Medication Reconciliation July 12, 2005

1
Medication Reconciliation July 12, 2005

• Glenn Billman, M.D.,
• Medical Safety Officer, Childrens Hospitals and
  Clinics of Minnesota

2

• First, do no harm.

3
The Issue

• Medicine used to be simple, ineffective and
  relatively safe.
• Now it is complex, effective, and potentially
  dangerous.
• Sir Cyril Chantler

4
Optimal care for patients requires totally
effective communication regarding medication use
among numerous people of varying disciplines in
multiple locations over time including the
families themselves.
Our Challenge
5
Our Aim Implement Medication Reconciliation

• Implement a Process that will ensure that
  patients and their caregivers possess the most
  accurate, and up to date medication list possible
  

6
Definition 1

• Medication Reconciliation
• Reconciliation is the process of comparing
  what medication the patient is taking at the time
  of admission or entry to a new setting or level
  of care, with what the organization is providing
  (admission or new medication orders) to avoid
  errors such as conflicts or unintentional
  omissions.

7
Definition 2

• Medication Reconciliation
• All medications appropriately and consciously
  continued, discontinued, or modified at all
  transitions of care.

8
Why Should We Do This?

• 140 discrepancies in 81 patients (1.7/pt)
• 65 omissions
• 59 wrong dose/frequency
• 16 wrong drug
• 32.9 discrepancies rates as potentially moderate
  harm 5.7 severe harm
• Arch Intern Med, Feb 2005

9
Why Should We Do This?

• Ineffective medication reconciliation upon
  hospital admission
• up to 50 of medication errors
• up to 20 of future ADEs

10
1) Increased Percent of Patients That Completed
Medication Coordination
Why Should We Do This?Because Its Doable !
11
Why Should We Do This?Because It Works !
12
Why Should We Do This?Because It Works !
4) An Increase In The Number Of Days Between ED
Visits Related To ADEs
13
Why Should We Do This?Efficiency !
14
Why Should We Do This?Its Cost Effective !
High
Investing In Safety
Do First
CPOE
Dedicated Unit Pharmacist
Automated ADE Monitoring
Bar Code Reconciliation
Diagnosis Specific Order Sets
Pharmacist Patient Interview
Medication Reconciliation
Impact on ADE
Pharmacy Managed Protocols
Pharmacist Order Entry
Zero Tolerance Ordering Standards
Preprinted Order Forms
Intervention Database
Pocket Formulary
Medication Competency Testing
Low
Dont Bother
Low
High
Cost To Implement
15
2005 NPSG Goal 8 Medication Reconciliation

• Accurately and completely reconciles medications
  across the continuum of care
• 8a During 2005, for full implementation by
  January 2006, develop a process for obtaining and
  documenting a complete list of the patients
  current medications upon the patients admission
  to the organization and with the involvement of
  the patient. This process includes a comparison
  of the medications the organization provides to
  those on the list.

16
2005 NPSG Goal 8 Medication Reconciliation

• Accurately and completely reconciles medications
  across the continuum of care
• 8b A complete list of the patients medications
  is communicated to the next provider of service
  when it refers or transfers the patient to
  another setting, service, practitioner, or level
  of care within and outside the organization.

17
Medication Reconciliation Is A Tool To Help
Bridge Gaps That Occur At Transitions and
Transfers of Care

• Process steps
• The medication history is completed
• The physician reviews and acts upon each
  medication
• The medication orders are written
• A 2nd person reviews medication history
• That 2nd person resolves discrepancies

18
Reconciliation Virtually all hospitals who have
successfully addressed admission reconciliation
have created a special form as part of the
solution. These forms pretty much look alike.
19
(No Transcript)
20
(No Transcript)
21
What is included?

• Current home meds / OTC / Herbals, including
  dose, route frequency
• Time of last dose
• Source of the information
• The medications ordered at admission
• An Assessment of patient compliance

22
There is no perfect medication list. Quit
thinking there is. Do not be paralyzed by trying
to perfect the list.
Steve Meisel, PharmD
23
Who uses the form?

• The nursing staff or pharmacist use the form to
  collect information at admission.
• The physician uses the form as a reference and/or
  order when writing initial orders for
  medications. In some cases the form itself
  serves as the order form, thereby obviating the
  need to rewrite orders.
• Both physicians and nurses use the form
  throughout the patients stay as a reference.

24
Source of the information

• The patient/family
• The patients pharmacy
• Previous medical records
• The patients medication bottles
• The physicians office

25
A completed Medication List is only the Half Way
Point.Reconciliation is real work!
26
A Big Problem Is Often Just Getting An Accurate
Medication List

• Patient brings in incorrect list.
• Patient does not take what is marked on bottle.
• Patient does not know what is on and family,
  pharmacy not available.
• Wrong name of med on ED sheet.
• Med bottles dont jive with what the patient
  says.
• Patient is unable to tell you. No family
  available. MD on call does not know either.
• Cant call the pharmacy after hours.

27
(No Transcript)
28
The Intent and Value of Medication Reconciliation
Is In Having An Accurate Medication List.
29
Transfer Reconciliation

• Critical especially upon transfer in and out of
  intensive care and other specialty units
• As much as 60 of the care plan after transfer
  may be different than what the physician expects
• Can utilize internal computer systems to
  facilitate, but there must be an active decision
  to continue, discontinue, or modify each line
  item

30
Transfer Reconciliation

• Automatic stops of certain critical-care-specific
  drugs (e.g. dopamine) are acceptable provided
  those stop orders appear in the medical record.
• ? Benzodiazepines
• Requirement to re-write all orders upon transfer
  introduces new opportunities for error

31
(No Transcript)
32
Discharge Reconciliation

• The patients reconciled list of admission
  medications is compared against the physicians
  discharge orders along with the last days MAR.
• The lists can either come from the computer
  system or be integrated with the original
  admissions list.

33
(No Transcript)
34
(No Transcript)
35
To Be Successful

• Put the patient first (this isn't someone else's
  job)
• You need to have some good change methodology to
  be able to develop a good product
• You need to use this to replace something else
  i.e. medication history in nursing data base

36
To Be Successful

• Understand Your Processes
• Process flow
• Data flow
• Roles and responsibilities
• Procedures
• Build Incrementally Start Small
• Leadership Support is Critical
• Project champions

37
To Be Successful

• You must have organization alignment (physician,
  nursing, pharmacy, administration)
• Process Owner and Sub-Process Owners
• A champion for the entire process
• Have a good education program when rolling it out
• Appropriately Resource the project
• You Need To Start!

38
Questions / Comments/ Discussion
39
Contact Information

• Contact Glenn Billman
• glenn.billman_at_childrenshc.org