Medication Reconciliation

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Medication Reconciliation

• What is it?Why should we do it?How can it be
  done?

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What is Medication Reconciliation?

• A process for obtaining and documenting an
  accurate list of current medications
• Must involve the patient
• Compare to what is ordered
• Reconcile discrepancies
• Eliminate unintended discrepancies

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Why Medication Reconciliation?

• JCAHO 2006 Patient Safety Goal
• 100K Lives Saved Campaign
• Patient Safety!
• Prevent Adverse Drug Events

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Adverse Drug Reactions/Event Literature Review
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Incidence of Adverse Drug Reactions in
Hospitalized Patients

• Incidence of serious ADR
• 4.7 of admissions due to ADR
• 2.1 had ADR while hospitalized
• 0.13 to 0.19 were fatal

Lazarou J et al JAMA 19982791200-1205
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Adverse Drug Reactions as Cause of Admission to
Hospital

• ADRs caused 6.5 of admissions
• 0.15 were fatal
• Most ADRs were considered avoidable

Pirmohamed M et al. BMJ 200432915-19
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Adverse Drug Events after Discharge

• Incidence of ADE was 13
• 25 preventable
• 38 ameliorable

Forster AJ et al. Ann Intern Med 2003138161-167
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Adverse Drug Events in Ambulatory Care

• 25 with ADE
• 13 were serious
• 11 were preventable
• 28 were ameliorable
• 14 required visit to clinical facility (i.e. ER)

Gandhi et al N Engl J Med 20033481556-64
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Summary of ADE Literature

• Evident that ADEs are
• common
• can be serious, life-threatening, or fatal
• many are preventable or ameliorable
• occur across the continuum of health care
• Medication errors are leading cause
• Most common type of error affecting patient care

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Medication Reconciliation Literature

• JAMA 1997277301
• 46 of med errors occur on admit or discharge
• JCOM 2002827
• 60 of med errors occur when pts admitted,
  transferred, or discharged
• Reconciliation ?d errors by 70
• Arch Int Med 2005165424
• Med recon prevented 8 potentially severe ADE in 3
  month period
• Am J Health-Syst Pharm 2004611689
• 22-59 of all medication discrepancies could
  result in pt harm
• Arch Int Med 2005165424
• Medication discrepancies lead to greater use of
  hospital services

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How Did We Begin?

• HFMEA Interdisciplinary Workgroup formed as a
  result of significant ADR
• JCAHO mandate announced
• Flowcharting found current process
• Inconsistent, error-prone, reactive rather than
  proactive
• Needs Re-Design

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Where Did We Go?Med Recon Study

• Baseline Measured current process
• Accuracy of electronic profile
• Frequency of medication histories obtained on
  admit
• Rate of unintended discrepancies
• Pilot Recon Program implemented and measured

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Methods

• Pharm Resident interviewed patient within 24-48
  hours after admit
• Obtained true med list
• Compared this list versus the electronic profile
  and initial admit orders
• Clarified discrepancies as intended versus
  unintended by interviewing prescriber

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• Current System
• Patient admitted
• MD performs HP
• obtains med history
• Uses electronic med profile
• MD orders medications
• RPh monitors for discrepancies after medications
  ordered
• RPh must decide if intended or unintended, then
  contact MD for clarification

• Pilot Reconciliation
• Patient admitted
• RPh notified, reviews med profile
• Enters reconciliation note with revised med list
  into CPRS
• MD performs HP, reviews revised med list with
  patient adds addendum to document changes
• MD orders medications
• RPh monitors for discrepancies after medications
  ordered

Reactive
Proactive
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RESULTS
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Electronic Profile Discrepancies
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Obtaining a Medication History
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Obtaining a Medication History
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Patients with Unintended Discrepancy
?38
?46
?68
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Discrepancies per Patient
53 Reduction
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Pharmacy Drug Admit List(Reconciliation Note)

• Cleans up electronic profile to user-friendly
  version
• Pharmacist highlights potential problems before
  orders written
• Expired meds patient possibly still taking
• Active meds not filled recently
• Remote electronic data from other VAs
• Highlights ½ tab and multiple tab directions

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• Drug....................................
  Last
• Rx Stat Qty
  Issued Filled Rem
• WARFARIN (COUMADIN) NA 5MG TAB
• 6494490A A 36
  06/21/2005 09/01/2005 (4)
• SIG TAKE ONE AND ONE-HALF TABLETS BY MOUTH
  EVERY MONDAY FRIDAY AND TAKE ONE TABLET ALL
  OTHER DAYS OF THE WEEK, OR AS DIRECTED BY
  WARFARIN CLINIC, TO PREVENT BLOOD CLOTS
• Provider PHYSICIAN,NAME Cost/Fill
  4.61
• AMIODARONE HCL (SANDOZ) 200MG TAB
• 6419532 A 65
  12/27/2004 08/29/2005 (4)
• SIG THEN TAKE ONE TABLET EVERY DAY
• Provider PHYSICIAN,NAME Cost/Fill
  9.62
• FUROSEMIDE 40MG TAB
• 6647405 A 270
  08/19/2005 08/20/2005 (3)
• SIG TAKE TWO TABLETS BY MOUTH EVERY MORNING
• Provider PHYSICIAN,NAME Cost/Fill
  3.78
• GLIPIZIDE 5MG TAB
• 6618894 A 180
  07/22/2005 07/22/2005 (3)
• SIG TAKE ONE TABLET BY MOUTH TWICE A DAY
• Provider PHYSICIAN,NAME Cost/Fill 2.34
• SPIRONOLACTONE 25MG TAB

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Drug
Last Refills
Qty Filled Remaining AMIODARONE
HCL (SANDOZ) 200MG TAB 65 08/29/2005 (4)
TAKE ONE TABLET EVERY DAY DIGOXIN (LANOXIN)
0.125MG TAB 90 04/04/2005 (3)
TAKE ONE TABLET BY MOUTH EVERY DAY FUROSEMIDE
40MG TAB 270 08/20/2005
(3) TAKE TWO TABLETS BY MOUTH EVERY MORNING
GLIPIZIDE 5MG TAB 180
07/22/2005 (3) TAKE ONE TABLET BY MOUTH
TWICE A DAY LISINOPRIL 40MG TAB
90 03/31/2005 (3) TAKE ONE TABLET
BY MOUTH EVERY DAY SPIRONOLACTONE 25MG TAB
90 05/05/2005 (3) TAKE ONE
TABLET BY MOUTH EVERY DAY WARFARIN (COUMADIN) NA
5MG TAB 36 09/01/2005 (4) Per
Warf Clinic note 10/3/05 Takes 7.5 mg on Mon and
Fri, 5mg rest of week
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• Expired Meds Patient May Still Be Taking
• ATORVASTATIN CALCIUM 80MG TAB 30
  06/14/2005 (9)
• TAKE ONE TABLET BY MOUTH EVERY MORNING
• expired 08/11/2005
• MIRTAZAPINE 30MG TAB 30
  06/05/2004 (5)
• TAKE ONE TABLET BY MOUTH AT BEDTIME
• expired 09/06/2005
• The following meds have not been filled recently.
  Please verify if patient is still taking
• Lisinopril last filled in March
• Please note, patient on amiodarone and digoxin
  significant interaction and no digoxin levels
  noted. Consider checking level.
• SIGNED RPH

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Provider Response Addendum
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Conclusions

• Electronic profile not accurate
• creates false sense of security
• Obtaining medication history is not routine
• Current system
• Does not meet JCAHO standard
• Catches discrepancies after meds ordered
• Ability to reconcile is inconsistent
• Pilot Reconciliation Program
• Proactive
• Improves obtaining medication history
• Significantly reduced discrepancies prior to
  orders
• Meets JCAHO standard