The medication reconciliation simulation took place within an established curricular format for second year students in which issues around the patient, physician, and society are addressed. This overall course spans the entire second year. The medical school class is separated into 4 groups of 40 students. Each group of students has a separate afternoon within any given week, and meets for 2 hours. Our simulation occurred over 1 week, with each of the 4 groups rotating through on their scheduled day. At the time of the simulation, students had completed the first half of their second year, which included microbiology, hematology/oncology, nephrology, neurology, gastroenterology, genito-urinary systems, and endocrinology. Students had also completed the first half of their pharmacology lectures including antibacterials, immunosuppressants, anti-virals, and medications related to the above subjects. While students had instruction on adverse reactions before this simulation, students had not received any instruction on safe prescribing or medication reconciliation.
The simulation was developed to fit this 2-hour format. The faculty for the course included a physician, pharmacist, and an actor playing the role of the patient. Materials for this session included 3 stopwatches (1 minute each), 3 hand flags for each student team, 1 brown bag of 5 pill bottles for half of the teams, 1 medication list for half of the teams, copies of prescription inserts, 2 sample medication packs for each team. The session was divided into 4 parts.
In the first part, the students received a 30-minute lecture by a pharmacist on the necessities of obtaining an accurate medication history and tools available for acquiring more information from pertinent sources. Strategies incorporated into the student lecture included: effectively phrasing questions to obtain medication information from patients, components of a thorough and complete medication list, sources to obtain medication histories, and steps to help identify unintended discrepancies. The second part involved the actress playing the role of an elderly woman “accidentally” entering the room interrupting the lecture trying to find her doctor or pharmacist as she had questions about her medications. The patient had been having red patches (ecchymoses) on the skin and felt “achy” all over. The patient attributed both of these symptoms to her medications. The pharmacist lecturer then sat down with the patient and “helped” by starting a medication history (see Table for the actual script). After 10 minutes of medication-history taking, a partial list from the patient had been obtained.
Script for Initial Medication History Taking from Pharmacist
The third part involved the students ‘helping’ and participating in the medication history/reconciliation taking process. Students were then broken into teams of 3 to 4. They were given 40 minutes to come up with an accurate medication list. Each student team was given a docier with information on pertinent drugs from drug sources, a list of the rules, and a drug list template to complete.
Half of the student teams were given a medication list that the patient brought and the other half were given a “brown bag” with the patient’s medication (see Table ). Student teams were allowed 20 minutes and then told to exchange the brown bag for a list or vice versa with another team. They then received another additional 20 minutes to continue working through the medication list with the additional information. Teams were also given 3 hand flags that represent “lifelines” that they could use only once. Each lifeline correlated with a 1-minute call/conversation to: (1) a community pharmacist, (2) the patient’s primary care doctor, or (3) another chance to ask the patient a few more questions. When the correct questions were asked, the community pharmacist, patient, and physician office gave the student teams the information listed under each perspective character in Table .
Initially Given Medication List and Medication “Brown Bag” Contents
Medication Lists for Each Character and the Perfect Medication List
The conversation with the patient also involved the patient clarifying the dosing and frequency of the warfarin, simvastatin/ezetimibe (Vytorin), and lantus insulin. When requested, the patient was also able to explain that she was only taking a half pill of metoprolol as it is cheaper to split the 50 mg. When asked about any samples, the patient also pulled out of her tote bag sample packs of omega-3 fatty acid (Omacor) and galantamine, which her physician had given her. When asked about over-the-counter medications and vitamins, the patient admitted to taking omeprazole OTC and calcium.
When students felt that they had a complete medication list, they turned in their list, which could be earlier than the allotted time.
After the allotted 40 minutes had elapsed, the fourth part of the session began with the pharmacist bringing the students together, as a class, to review the complete medication list (see Table : The Perfect Medication List) as well as which of the medications were causing the earlier complaints of ecchymoses and muscle aches. The combination of the simvastatin/ezetimibe (Vytorin) and simvastatin, which the patient did not stop taking after the simvastatin/ezetimibe (Vytorin) was started, caused the muscle aches. The combination of the warfarin, aspirin, and the newly added samples of omega-3 fatty acid (Omacor) caused the ecchymoses. With our simulation, we gave the incentive that the group that completed an accurate medication list in the shortest amount of time received a prize.
Each day of the course, 37 to 43 students participated, and among the patient medication lists, there were only 4 groups that had reconciled “perfect medication lists”.