SHN-CAPHC Paediatric Medication Reconciliation Orientation and Training Workshop August 9, 10, 2005

1. SHN-CAPHC Paediatric Medication Reconciliation Orientation and Training WorkshopAugust 9, 10, 2005 Margaret Colquhoun Project Leader ISMP Canada

2. Agenda About ISMP Canada Partnership with SHN, CAPHC The Canadian Getting Started Kit What is in it? What is different? Next Steps

3. ISMP Canada Vision Realizing an international network that shares recommendations for the prevention of medication error-induced patient injuries.

4. ISMP Canada Mission: Committed to the safe use of medication through improvement in drug distribution and drug delivery system design. Collaborate with healthcare practitioners and institutions, schools, professional organizations, pharmaceutical industry and regulatory & government agencies to provide education about adverse drug events and their prevention

5. ISMP Canada Voluntary incident reporting Errors, near-misses and hazardous situations Confidential Non-punitive Front-line practitioners provide detailed, unrestricted information on incidents Analysis & recommendation of prevention strategies

6. Publications: Newsletters ISMP Canada Safety Bulletin (monthly)

7. Bulletin Excerpt

8. How Error Reports are received: website: www.ismp-canada.org; e-mail: info@ismp-canada.org; Phone: 1-866-54-ISMPC [47672] or 416-480-4099. ISMP Canada guarantees confidentiality and security of information received. ISMP Canada respects the wishes of the reporter as to the level of detail to be included in publications.

9. CMIRPS (Canadian Medication Incident Reporting and Prevention System) 3 partners: ISMP Canada, Canadian Institute for Health Information (CIHI) Health Canada ISMP Canada Programs

10. Safer Healthcare Now! 12 month Fellowship program Hospital Consultations CPSI/ISMP Canada Root Cause Analysis (RCA) workshops Failure Mode and Effects Analysis (FMEA) Education/ Presentations ISMP Canada Programs

11. Canadian Council on Health Services Accreditation (CCHSA) Collaborative Patient Safety Project New standard 14.5 - MSSA Review and revisions of standards related to medication use Collaborative workshops ISMP Canada Programs

12. ISMP Canada Programs Medication Safety Support Service � Ontario Potassium Chloride Narcotics (opioids) Long term care EMS Error Reporting Alberta Medication Safety Collaborative MSSA � British Columbia

13. �Canadianizing� the Medication Reconciliation Starter Kit Partnership with CPSI The Process: Multidisciplinary review Canadian references and experiences Canadian tools A new Canadian conceptual framework CAPHC conference feedback � a work in progress

14. Getting Started with Medication Reconciliation � the Kit Contents: The goal The case What is medication reconciliation? Potential impact Why there is a problem Model for improvement How to conduct medication reconciliation

15. Other Contents Guide Potential barriers Tips for data collection Tips for interviewing patients Data collection tools Data reporting tools Sample reconciliation tools Sample policies and procedures Online forms Staff education Suggested literature

16. The Goal The goal of medication reconciliation is to eliminate: Undocumented intentional discrepancies Unintentional discrepancies Potential Harm to patients

17. The Case 2004 study, Forster et.al., found �23% incidence of adverse events in patients discharged from internal medicine service, of which 72% were ADEs� �53.6% of 151 patients (>4 meds) had at least one unintended discrepancy. 38.6% had potential to cause moderate to severe discomfort or clinical deterioration�

18. The Case Cont�d 2001 UK Audit Commission report �A Spoonful of Sugar� states � ..at some hospitals visited 30% of patients had incorrect or incomplete medicines or allergies recorded on admission�

19. What is Medication Reconciliation ? �a formal process of obtaining a complete and accurate list of each patient�s current home medications � including name, dosage, frequency and route � and comparing the physician�s admission, transfer, and/or discharge orders to that list. Discrepancies are brought to the attention of the prescriber and, if appropriate, changes are made to the orders. Any resulting changes in orders are documented.�1

20. Potential Impact of Medication Reconciliation A series of interventions, including medication reconciliation, decreased the rate of medication errors by 70% and reduced adverse drug events by over 15%.1 Initiating reconciling process by obtaining medication histories for the scheduled surgical population reduced potential adverse drug events by 80% within three months of implementation.2 Successful medication reconciling process reduces work and re-works associated with the management of medication orders. After implementation, nursing time at admission was reduced by over 20 minutes per patient. The amount of time pharmacists were involved in discharge was reduced by over 40 minutes.3 1 Whittington J, Cohen H. OSF Healthcare�s journey in patient safety. Qual Manag Health Care. 2004;13(1):53-59. 2 Michels RD, Meisel S. Program using pharmacy technicians to obtain medication histories. Am J Health-Sys Pharm. 2003;60:1982-1986. 3 Rozich JD, Howard RJ, Justeson JM, Macken PD, Lindsay ME, Resar RK. Standardization as a mechanism to improve safety in health care: impact of sliding scale insulin protocol and reconciliation of medications initiatives. Jt Comm J Qual Saf. 2004;30(1):5-14.

21. Why Is there a Problem? Low priority No clear owner Lack of understanding of potential impact No established criteria No standardized process Patients do not know how important it is to know what they are taking

22. Model for Improvement Set clear aims Establish measures to identify whether a change is an improvement Identify changes that are likely to lead to improvement PDSA cycle

23. How Do We Do This? Secure Leadership Commitment Form a team Collect Baseline Data Set Aims (Goals and Objectives) Start with a Pilot Project & Begin to Learn How to Reconcile Medications Continue to Implement Medication Reconciliation, Test Results and Spread Evaluate

24. 1. Leadership Establish clear goals Identify Executive Sponsor Identify and remove potential barriers Allocate dedicated resources Develop a framework for monitoring and evaluation Communicate continuously with front line staff regarding progress and successes at critical stages of the project Consider incentives or special recognition

25. 2. The Team Executive sponsor Clinical leaders: physicians, nursing and pharmacy staff Front line caregivers from key settings of care, and from all shifts Representatives from patient safety (e.g. Patient Safety Officer, Quality Improvement/Risk Management, Patient Representatives, Pharmacy and Therapeutics committee)

26. 3. Collecting Baseline Data Review medication histories and admission medication orders on 10 - 20 current cases over the course of one week. Let the normal process of taking a medication history (primary medication history (PMH) occur. Get a best possible medication history (BPMH). Compare the admission medication orders (AMO) with the best possible medication history (BPMH) to identify any discrepancies. Clarify discrepancies with the ordering or most responsible physician Identify Unintentional Discrepancies (the potential for patient harm) and Undocumented Intentional Discrepancies

27. Conceptual Framework PMH � primary medication history AMO � admission medication orders BPMH � best possible medication history Discrepancies � intentional & unintentional, documented and undocumented

28. Intentional Discrepancy An intentional discrepancy is one in which the physician has made an intentional choice to add, change or discontinue a medication and their choice is clearly documented. This is considered to be �best practice� in medication reconciliation.

29. Undocumented Intentional Discrepancy An undocumented intentional discrepancy is one in which the physician has made an intentional choice to add, change or stop a medication but this choice is not clearly documented.

30. Example of an Undocumented Intentional Discrepancy A patient on a maintenance dose of atenolol for hypertension was admitted for surgery.� The surgeon did not order atenolol on admission, due to concerns about perioperative hypotension; however, the reason for not ordering atenolol was not documented in the medical record.� The patient was discharged on the third postoperative day and was given a discharge prescription that did not include atenolol.� The patient was unsure whether to resume treatment with atenolol at home and called his family physician for advice.

31. An Unintentional Discrepancy An unintentional discrepancy is one in which the physician unintentionally changed, added or omitted a medication the patient was taking prior to admission.

32. Unintentional discrepancies are medication errors than can lead to ADE�s. They can be reduced by ensuring good training of nurses/MDs/pharmacists at obtaining in-depth medication histories and by wisely involving clinical pharmacists to identify and reconcile these discrepancies.

33. Example of an Unintentional Discrepancies Patient on multiple medications admitted with stroke.� Admission medication orders included propafenone, based on information in a recent volume of the patient's chart.� A follow-up interview with the patient's family and community pharmacy revealed that this medication had been discontinued one month prior to admission.� Propafenone was stopped.

34. Baseline Data � Concurrent Chart Audits Identifies patients at �hazard� while at �hazard� and immediate actions for improvement can be made. Measures of success: Mean # undocumented intentional discrepancies Mean # unintentional discrepancies Rate of Potential Harm Averted (Percent)

35. 4. Set Aims E.g. Conduct a BPMH on all patients with greater than 5 medications within 24 hours of admission and reconcile discrepancies Reduce the percentage of unintentional discrepancies at admission on pilot unit by 75% in 3 months

36. 5. Pilot Projects Admission High level process map Test a medication reconciliation form Modify form Continue testing and changing

37. 6. Roll Out Pilot Test � PDSA Implement � Define patient groups Define criteria Test tools Spread

38. 7. Evaluate Errors � unintentional discrepancies Documentation Accuracy Potential Harm Averted Run Charts Documented Intentional should become �THE NORM�

41. Mean Number of undocumented intentional discrepancies

43. Mean Number of unintentional discrepancies

45. Rate of Potential Harm Averted (Percent)

47. Run Charts Improvement takes place over time. Run charts are graphs of data over time and are one of the single most important tools in performance improvement.

48. Benefits of Run Charts Help improvement teams formulate aims by depicting how well (or poorly) a process is performing Help in determining when changes are truly improvements by displaying a pattern of data that you can observe as you make changes Give direction as you work on improvement and information about the value of the particular changes

49. Run Chart Example

50. Tips Involve patients and families!!!! Develop criteria for patients who should receive BPMH

51. Medication Reconciliation Not complicated Will take: time, resources, Commitment CAPHC, ISMP Canada, Safer Healthcare Now! will focus on: Sharing Learning

52. Together we will reduce potential adverse outcomes of care related to medications