge. Indiscriminately, small areas of the dorsal side of the hands are tapped with the sponge. (b) With a wetted finger, the makeup is blended to produce the bruise effect desired. (c) This process is repeated on the inside of the forearms. (d) For a more aged presentation of bruising, a small amount of yellow makeup is applied around the peripheral edges of the bruise.
a. Patient has a purse (or other bag) containing prescription vials and drug samples. Patient admits that some of the prescription vials have old dates on them, but states s/he has been carrying them around for quite a while. Medications dumped from the patient’s purse (or bag) include:
- Warfarin 1 mg. Instructions: Take as directed. Date on vial is October 6, 2010.
- Lovaza (supplied as a drug sample).
- Vytorin 10/40 (supplied as a drug sample).
- Bottle of Calcium Carbonate 600 mg with Vitamin D (supplied as an over-the-counter item).
- Lantus insulin vial. Instructions: Use as directed. Date on vial is July 6, 2011.
- Toprol XL 100 mg. Instructions: Take 1 tablet daily. Date on vial is October 6, 2010.
- Levothyroxine 25 mcg. Instructions: Take 1 tablet daily. Date on vial is July 6, 2011.
b. Patient has a cane.
c. Patient has a partial (and somewhat vague and inaccurate) medication list in wallet, which was last updated July 19, 2011.
The list states:
- Simvastatin 1 x a day
- Metoprolol 2 x a day
- Aspirin 1 x a day
- Water pill 1 x a day
- Levothyroxine 25 mg daily
- Insulin shot 1 x a day
- Warfarin 1 tab on MWF; 2 tabs on TThSS
d. Patient also has “business cards” for her “pharmacy” and her “doctors’ office”. The names and addresses of these facilities are arbitrary, but the telephone numbers should be numbers where other faculty/staff actors are fielding telephone calls from the students as the “pharmacist” and the “nurse” at the doctors’ office.
We have learned several things as we have run this case.
- Initially, we did not inform the students that they would have a limited amount of time with each of their information sources, they found this out only when the "nurse" or "pharmacist" indicated abruptly that they "had to go" and hung up the phone. This seemed to stress the students needlessly; they didn't like this element of surprise.
- We have extended the minute time limit for the students to call the “pharmacist”, “doctors’ office”, and interview the SP. Initially, we tried 2 minutes, but we found that we needed to increase the amount of time to 4 minutes so the students could have more of their questions answered.
- At the first session, we had included a drug sample of Razadyne in the patient’s purse. This medication (galantamine) is used to treat Alzheimer’s dementia. When students encountered this medication, they did not treat information provided by the SP as “reliable” (they assumed the patient was demented and was unable to supply useful information). Therefore, we removed this medication the 2nd time that we ran the session.
- One interesting observation we have made with this case pertains to the students’ willingness to talk to the SP about the obvious bruises on her arms. All students have indicated that they saw the bruises, but students have sometimes been hesitant to ask the patient about the injuries. The SP has been instructed to prompt the students if they don't ask about the injuries.
- The first time that we used this simulation session, the SP had an ear bud in place through which a case director (nurse) supplied answers to specific medication-related questions that students asked. The case director was not available the second time we ran the case. However, the SP has requested that a case director be used for future sessions. The SP feels unprepared to respond appropriately to detailed medication questions that students may pose; therefore, an available nurse or other healthcare provider with knowledge of medications is ideal to serve in the role of a case director.
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