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Reconciling Medications

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Title: Reconciling Medications


1
Reconciling Medications
  • Safe Practice Recommendations
  • and
  • Implementation Strategies

2
Medication Safety Facts
  • Medication errors account for more than 7,000
    deaths annually
  • Approx. two out of every 100 patients admitted to
    the hospital will experience a preventable
    adverse drug event
  • Over 12 of patients with an ADE within 2 weeks
    of discharge

3
Reconciling Medications
  • A systematic process to reduce the number of
    medication events occurring at interfaces of care
  • Creating the most complete and accurate list
    possible of all home medications for each patient
    and then comparing that list against the
    physicians admission, transfer, and/or discharge
    orders. Discrepancies are brought to the
    attention of the physician and, if appropriate,
    changes are made to the orders. Any resulting
    changes in orders are documented.

4
RESEARCH
  • Errors that are the result of an omission are
    often not reported as errors, although they may
    result in an adverse outcome for the patient.
  • They may manifest themselves as
  • Unexplained elevated lab values
  • Due to inaccurate dosing
  • Missed medications
  • Readmissions due to
  • Doubling up of medications
  • Missed medications at discharge
  • Contraindication to unknown OTC or herbal meds

5
Problem identified
  • Info on patients home meds not being
    systematically collected in multiple places in
    the chart, often incomplete
  • Poor or inadequate processes to compare list of
    pre-admit medications to orders
  • Research study demonstrated that over half of all
    hospital medication errors occurred at the
    interfaces of care
  • Rozich, Resar 2001

6
Medication errors based on chart review
Source Luther Midelfort Hospital -- Mayo Health
System chart review
We found that the list of medications that
details current drug use was either nonexistent
or wrong more than 85 of the time
Rozich/Resar 2004, p.8
7
Examples of errors
  • No orders for needed home meds
  • Missed or duplicate doses from inadequate records
    of frequency/last administration time
  • Surgeon inadequately addressing meds for chronic
    conditions
  • Failure to restart meds at transfers
  • Doubling up (brand/generic combinations,
    formulary substitutions)

8
Unintended medication discrepancies at admission
  • Studies show over half of patients have
    discrepancies between home medications and
    medications ordered at admission, many with
    potentially serious results
  • 54 of patients 39 potentially serious
    Cornish Arch Intern Med 2005
  • More than half 59 could have caused harm if
    the error continued after discharge Gleason Am
    Jnrl H-Sys Pharm 2004 

9
More evidence on impactJohns Hopkins Surgical
ICU
  • Dramatic reduction in medication errors resulted
    from reconciling
  • Baseline 31 of 33 (94) of patients with MD
    changing orders when discrepancies brought to
    their attention
  • By week 24, nearly all medication errors in
    discharge orders eliminated
  • As a result of routine reconciling, average of 10
    orders per week are changed

Pronovost, 2003
10
  • The
  • Reconciling Process

11
THE PROPOSED SOLUTION
  • A process to obtain the best home medication list
    possible through a defined resource list and
    active review of the patients medical history.
  • Patient
  • Pharmacy
  • Family
  • Patients Med List
  • PCP
  • VNA
  • Utilize strategic interviewing practices.
  • Ask open ended questions to obtain info on OTC
    meds herbals.

12
Reconciling process admission
  • Getting the home med list (at intake)
  • Interviewing strategies to promote accuracy
  • Input from patient/family/alternative sources
  • Outreach patients arrive with accurate list
  • Writing medication orders
  • Goal work from accurate home med list
  • Identify and reconcile discrepancies
  • ?Order (no omissions, no duplicates, right
    med/dose/
  • frequency/route)
  • ? Communicate (to next level of service)

13
BECOMING A STATEWIDE INITIATIVE
  • The Massachusetts Hospital Association in
    collaboration with the Massachusetts Coalition
    for the Prevention of Medical Errors reviewed
    evidence of medication reconciliation to
    determine
  • Importance How much can we impact safety?
  • Feasibility Is this a doable process?
  • Measurability Can we monitor our progress?
  • Statewide advisory board voted to accept this
    initiative!

14
Getting started
  1. Initiate leadership dialog resource commitment,
    regular reporting channels
  2. Form a multidisciplinary team
  3. Risk assessment/baseline measurement
  4. Aim statement, timeline
  5. Pick pilot unit
  6. Begin testing

15
Define Aim / Obtain Baseline Measure
  • Aim
  • To reduce the rate of unreconciled medications at
    admission by 50 within 9 months.
  • Measure
  • Baseline measurement of 20 charts, subsequent
    measures performed on 30 charts per month for the
    first 3 months after implementation of form.
    Evaluate the frequency of the measure after the
    first three months.

16
1. Getting the home med list
  • What have we learned?
  • Adopt standardized form
  • Share responsibilities, ordering prescriber
    accountable... crew resource management
    principles
  • Validate with the patient
  • Dont let perfection be the enemy of the good

17
1. Getting the home med list
  • Who? Shared responsibilities, always someone
    with sufficient expertise
  • RN who completes the initial admission history
  • Pharmacist/pharmacist technician
  • Michels/Meisel 2003 Gleason/Groszek 2004
  • MD if reconciling form not complete when ready to
    write orders

18
1. Getting the home med list
  • What?
  • Current home meds
  • Include OTCs herbals
  • Dose, frequency, time of last dose
  • Optional route, source of information,
    compliance, purpose
  • Many building collection of patient allergies
    into the process

19
2. Using home list when writing orders
  • What have we learned?
  • Make highly visible
  • Provide access at point when orders are written
  • Have reconciling form serve as an order sheet.
    benefits and issues...

20
Project phasing
  • Pilot testing identify changes, measure to know
    if the changes are an improvement
  • Implementation take a successful change and
    build it into the way the entire pilot
    population/pilot unit does their work
  • Spread replicating a change/package of changes
    beyond the pilot unit into other parts of the
    organization
  • Maintain the gains

21
3. Identifying, reconciling discrepancies
  • Who?
  • Generally nursing assigned responsibility of
    comparing the home list to the admit orders,
    identifying variances, and reconciling all
    differences
  • Pharmacist involvement can be productive,
    especially for organizations with decentralized
    pharmacy
  • Need strategy for handing off any unresolved
    differences at shift change

22
  • Implementation Strategies

23
Resource requirements
  • During testing/implementation phase
  • Make explicit allocation for those with patient
    care responsibilities
  • Managers need to pay attention to workloads
    dont assign tests to someone overloaded
  • Ongoing
  • Build into regular workflows
  • Collecting home history IS time consuming some
    have added resources to support that (e.g.
    pharmacy techs)

24
Post Team Members- Encourage Input
  • Contact any of the following Medication
    Reconciliation PI Team members to answer any of
    your questions
  • Melissa Bartick, MD - X9335
  • Jennifer Fexis, Quality - X9406
  • Darlene Civita, RN ICU- X9350
  • Vicky Casto, RN ACU - X9335
  • Deb Wilkinson, RPh - X9363

25
Tips for engaging MDs
  • Personal appeals from VP of Medical Affairs
    and/or Chiefs of services
  • Trial with key leaders on each unit get their
    input via hallway consultations not meetings
  • Identified Ambassadors from engaged
    hospitalists they then educated others
  • Developed into CME risk program
  • MDs from key committees (PT, Medical Records)
  • Chief Medical Resident on the team, with
    responsibility to report back to other residents

26
Baseline risk assessment
  • Chart review
  • Institution-wide
  • Mini-FMEA, flow charting existing processes
  • Do in conjunction with initial tests of change
  • Just-enough measurement/analysis
  • Dont get bogged down here!!

27
Mission
  • Every patient will receive all medications they
    have been taking at home unless they are
    held/discontinued by their caregiver(s) and all
    new medications as ordered -- correct drug, dose,
    route, and schedule.
  • The goal of reconciling is to design a process
    that will ensure the most accurate patient home
    medication list available, thus reducing the
    number of medication events upon admission,
    transfer and discharge

28
Choosing where to start
  • Use risk assessment process
  • Willing volunteers
  • At admission logical place
  • Pros cons Med vs Surg units
  • Some success starting _at_ transfer ICU, CCU,
    telemetry units
  • Probably not ED

29
Start small, focus on one unit
  • Small tests... 1 unit, 1 RN, 1 MD, 1 patient
  • Add more staff, more shifts, refining process and
    form
  • Keep testing on that one unit until you refine
    the process and can show that it works (test on
    all shifts, patients coming in as direct admits,
    from ED, transfers, etc)

30
Pilot unit
  1. Mini-team including nurse managers, front-line
    nurses, MD champion
  2. Project introduction, staff education
  3. Baseline measurement for the unit
  4. Pick reconciling form to test (steal
    shamelessly...)
  5. Begin testing

31
Piloting a reconciling form
  • Testing avoid forms committees...
  • Simple vs complex
  • Reconciling status
  • Orders continue, change, d/c, hold
  • Optional data sources, purpose/indication,
    date/time of last dose, amt of non-compliance
  • Columns for reconciling at discharge?
  • Signature lines

32
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34
Fundamental ingredients...
  • Get support of your CEO cannot do it without
    leadership at the top
  • Use data (to motivate, to know if changes are
    leading to improvement)
  • Strong representation from leadership of the 3
    key stakeholder groups MD, RN, pharmacy
  • Start small

35
Culture...
  • Core issues of teamwork and communi-cation...
    organizational culture matters
  • Changing the way people do work every time you
    try to change behavior, its only natural to be
    met with resistance
  • Recognize that this is HARD
  • Difficult task but not impossible
  • Unit briefings/pharmacy rounding

36
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37
Challenges and barriers
  • Time and resources
  • How can we find the time to do this?
  • Roles and responsibilities
  • Its not my job
  • Im not going to sign that form
  • Data collection
  • Need data... but dont let data collection delay
    testing, overwhelm

38
Medication ChecklistHeres how patients can help
the medication reconciliation process
? Keep an updated list of all medications
including herbals, vitamins and OTC. Including
dosage and reason for taking the drug ? Include
all allergies and describe reaction ? Include
immunization history ? Take the list to all
doctor visits and medical testing labs, as well
as pre-assessment visit for admission or surgery
and all hospital visits including ER ? When you
leave the hospital, be sure to update your list
with new medications and ask if any medications
are duplicated ? Keep this list in with you at
all times
39
Staff education
  • Include staff ed rep on your team
  • Create simple template clarifying the steps to be
    taken to complete reconciling
  • Lead off with examples of errors from your own
    hospital
  • Use front line staff from pilot unit to educate
    staff on subsequent units
  • Build into orientation, ongoing staff ed
  • Publish your data and progress in your
    organizations newsletter

40
  • Measurement

41
Just-enough measurement
  • Core measure
  • Percent Medications Unreconciled
  • Orders changed, great catches, stories
  • Measures linked to each test, for example
  • patients with reconciling form in chart
  • RN/MD assessments of process
  • Spread patients on units w/ reconciling
  • Context of institution-wide ADE reduction

42
Medications Unreconciled(per 100 Admissions)
Luther Midelfort Implementation Impact
43
Baseline data collection
  • GOAL Identify current safety risks
  • How complete is info on patients pre-admission
    meds? How hard to find? In multiple places?
  • How often are home meds omitted from admit
    orders? not re-started after transfer, at
    discharge? duplicate therapies at discharge?

44
Example Why is it Needed?
  • In a chart review of our admit orders, we found
    an average of over 4 discrepancies per patient,
    with omitted medications the most significant
    error.
  • Source University of Kansas Hospital
  • Terry Rusconi 2003

45
Collecting your data
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47
Baseline practical process
  • Multidisiplinary team of reviewers
  • RN, MD, Pharm... QI rep to combine
  • Minimum 20 charts
  • Institution-wide, random or stratify to ensure
    all units represented
  • Minimum stay of 3 days
  • Can be fruitful to include re-admits
  • Find home meds and list on form
  • Compare to admit orders
  • Identify unreconciled medications

48
Ongoing data collection
  • Need frequent measurement on every unit where you
    are testing monthly charts to display on unit
  • Process easy for patients where the reconciling
    form has been completed follow process used in
    baseline data collection when no reconciling form
  • DONT CHEAT
  • Dont skip patients without a reconciling form
  • Dont just look for home med list the question
    is, have the home meds been RECONCILED?

49
TIPS on collecting your data...
  • Share responsibilities, engaging implementers
  • Limit sample 20 charts
  • Real-time review patients on unit for 24 hours
  • Establish rules for consistent treatment where
    judgment required (omission or obvious hold or
    d/c based on patient condition but strategy
    should encourage increased documentation by
    prescriber)
  • Set time limit (when unable to find home meds,
    use list from admit orders and indicate that all
    are unreconciled)
  • Share Great Catches examples of orders
    changed, errors prevented

50
  • Beyond Admission
  • and
  • Longer-term Considerations

51
Reconciling at Transfer
  • Compare most recent med record (MAR) and home med
    list against transfer orders. Issues
  • Access to reconciling form with home med history
    at point when new orders written
  • Need to modify reconciling form to add columns
    for reconciling at transfer?
  • Identifying responsibilities of both the
    transferring and the receiving unit
  • Embedding into workflow Who writes transfer
    orders? When? Where?

52
Reconciling at Discharge
  • Patients especially vulnerable immediately
    post-discharge
  • Over 12 of patients with an ADE within 2 weeks
    of discharge Forster 2003
  • Address potential for doubling up based on
    formulary substitutions or other brand/generic
    name confusions
  • Prohibit resume home meds!!!
  • Verification of dosing instructions

53
Outpatient Settings
  • Applies to settings where the outpatient
  • may receive medication
  • where patient's response to treatment might be
    affected by medications they are on
  • where a practitioner who can review and modify
    the patient's medications is a part of the
    outpatient service
  • Examples include outpatient oncology services, GI
    laboratories, emergency department, urgent care
    clinics, certain imaging procedures.

54
Using as an order sheet
  • Proceed with caution, but efficiency gains
  • Most MDs find it very helpful makes their life
    easier, decreases duplication
  • Timing 6-10 months into the process?
  • Modifications to reconciling form
  • Add MD signature line(s)
  • Columns to indicate continue or discontinue
  • Amendment form

55
Automation
  • If you cant do it on paper,
  • dont even try it in vapor
  • First must have a stable process adequate
    testing of the form, implementation on multiple
    units
  • Careful design required who enters info, who can
    update/change, may introduce new errors

56
Automation John Hopkins ICU project
  • Revised form to strike balance between burden of
    data collection and comprehensiveness of
    medication information
  • Automated process after 48 weeks, paper forms
    converted to electronic form
  • Intervention now takes 20 minutes on admission
    and 20 minutes at discharge with minimal marginal
    costs

57
Better access to medication histories
  • Promote patients maintaining medication cards
  • Provide in ED, at discharge
  • Disease specific support groups
  • Pharmacy medication review
  • Senior center (file of life)
  • Partner with PCPs, nursing homes, VNA, health
    plans

58
Better access to medication histories
  • Interview strategies including increased use of
    open ended questions
  • Link medications to conditions, prescribing
    physicians
  • Checklists of OTCs/herbals and commonly missed
    meds
  • Leverage expertise of VNAS
  • Shared databases
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