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EMR tool improves process of documenting medications

Jul. 17, 2014, 9:01 AM

Vanderbilt’s new Med List Tool helps providers more accurately document every patient’s home medications. (photo by Daniel Dubois)

Vanderbilt University Medical Center is rolling out a new electronic tool to facilitate the documentation of every patient’s home medications. Called the Med List Tool, this new part of the electronic medical record is a way for providers of all disciplines to accurately collect, record and communicate the medications a patient takes.

“This is an effort to address medication errors, which pose a significant patient safety threat. We’re addressing preventable errors based on discrepancies in the list that occur across care settings,” said Kelly Sponsler, M.D., assistant professor of Medicine and the clinical operations lead for this project.

Kelly Sponsler, M.D.

According to the PILL-CVD study completed at Vanderbilt and Brigham and Women’s Hospital, 42 percent of patients had at least one error in their pre-admission medication list. Other research shows that up to 67 percent of admitted patients have an error in their list.

“Medication errors can certainly contribute to readmissions and increased utilization of resources. But really this is about good patient care,” Sponsler said.

According to Sponsler, there currently isn’t a lot of trust around a patient’s medication list because so many versions exist in the medical record, and as a result, redundant work is being done by multiple providers within a patient encounter.

With the new Med List Tool, typically the nurse or other support staff will collect and document the list and flag it as ready for the clinician to review. The clinician will then validate and finalize the list. This updated medication list will save to the medical record, for use and viewing by other members of the care team. There are checks built into the tool to help with compliance.

“This tool supports a multi-provider workflow, which is a novel feature and particularly important in settings where we have nurses, medical assistants, students, residents, pharmacists, etc., involved in a patient’s care. Now everyone works off the same list and edits are noted similar to the track changes function in a Word document,” Sponsler said.

An advantage to the Med List Tool is that it is integrated with the medical record and available wherever a patient sees Vanderbilt providers, including inpatient and outpatient care. The tool also maximizes the safety controls that are built into RxStar to reconcile medications.

The Med List Tool, also known as MLT, was first piloted in April at Vanderbilt Psychiatric Hospital.

A pre- and post-survey revealed that the tool improved confidence in the accuracy of the medication list, increased satisfaction and usability and resulted in perceived improvements in patient safety.

The tool is now going live in Vanderbilt University Hospital and the Monroe Carell Jr. Children’s Hospital at Vanderbilt on all inpatient nursing units and Emergency Departments.

A training module is available for inpatient nurses in LMS. Sponsler’s team is also training nurses on taking a medication history.

“The tool is just a vehicle to collect and document, but it’s up to our staff and clinicians to take a good medication history. We need to know to ask about creams and inhalers and over-the-counter medications. If we take a few minutes to learn how to document this right, it makes a big downstream difference with regard to safety and efficiency,” Sponsler said.

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