Medication Reconciliation

1
Medication Reconciliation

• Implementation at Southwest Washington Medical
  Center

Lonnye Finneman, PharmD
2
Southwest Washington Medical Center

• 442-bed hospital and medical center
• Emergency Department/Urgent Care
• Cancer Center
• Family Medicine Medical Residency Clinic
• Healthy Steps Women and Childrens Clinic
• Home Health/ Hospice/Hospice House
• Interventional Pain Clinic

3
Benchmarking

• Pharmacy Quality Improvement Project
• IHI 100K Lives Campaign
• Portland- Vancouver Citywide Group
• Other Hospital Tools/Processes
• Massachusetts Coalition
• OSF Medical Center
• Luther Midelfort
• Northwest Area Hospitals

4
Historical Processes

• Admission
• Medication Profile- section for Home Meds
• ED/H P- separate documentation of home meds
• No Process to Reconcile
• Transfer
• Transfer/Post-Op Med Update Form
• Discharge
• Discharge Order- place to document Med Rx
• Only sent to PCP if box checked

5
Admission

• Baseline Chart Review
• 10 patients
• 70 had Admission Med Profiles that were not
  complete or accurate
• 70 had multiple med lists that did not match
• 17 unreconciled medications per the 10 patients
• We knew we had a lot of work to do!!!

6
Admission Pilot

• Initial Pilot- Reconciliation Form with 1 nurse
• Required too much nurse time (actual
  reconciliation)
• Required contacting provider
• Revision 2
• Made form an order
• Required double documentation as not approved yet
• Recognized difficulty in having provider complete
  their sections

7
Admission Pilot cont

• Revision 3
• Expanded Pilot- one nursing unit
• Got approval
• Educated providers/nurses/pharmacists
• Piloted for 1 month

8
Admission Pilot Results
9
Pilot Feedback

• Rename the form
• Simplify
• Add section that states No Home Medications
• How do we handle medications already ordered on
  admit?
• What if patient/family cannot provide
  information?
• Physicians not completing the form and form gets
  buried in the chart

10
Current Admission Revision

• Revision 4
• Incorporated Recommendations from Feedback
• Will pilot the new form on the pilot unit
• Reeducate providers
• Finalize workflow processes
• Do not want to roll it out to other units until
  ready

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Admission- Biggest Barriers

• Gathering complete information
• Physician education/leadership
• Surgery
• Emergency Department
• Culture Change

12
Transfer

• Transfer/Post-Op Medication Update form
• Provides list of current medications with a Yes
  or No for provider to indicate its future
  status
• Fulfills requirement as long as it is used
  appropriately
• Barriers/Questions
• Cath Lab
• Diagnostic Imaging
• Post-Op (if not in hospital prior to surgery)-
  goes along with admission

13
Discharge

• Discharge Planning Meeting
• Nurses
• Unit Secretaries
• Pharmacists
• Care Management
• Information Systems
• Discharge Process Flow Chart
• No Standardized Process
• Not always communicated to next level of service

14
Discharge Plan

• Tools already available
• AcuScan Patient Profile
• AcuScan Shift Summary
• Admission Medication Profile
• Process
• Print all 3 forms for provider use at discharge
• Fax discharge form to PCP
• Future
• Electronic Form with active/home meds serves as
  RX

15
Discharge Barriers

• Time
• Provider Time- completing discharge prescriptions
• Unit secretary/nurse- faxing discharge form
• Ensuring the Provider actually reconciled the
  medications
• City Call Patients or Out of Town Patients

16
Task Forces

• Inpatient/Perioperative/Family Birth Center
• Emergency Department
• Outpatient Services
• Community
• Physician Leadership
• Clinical Information System Support

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Inpatient/Periop/FBC

• Pilot Unit
• General Medicine/Peds/Post-Op patients (and even
  some FBC patients)
• Meeting with Perioperative Services Separately
• SDS Processes
• Post-Op- Resume Home Medications
• Discharge Prescriptions
• FBC processes- similar to rest of hospital

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Emergency Department

• Initial Resistance
• Time/Workload is large barrier
• Feedback from providers- need to start process in
  ED
• Goal ED Completes the Form Initially (instead
  of documenting in 2 different places)
• ED may have the best chance to document complete
  list

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Outpatient Services

• Home Health/Hospice
• Cancer Center
• Urgency Care
• Family Medicine Medical Resident Clinic
• Healthy Steps Womens and Childrens Center
• GOAL Developing standardized form for
  documenting/verifying home medications

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Community

• Standardized Personal Medication Record
• Portland/Vancouver area Citywide group finalizing
• Will market to whole community
• Physician Offices
• Monthly meetings
• Encouraging them to keep updated patient
  medication list

21
Physician Leadership

• Oversight through Pharmacy and Therapeutics
  Committee
• Memo to providers in community
• 4 Hospitalist Groups
• Education presented to each
• One-on-one real time education on pilot unit

22
Clinical Information System (CIS)

• New CIS began implementation in Spring 05
• New Pharmacy System to implement June 06
• CPOE to implement in 2007
• Current, Pilot, and Future Flow Charts Developed
• Goal Electronic Medication Closed Loop System

23
Medication Reconciliation Pearls

• Focus on Patient Safety (and not JCAHO)
• Gain Support Early (especially provider support)
• Do Not Rush the Process
• Do Not Reinvent the wheel but adapt to own
  institution
• Reach out to the community
• Have core group to take responsibility (members
  enthused about medication safety)

24
Medication Reconciliation Pearls

• Expect Barriers and Do Your Best to Overcome
• Involve Information Systems Support
• Flowchart the Process (Current and Future)
• Continually evaluate new processes- Feedback

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• Do Not Let the Perfect Get in the Way of the
  Good