Medication Information Management and Error Recovery in Primary Care

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Medication Information Management and Error
Recovery in Primary Care

• Tosha B. Wetterneck, MD, MS
• Associate Professor of Medicine, University of
  Wisconsin School of Medicine and Public Health
• Researcher, Center for Quality and Productivity
  Improvement, University of Wisconsin-Madison

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Medication Safety at Transitions of Care (TOC)

• Transitions of care are risky for pts
• 10-23 of pts experience errors adverse events,
  many medication related
• Many adverse events after TOC are preventable
• Lack of communication / information flow major
  factor
• No studies of how PCPs recover from information
  failures

Forester et al, 2003 2004 Schnipper et al,
2006 Coleman 2005 Smith et al 2005 vanWalraven
et al 2002 Bell et al 2008
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Assessing Risk in Ambulatory Medication Use after
Hospital Transitions

• Specific Aims To assess transitions of care from
  hospital to ambulatory primary care from a
  primary care perspective
• To analyze the system failures in the medication
  information management (MIM) process.
• To evaluate the methods for detection of failures
  and the subsequent correction of failures in the
  MIM process.

AHRQ K08HS17014
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Methods

• 3 Primary care clinics associated hospitals
• Varied by EHR use, rural/urban location,
  organizational ties, continuity of care
• 18 PCPs, 26 RNs/MAs
• 100 patient visits
• Observations of clinician work pt visits and
  interviews of PCPs, nurses patients

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Data collection med information flow -
communication

• Failures / errors
• Error recovery
• Detection
• Explanation
• Correction
• Missed opportunities for recovery
• Consequences
• Contributing factors

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Failure / Error Recovery
Failure
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Anatomy of pt-visit related observations

• Pre-visit work PCP Nurse
• Review pt info, CC, last visit, prob list
• Intake for pt visit Nurse
• Vital signs, review medication list, allergies
• Provider visit PCP
• Post-visit work PCP Nurse
• Documentation, referrals, Rxs, billing
• PCP nurse may verbally or electronically
  communicate

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Paired Observations

• 1 HFE 1 HF-MD observing a PCP-nurse pair for
  half day
• Able to follow both clinicians for entire pt
  visit, pre post work
• ID failures recovery across clinicians
• Teamwork / coordination
• HFE MD share insights from medical HF
  viewpoints
• Downside space constraints

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Preliminary Analyses

• Failures are common up to 50 visits
• Common failures
• Lack of complete med list verification
• Only med name checked with pt
• Med list not complete
• Lack of OTC med documentation
• Not asking about other meds
• Duplicate meds on list
• Changes in dose / dose form not documented
• Compliance not documented

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Scenario Nurse observation

• Nurse checks in new pt for clinic visit
• Pt called 1 wk earlier for appt, got Rx for
  Ambien 10mg nightly over phone for insomnia
• Nurse reviews med list in EHR (Ambien) checks
  that pt is taking med, reviews allergies, smoking
  hx chief complaint
• Pt states Ambien not working well, took double
  dose x 2 days and still not sleeping
• Nurse tells pt he should not take more med than
  prescribed. Does not document pt taking higher
  dose.

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PCP observation

• MD greets new pt, 20min late for appt
• Reviews pts medical hx, social hx
• MD notes pts BP is high (not on meds) and that
  pt smokes discusses implications with pt
• MD discusses insomnia and Ambien use (now 15 min
  into 15 min visit)
• Pt states medication not working well
• MD tells pt to take 2 tablets nightly to see if
  this helps
• MD tells pt to f/u in a few weeks with longer
  visit to discuss multiple problems

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Analysis

• Paired observation reveals info failure MD did
  not have accurate med info
• Lack of nurse documentation of 20mg dose
• Lack of expectations for doc med history, info
• Not easy to indicate pt taking more med
• Focus on list of meds,
• ? Pt expected nurse documented conversation
• Nurse comment to pt may have prevented pt from
  admitting higher dose to MD
• Time pressure new pt, short visit, other
  problems

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Recovery scenario

• 70 y/o man here for f/u BP visit
• Nurse takes VS, reviews allergies.
• MD knows pt well. Reviews BP and need for more
  medication w/ pt.
• MD reviews written med list in front cover of
  paper chart. List has many meds crossed off over
  time. MD asks pt what he is taking for BP. Pt
  shakes his head and says he cant remember the
  name.

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• MD reviews prior notes and asks pt if it is
  Doxazosin. Pt asks if that is the prostate med?
  MD states it does both. MD asks what dose he is
  taking. Pt states he doesnt know but its one
  pill a day.
• Between reviewing notes and med list, MD is
  uncertain of the dose that pt is taking. MD
  spends 10 min describing two scenarios based on
  the dose he is taking one to double the dose,
  the other to make a small increase. MD confirms
  pts pharmacy.

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• MD tells pt he should keep a med list with him
  and ends visit.
• MD jots note about increasing med for BP.
• MD sees 4 more pts, then sits to complete chart
  documentation.
• MD calls the pharmacy, asks the RPh about the
  last Rx dose. It was a higher dose than what was
  documented on the med list. MD tells RPh she is
  faxing a Rx for a higher dose and asks RPh to
  give pt a med list.
• MD calls pt about med increase updates med list
  in chart.

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Analysis

• Failures
• Medication list incorrect
• Detection
• MD error suspicion
• Correction attempts
• Reviews chart supporting documentation but cannot
  confirm med dose
• Calls Pharmacist and confirms dose
• Consequences MD time, ?pt confusion

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Analysis

• Contributing factors
• Pt does not know meds, reasons taking them
• Medication list in chart not up-to-date
• Missed earlier recovery?
• Medication list could be updated before MD sees
  pt
• Pre-visit or during intake by RN

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Conclusions

• Failures are common in the medication management
  process in primary care
• Failures are normalized treated as part of
  everyday practice
• Recovery is common and built into normal work
  processes
• Understanding failures recovery mechanisms may
  guide the building of more robust work processes
  and decrease information failures consequences
  to PCPs and pts

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Acknowledgments

• Mentor Pascale Carayon, PhD
• Advisory committee Paul Smith, Maureen Smith,
  Mark Linzer
• Research Team Talley Holman, Jamie Lapin, Dan
  Krueger, Peggy OHalloran
• WREN
• Funding
• AHRQ K08HS17014
• Dept of Medicine RD grant, UWSMPH

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Thank you!