Spotlight Case November 2005

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Spotlight Case November 2005

• Reconciling Doses

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Source and Credits

• This presentation is based on the November 2005
  Spotlight Case in Emergency Medicine
• See the full article at http//webmm.ahrq.gov
• CME credit is available through the Web site
• Commentary by Frank Federico, RPh, Director,
  Institute for Healthcare Improvement
• Editor, AHRQ WebMM Robert Wachter, MD
• Spotlight Editor Tracy Minichiello, MD
• Managing Editor Erin Hartman, MS

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Objectives

• At the conclusion of this educational activity,
  participants should be able to
• List the steps involved in medication
  reconciliation
• Describe the role of each of the stakeholders in
  medication reconciliation
• Discuss how medication reconciliation decreases
  the opportunity for medication errors and harm

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Case Reconciling Doses

• A 68-year-old man with a history of diabetes and
  atrial fibrillation (maintained on warfarin)
  presented to the emergency department (ED) with
  fever and mental status change. Lumbar puncture
  was attempted three times without success
  empiric treatment for meningitis was started.
  Further examination revealed an area of
  cellulitis, and intravenous antibiotic therapy
  was changed accordingly.

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Case (cont.) Reconciling Doses

• At the time of admission, the patient was unable
  to recite his medication list, and his wife was
  unclear about the doses. However, the EMS
  run-sheet had a list of the patients medication
  and doses. The patient was started on the
  medication regimen per the EMS report.

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Medication Reconciliation

• The process of collecting the best medication
  history possible, verifying that list, and
  comparing it with orders written at admission,
  transfer, and discharge
• Ensures each member of health care team has
  access to a list of home medications and what was
  ordered at transitions in levels of care
• Provides a method to communicate when an
  intentional medication change is made

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Medication Reconciliation The Data

• More than one half of medication errors occur at
  the interfaces of care
• Up to 67 of cases had errors in prescription
  medication histories
• An average of 10 prescriptions needed to be
  changed weekly in the ICU as a result of
  implementing a reconciliation process

Rozich JD, Resar RK. JCOM. 20018(10)27-34.Tam
VC, et al. CMAJ 2005173510-515.Pronovost P. J
Crit Care. 200318201-205.
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Medication Reconciliation

• Recommended change for teams participating in IHI
  collaboratives to reduce adverse drug events
• One of six changes chosen by the 100,000 Lives
  Campaign to improve patient care and prevent
  avoidable deaths
• JCAHO selected medication reconciliation as one
  of the National Patient Safety Goals

100K Lives Campaign. IHI Web site. National
Patient Safety Goals for 2006 and 2005. JCAHO Web
site.
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Case (cont.) Reconciling Doses

• After 2 days, the patient was transitioned to
  Augmentin. While in hospital, the patient had
  been receiving 5 mg of warfarin at bedtime,
  which, according to the EMS intake sheet, was his
  usual outpatient dose. The team did not confirm
  this dose with the patients family, primary
  physician, or pharmacy.

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Case (cont.) Reconciling Doses

• At the time of discharge, the patients INR was
  noted to be 4. Realizing the warfarin dose was
  too high, the team instructed him to decrease his
  dose to 3 mg at bedtime and to have his INR
  rechecked in 3 days. After 3 days, his INR was
  10. He was treated with vitamin K.

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Case (cont.) Reconciling Doses

• Two days later, the patient returned to the ED
  with back pain, lower extremity weakness, and
  incontinence. He was found to have an epidural
  hematoma. The hematoma was emergently evacuated.
  One week post-operatively, the patient still had
  neurologic deficit.

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Starting a Medication Reconciliation Program

• Identify a champion and a multidisciplinary team
  to work on testing changes that will lead to the
  desired system
• Ensure senior leadership support
• Secure commitment for resources for the project
  during its development
• Start with a small sample of the hospital
  population

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Recruiting Medication Reconciling Team

• Multidisciplinary team should include
• Executive sponsor
• Physician champion
• Nursing leader, staff nurse
• Pharmacy leader, pharmacy support
• Patient safety/QI representative
• Staff education representative
• Other group representatives (see form)
• Team planning form available here

Massachusetts Coalition for the Prevention of
Medical Errors.
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Developing a Medication Reconciliation Program

• Examine the system currently in place
• Use high-level flow diagram to determine the
  different entry points into the hospital
• Use similar diagram for transfers and discharges
• Use a proven improvement methodology (eg, Model
  for Improvement) to test and implement changes

Plsek PE. Pediatrics. 1999103 (suppl)203-214.Mo
del for Improvement. IHI Web site.
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Developing the Reconciliation Process

• Identify who should participate in each step and
  define the responsibility of each position
• Medication history can be completed by a
  physician, nurse, pharmacist, or pharmacy
  technician
• Base decision on available resources
• Pharmacists found to be more effective in taking
  medication history but may train others to do so

Michels RD, Meisel SB. Am J Health Syst Pharm.
2003601982-1986.Nester TM, Hale LS. Am J
Health Syst Pharm. 2002592221-2225.
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Potential Reconciliation Model
RN collects medication history
Pharmacist verifies information
Physicians use the list to aid in decisions about
drug therapy and document reasons to
discontinue, change, or hold medications
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Medication Reconciliation Forms

• Most organizations use forms
• Often adapted to serve as order form
• Columns can indicate whether medication should be
  continued, discontinued, or placed on hold
• Place the list prominently in the chart or use
  colored paper to facilitate access to information
• Hospitals must determine if these changes
  introduce new opportunities for errors

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Example Reconciliation Form
http//www.macoalition.org/Initiatives/RecMeds/Coo
leyDickinsonReconcilForm.doc
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Example Form (cont.)
http//www.macoalition.org/Initiatives/RecMeds/Coo
leyDickinsonReconcilForm.doc
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Another Reconciliation Form
http//www.macoalition.org/Initiatives/RecMeds/Car
itasNorwoodReconcilForm.doc
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Another Form (cont.)
http//www.macoalition.org/Initiatives/RecMeds/Car
itasNorwoodReconcilForm.doc
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More Example Forms and Tools

• Massachusetts Coalition for the Prevention of
  Medical Errors
• Reconciling medication toolkit
• Institute for Healthcare Improvement
• Medication reconciliation tools

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Medication Reconciliation Technology

• Linking electronic medical records to download
  medication histories onto a form reduces the
  number of steps and the need to manually complete
  form
• At discharge, reformatting the medication profile
  from the pharmacy system onto a prescription form
  can efficiently generate discharge prescriptions

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Evaluate Reconciliation Success

• Use a measurement strategy to determine programs
  effectiveness
• Assessment form available here
• Collecting data per admission or chart may help
  determine if reconciliation is occurring
• Information about the percent of unreconciled
  medications at different transfer points can
  identify how well the process is working

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Medication Reconciliation Role of the Patient

• Patients can be active participants in medication
  reconciliation
• Organizational level One health system has
  engaged patients in developing a statewide
  universal medication form
• Individual level Carry up-to-date medication
  list and present it at each health care visit
• Patient medication card available here

Medication Reconciliation can Save Your Life.
McLeod Health Web site.
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How to Perform Medication Reconciliation

• Collect the best medication list possible
• If patient is unable to provide list, interview
  family members and contact primary physician or
  local pharmacy
• Complete medication reconciliation at each
  transition of care
• At discharge, reconcile prescriptions with most
  recent inpatient orders and patient medication
  list prepared at admission

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Take-Home Points

• Medication reconciliation is an effective process
  to reduce errors and harm associated with loss of
  medication information at transitions in care
• Collect the 'best' medication history possible
  use open-ended questions when taking a medication
  history
• Patients can play a vital role in this process by
  carrying up-to-date medication list

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Take-Home Points

• Hospitals should develop medication
  reconciliation processes based on patient entry
  points and available resources
• Medication reconciliation should be applied
  whenever medication orders are rewritten or
  whenever there is a change in treatment plan or
  level of care
• For medication reconciliation to be successful,
  all stakeholders must be involved