Title: Reconciling Medications
1Reconciling Medications
- Safe Practice Recommendations
- and
- Implementation Strategies
2Medication 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
3Reconciling 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
5Problem 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
6Medication 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
7Examples 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)
8Unintended 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 2004Â
9More 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 11THE 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.
12Reconciling 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)
13BECOMING 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!
14Getting started
- Initiate leadership dialog resource commitment,
regular reporting channels - Form a multidisciplinary team
- Risk assessment/baseline measurement
- Aim statement, timeline
- Pick pilot unit
- Begin testing
15Define 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.
161. 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
171. 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
181. 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
192. 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...
20Project 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
213. 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
23Resource 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)
24Post 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
25Tips 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
26Baseline 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!!
27Mission
- 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
28Choosing 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
29Start 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) -
30Pilot unit
- Mini-team including nurse managers, front-line
nurses, MD champion - Project introduction, staff education
- Baseline measurement for the unit
- Pick reconciling form to test (steal
shamelessly...) - Begin testing
31Piloting 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(No Transcript)
33(No Transcript)
34Fundamental 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
35Culture...
- 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(No Transcript)
37Challenges 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
38Medication 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
39Staff 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 41Just-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
43Baseline 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?
44Example 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
45Collecting your data
46(No Transcript)
47Baseline 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
48Ongoing 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?
49TIPS 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
51Reconciling 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? -
52Reconciling 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
-
53Outpatient 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. -
54Using 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
55Automation
- 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
56Automation 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
57Better 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
58Better 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