Medication Reconciliation: A reliable process

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Medication ReconciliationA reliable process?

• Sharon I. Eloranta
• October 29, 2005

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In the Beginning

• There was Don Berwick, MD, MPP, CEO of the
  Institute for Healthcare Improvement
• Plenary speech at 2004 IHI National Forum
• Remarked on progress made by hospitals in
  improving care
• Issued a challenge
• Now is the time to harness those experiences and
  apply the best methods reliably 100 of the
  time. 

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Campaign Objectives

• Save 100,000 lives across the country over 18
  months (end date of June 14, 2006).
• Enroll as many as 2,000 hospitals to join us in
  this work.
• Now, more than 2600 hospitals have enrolled.

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Key Campaign Principles

• Some is not a number soon is not a time.
• Welcome anyone at any level.
• We do this together.

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Six Changes That Save Lives

• Deploy Rapid Response Teams
• Deliver Reliable, Evidence-Based Care for Acute
  Myocardial Infarction (Heart Attacks)
• Prevent Adverse Drug Events (ADEs)
• Prevent Central Line Infections
• Prevent Surgical Site Infections
• Prevent Ventilator-Associated Pneumonia

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Prevent Adverse Drug Events by Implementing
Medication Reconciliation

• Reconciliation A process of identifying the most
  accurate list of all medications a patient is
  takingincluding name, dosage, frequency, and
  routeand using this list to provide correct
  medications for patients anywhere within the
  health care system
• Requires comparing the patients list of current
  medications against the physicians admission,
  transfer, and/or discharge orders

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Errors on Reviewed Charts/100 Admissions Luther
Midelfort
Discharge Reconciliation
Admission Reconciliation
Transfer Reconciliation
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A Complex Process

• Medications are used by nearly everyone.
• Individuals experience multiple transitions
  during encounters with the healthcare system.
• There are many portals of entry into the
  healthcare system all should be covered by the
  process.
• HOW WILL WE DO IT???

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Three steps to get started

• Segment the population
• Use reliability science
• Use small tests of change (PDSA)

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Segments

• Suggestion an early easy win
• Scheduled surgery
• For later
• ED admissions
• Direct admits
• Patients being discharged (can sub-segment)
• Transfers (again, sub-segment)
• Find champions along the way.

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Defining Reliability

• 1.The measurable capability of an object to
  perform its intended function in the required
  time under specified conditions.
• (Handbook of Reliability Engineering, Igor
  Ushakov, editor)
• 2.The probability of a products performing
  without failure a specified function under given
  conditions for a specified period of time.
• (Quality Control Handbook, Joseph Juran, editor)
• 3.The extent of failure-free operation over time.
  (David Garvin)

Thanks to the Institute for Healthcare Improvement
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Healthcare Reliability Terminology(Different
from the mathematical)

• Unstable process Failure in greater than 20 of
  opportunities
• 10-1 80 or 90 success. 1 or 2 failures out
  of 10 opportunities
• 10-2 5 failures or less out of 100
  opportunities
• 10-3 5 failures or less out of 1000
  opportunities
• 10-4 5 failures or less out of 10,000
  opportunities

Thanks to the Institute for Healthcare
Improvement
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René Amalberti
Increasing safety margins
No limit on discretion
Becoming team player
Excessive autonomy of actors
Agreeing to become  equivalent actors 
Craftmanship attitude
Accepting the residual risk
Ego-centered safety protections, vertical
conflicts
Accepting that changes can be destructive
Loss of visibility of risk, freezing actions
Blood transfusion
Fatal Iatrogenic adverse events
Anesthesiology ASA1
Cardiac Surgery Patient ASA 3-5
Medical risk (total)
No system beyond this point
Himalaya mountaineering
Chartered Flight
Civil Aviation
Railways (France)
Microlight or helicopters spreading activity
Road Safety
Nuclear Industry
Chemical Industry (total)
Fatal risk
10-2
10-3
10-4
10-5
10-6
Very unsafe
Ultra safe
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Observation Almost all studies that investigate
the rate of failure to apply the appropriate
clinical evidence in health care production
find a rate in the order of 10-1
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Health Care Process Reliabilities
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Three-Tier Design Strategy

• Prevent Initial Failure using intent and
  standardization
• Identify failure and mitigate
• Redundancy function
• Critical failure mode function (identify
  critical failures and then redesign)

Thanks to the Institute for Healthcare
Improvement
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Examples in med rec

• Standardization
• Use of standard medication lists in all
  departments
• Assignment of roles
• Identify failure and mitigate
• Reminder to pharmacy if no form accompanies
  patient upon transitions
• Require the discharge med rec form before a
  patient can be released
• Critical failure mode function
• Redesign of system such that pharmacist is
  available in the ED

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Generic 3 Tier Design
Prevent failure Standardization to achieve 10-1
(Tier 1)
1-Specify the steps 2-Use both level 1 and level
2 changes to attain 10-1 3-Segment population to
test the design
10 only partially done
10 not done at all
1-Utilize a system level redundancy 2-Measure
failure rates from step 1 3-Do not use unless
step one is at least 10-1
Identify Failures and Mitigate failures if
possible to achieve 10-2 (Tier 2)
1-Redesign only if articulated goal not
reached 2-Tackle one failure mode at a time
Prioritize failure modes and redesign steps 1 and
or 2 if articulated goal has not been reached
(Tier 3)
Thanks to the Institute for Healthcare
Improvement
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How to get there

• Small tests of change
• Plan what do you predict will happen
• Do conduct the test
• Study note the results and make conclusions
• Act adopt, adapt or abandon the change

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Lets get started!