Effectiveness of a Medication Reconciliation Simulation in an Introductory Pharmacy Practice Experience Course

Kathy Komperda, PharmD; Kelly Lempicki, PharmD

Disclosures

Am J Pharm Educ. 2019;83(4) 

In This Article

Discussion

The medication reconciliation simulated learning exercise was developed to prepare third-year pharmacy students to independently obtain a patient's medication history and then reconcile his or her medications, identify any discrepancies that exist, and propose appropriate resolutions. Based on scores from the SP encounter, the combined simulated learning exercise had a greater impact on student performance than lecture alone. This suggests that the previous curricular content related to medication reconciliation was insufficient to prepare students to independently complete this task and that the addition of a review lecture alone would not have significantly improved their performance. After the simulated learning exercise, students were still not able to compile a perfect medication list or identify all discrepancies and appropriate resolutions. Frequently missed items on the medication list were related to route of administration (omitted for some or all medications) and the specific dosing of nonprescription (over-the-counter) products (eg, nicotine replacement therapy).

While a variety of activities to teach medication reconciliation have been published, students' ability to individually demonstrate their skills as a result of the training has rarely been assessed.[16–20] Karpa and colleagues described a workshop during which medical students worked individually and then as a class to review a patient's chart, identify medication-related problems, and propose resolutions. After this one-hour workshop, students correctly identified 64% of problems, as compared to 39% before the course began (p<.001).[19] Van Zuilen and colleagues assessed the ability of medical students to interview a patient (portrayed by a faculty member), identify potential medication concerns, and provide recommendations. The student groups identified, on average, 16.1 out of a possible18 medication concerns (range 13–18). Students' individual competency was then assessed at the end of the year using an online assessment. Out of 14 possible points, students scored an average 10.2±1.9 points (range 2–14 points). Eight students (4.5%) did not pass and required remediation.[18] Similar to our experience, additional hands-on training in the form of a workshop improved students' abilities to perform medication reconciliation. However, as seen in the literature and in our experience, students' skills still needed further improvement.

There are also opportunities for improvement in medication reconciliation performed in patient care settings. In one systematic analysis of hospital-based medication reconciliation practices, at least one unintentional discrepancy with the potential for harm was identified in a median 45% of patients (interquartile range 31%-56%).[8] In Shiu and colleague's study, 38.8% of patients had at least one unintentional medication discrepancy at 30 days after discharge. These discrepancies occurred despite the presence of an interprofessional medication reconciliation process that included pharmacists, nurses, staff physicians, medical residents, and medical students. However, the presence of a discrepancy was not associated with readmission, emergency department visits, or death 90 days after discharge (p>.05).[21] These studies suggest the continued need to identify strategies to prepare students and practitioners to be effective at this important patient safety initiative.

In this study, students' perceived confidence in completing activities related to medication reconciliation knowledge and skills increased regardless of group assignment. This may have been due, in part, to the SP encounter that all students completed. Several students across all groups commented that the SP encounter was a helpful or valuable learning experience. The perceived confidence ratings of students who participated in an active intervention (lecture or lecture and workshop) increased, while the confidence ratings of students in the control group decreased or remained unchanged. Overall, students did not identify themselves as very confident or very unconfident. There is room to further develop student confidence in performing medication reconciliation.

The simulated medication reconciliation activity was well received, especially the workshop component, as more than 97% of respondents who completed the workshop strongly agreed or agreed that it was a positive learning experience, improved their ability to perform medication reconciliation, and that more activities like it should be included in the curriculum. An interesting finding was that for items related to the 30-minute lecture, more students in group B consistently selected "strongly agree" as compared to students in group A, even though the lecture was the same experience for both groups. This difference highlights that incorporating an active-learning component such as a workshop can influence students' perception of the value of a more traditional teaching approach, such as a lecture. Students considered the lecture to be more valuable when it was paired with a workshop where they could practice what was discussed in the lecture than when the lecture was standalone without the active component. The perceived value of the workshop was similarly reflected in students' optional written comments. While those in group B (n=4) commented that they felt prepared or confident when completing the SP encounter, students in group A (n=2) and C (n=10) felt unprepared.

Based on the positive impact of the simulated medication reconciliation activity on students' skills and perceived confidence, the activity will continue to be required for all third-year pharmacy students as a component of the IPPE III: Clinical course. In addition, IPPE courses earlier in the curriculum have been revised to include more active workshop components in the medication reconciliation units. The activity could easily be adapted for any health care professionals or trainees involved in the medication reconciliation process. Depending on baseline knowledge about medication history-taking and the medication reconciliation process, the length of the lecture may need to be increased or pre-class readings provided as the 30-minute lecture in this activity was intended to serve only as a refresher on the topic. The case scenario itself also may be adjusted to include only medications previously taught (for students earlier in their curriculum) or to purposefully include high-risk medication or complex patient problems (for advanced students or practitioners). Inclusion of medications not previously discussed would also provide an opportunity to reinforce and assess drug information skills. The setting for the workshop and the SP encounter in the CSC could also be varied, given the importance of medication reconciliation at all transitions of care.

This study is not without limitations. Results collected were from only one year of students at a single institution. A portion of the students completed the study each quarter and, while the simulated learning exercise and SP encounter scenario remained the same to minimize variability, there is a chance that students may have shared information with students who took the course during a later quarter. Other potential confounding variables, such as students' work history or previous experience with medication reconciliation, were not controlled for and may have affected the results. Furthermore, the students' ability to perform medication reconciliation was assessed one week after the simulated learning exercise. The differences identified between the groups are reflective of short-term retention of the skills and knowledge needed to perform medication reconciliation. A more ideal assessment would control for potential confounding factors and be administered several weeks after the workshop. In addition, evaluating the impact of the intervention on medication reconciliation performed in the clinical setting would be extremely valuable as that is ultimately the goal of this simulated learning exercise. Finally, it is unclear how many hands-on learning opportunities are necessary to prepare students to perform medication reconciliation without errors. These concepts present several different areas for future evaluation.

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