You are the Answer:

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You are the Answer

• Nurses Save Patients with Medication
  Reconciliation
• Karla Davis, Mary Hanna,
• Alicia Hegwood, Lisa Sims

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1999 Institute of Medicine (IOM) ReportTo Err is
Human.

• Medication errors occur frequently and most are
  due to process failures
• 2009 TJC- National Patient Safety Goal
• Accurately and completely reconcile medications
  across the continuum of care.
• When a patient leaves the organizations care a
  complete and reconciled list of the patients
  medications is provided
• Directly to the Patient/Family
• Explained to the Patient/Family.

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Research Question

• Have medication errors decreased during the
  transition from acute care to home, in the adult
  population, since initiation of the requirements
  for medication reconciliation by The Joint
  Commission 2005 National Patient Safety Goals?

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Case Study 1

• 49 YO female IDDM, kidney transplant, Breast CA
  with spinal metastasis
• Admitted for vertebroplasty kyphoplasty
• 9/3 DC home
• 9/6 Presented to another hospital with fever
• MR noted low grade fevers, BC for Gram cocci
  / Gram - rods
• 9/8 Transferred to primary hospital
• Febrile MD failed to continue Gram AB coverage

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Critical Thinking

• Would medication reconciliation have avoided this
  error from occurring? If so, how?
• What is the process at your organization for
  external transfer patients and would it have been
  able to prevent a similar event from occurring?
• What disciplines are expected to reconcile
  medications for external transfer patients at
  your organization?

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Always Remember

• External transfer is a vulnerable process for
  medication error
• You are the patients last line of defense

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Case Study 2

• 87 YO male PHH - CAD, HF, Afib, HTN, severe MR
• 4/17 Anemic- Colonoscopy/EGD to R/O GI bleed
• Warfarin held for one week as prep for procedure
• Discharge- No ASA/NSAIDS for 10 days
  post-procedure
• 4/19 F/U with cardiologist
• 4/26 Missed Warfarin Clinic
• 4/31 Admitted with left side weakness, slurred
  speech, AMS
• CT negative, INR 1.2
• 5/01 - Repeat CT positive for ischemic CVA

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Critical Thinking Questions

• At what point in the hospital stay was medication
  reconciliation done?
• When is medication reconciliation required by
  Joint Commission?
• What could have been done differently to avoid
  this mediation error from occurring?

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And The Answers Are

• Medication Reconciliation- ALL transitions of
  care
• Updated Home Medication Record
• Patient
• Next provider of care
• Counsel patients on changes at discharge
• Increase compliance
• Decrease harm

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The Case for Medication Reconciliation

• Adverse events after discharge to home
• 19 of US patients
• 23 of Canadian patients
• In 2003, over 38 million Americans were
  discharged from hospitals

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Literature Review

• Key words
• medication reconciliation, discharge,
  medicine reconcile, and patient safety
• Databases accessed
• CINAHL
• ProQuest
• PubMed
• Cochrane
• HealthSource Nursing Academic Edition
• Cochrane Reviews
• No Systematic Reviews
• 3 Clinical Trials

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Levels of Evidence

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Bell, et al.

• Level of Evidence- Level IV
• Mode- Ex post facto
• Setting
• Population
• Sample
• Findings

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Varkey, et al.

• Level of Evidence- Level III
• Mode- Correlation quantitative quasiexperimental
• Setting
• Population
• Findings

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Holzmueller, et al.

• Level of Evidence- Level III
• Correlation quantitative quasiexperimental
• Setting
• Population
• Findings

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Vira, et al.

• Level of Evidence- Level IV
• Mode- Prospective, descriptive, nonexperimental
• Setting
• Population
• Findings

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Ethical Issues

• 3 Self-Executed Studies
• 1 Unknown Outside Agency

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Findings

• Positive relationship exists between MR processes
  medication errors
• Risk for morbidity-20 to 25 of chronic
  life-sustaining medications unintentionally
  discontinued (Bell, et al.)
• Implementation of MR process
• Post MR implementation the error rate improved
  42 to 0.74 errors per patient (Holzmueller, et
  al.)

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Findings

• Preliminary MR process (Varkey, et al.)
• Significant number of medication errors were
  noted
• Medication errors increased as medications at
  discharge increased
• MR process reduced discrepancies by 50 and
  significantly decreased the severity of ADE
• Vira, et al. reported
• 51 patients required physician intervention
• 9 pts had orgt 10 clinically important dc
  variances

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Best Practice

• Three Step Process
• Verification
• Clarification
• Reconciliation

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Best Practice Guidelines

• Four guidelines with complete toolkits
• Health Care Association of New Jersey, 2006
• 5 Million Lives Campaign, IHI, 2008
• Legacy Health System, 2008
• The Carolinas Center for Medical Excellence, 2005
• All Included
• Role Delineation
• References

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Fax Cover Sheet

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Challenges

• Change fatigue
• Just another task
• No plug and play
• High levels of continuum of care
• Electronic health records not connected
• Source of information- not knowledgeable
• MR is expensive
• (Thompson, K. K., 2007)

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Recommendations

• Standardize Discharge Medication Reconciliation
  Process
• Flow Chart
• Medication Reconciliation Form at discharge-
  include medications to be STOPPED.
• Discharge Medication List
• Sent to primary care provider or next level of
  care with verification of receiving document.

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Conclusion

• Complexity slows and frustrates the MR process
• Make process simple as possible
• Nursing owns the process

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Questions???
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References

• 5 Million Lives Campaign. (2008). Getting started
  kit Prevent adverse drug events (medication
  reconciliation) how-to guide. Cambridge, MA
  Institute for Healthcare Improvement. Retrieved
  November 16, 2008, from http//www.ihi.org/NR/rdon
  lyres/98096387-C903-4252-8276-
  5BFC181C0C7F/0/ADEHowtoGuide.doc.Bell, C. M.,
  Rahimi- Darabad, P., Orner, A. I. (2006).
  Discontinuity of chronic medications in patients
  discharged from the intensive care unit. Journal
  of General Internal Medicine, 21(6), 937-941.
  Retrieved September 1, 2008, from
  http//www.pubmedcentral.nih.gov/articlerender.fcg
  i?artid1831608. Best Practice Committee of the
  Health Care Association of New Jersey. (2006).
  Health Care Association of New Jersey Medication
  Management Guideline. Retrieved November 10,
  2008, from http//www.hcanj.org/docs/hcanjbp_medmg
  mt.pdf. Delate, T., Chester, E. A., Stubbings,
  T. W., Barnes, C. A. (2008) Clinical outcomes
  of home-based medication reconciliation program
  after discharge from a skilled nursing facility.
  Pharmacotherapy, 28, 444-452. Aurora, CO
  Department of Pharmacy, Kaiser Permanente
  Colorado. Retrieved November 19, 2008, from
  Cochrane database.Finkleman, A. W. (2006).
  Leadership and management in nursing. Upper
  Saddle River, NJ Prentice Hall.Greenwald, J.
  L., Denham, C. R., Jack, B. W. (2007). The
  hospital discharge A review of a high risk care
  transition with highlights of a reengineered
  discharge process. Journal of patient safety The
  official publication of National Patient Safety
  Foundation, 3(2), 97-106. Retrieved October 9,
  2008, from Auburn University Montgomery -
  Interlibrary Loan. Holzmueller, C. G., Hobson,
  D., Berenholtz, S. M., Feroli, E. R., et al.
  (2006). Medication reconciliation Are we meeting
  the requirements? Journal of Clinical Outcomes
  Management, 13(8), 441-444. Located on CINAHL
  with Full Text. Retrieved October 10, 2008, from
  Auburn University Montgomery Library
  Interlibrary Loan.Institute of Medicine.
  (2000). To err is human Building a safer health
  system. Retrieved November 19, 2008, from
  http//www.iom.edu/Object.File/Master/4/117/ToErr-
  8pager.pdf Legacy Health System, (2008).
  Flowchart for medication reconciliation at
  discharge. Retrieved November 8, 2008, from
  http//www.legacyhealth.org/body.cfm?id1878http/
  /www.legacyhealth.org/documents/Medication20Recon
  ciliation/Flowcharts/EchartDischarge.pdf.Manning,
  D. M., O'Meara, J. G., Williams, A. R., Rahman,
  A., Myhre, D., Tammel, K. J., Carter, L.C.
  (2007). 3D A tool for medication discharge
  education. Quality Safety in Health Care, 16,
  71-76. Rochester, MN Department of Medicine,
  Mayo Clinic. Retrieved November 19, 2008, from
  Cochrane database.

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References

• Manno, M. S., Hayes, D. D. (2006). Best
  practice interventions How medication
  reconciliation saves lives. Nursing 2006, March.
  Retrieved November 10, 2008, from CINAHL with
  Full Text http//aumnicat.aum.edu2055/ehost/pdf?v
  id5hid3sidf1c7dec3-588d-40e0-859d-6a11bb7f2d0
  840sessionmgr8.Nickerson, A., MacKinnon, N.
  J., Roberts, N., Saulnier, L. (2005).
  Drug-therapy problems, inconsistencies and
  omissions identified during a medication
  reconciliation and seamless care service.
  Healthcare Quarterly (Toronto, Ont.), 8, 65-72.
  Moncton, NB South-East Regional Health
  Authority. Retrieved November 19, 2008, from
  Cochrane database.The Joint Commission. (2008).
  The Joint Commission announces 2009 National
  Patient Safety. Retrieved November 10, 2008, from
  http//www.jointcommission.org/NR/rdonlyres/40A723
  3C-C4F7-4680-9861-80CDFD5F62C6/0/09_NPSG_HAP_gp.pd
  fThe Joint Commission. (2005). 2005 Hospitals
  National Patient Safety Goals. Retrieved November
  10, 2008, from http//www.jointcommission.org/NR/r
  donlyres/CA814047-805D-4143-AD3C-0C1944C49E75/0/05
  _hap_npsg.pdf Thompson, K. K. (2007).
  Medication reconciliation Challenges and
  opportunities. American Journal Health Systems
  Pharmacists, 64(9), 1912. Retrieved August 30,
  2008, from ProQuest. Titler, M. (2006).
  Developing an evidence-based practice. Nursing
  research Methods and critical appraisal for
  evidence-based practice, Eds. LoBiondo-Wood, G.
  Haber, J. 6th ed., Chap. 16, p. 450.
  Mosby-Elsevier, St. Louis, MO. Tsilimingras, D
  Bates, D. W. (2008).Performance improvement
  Addressing postdischarge adverse events A
  neglected area. Joint Commission on Accrediation
  of Healthcare Organizations, 34(2), 85-97.
  Retrieved October 08, 2008, from Interlibrary
  Loan. Varkey, P., Cunningham, J., O'Meare,
  J., Bonacci, R., Desai, N., Sheeler, R. (2007).
  Multidisciplinary approach to inpatient
  medication reconciliation in an academic setting.
  American Journal of Health-Systems and
  Pharmacology, 64, 1-12. Retrieved August 30,
  2008, from CINAHL with Full Text. Vira, T.,
  Colquhoun, Etchells, E. (2006). Reconcilable
  differences Correcting medication errors at
  hospital admission and discharge. Quality and
  Safety in Health Care, 15, 122-126 Retrieved
  August 30, 2008, from PubMed Central.