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Reconciling Medications. Safe Practice Recommendations and Implementation Strategies. Medication Safety Facts. Medication errors account for more than 7,000 deaths annually

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Reconciling medications l.jpg

Reconciling Medications

Safe Practice Recommendations

and

Implementation Strategies


Medication safety facts l.jpg
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


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“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 physician’s 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.


Research l.jpg
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


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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]


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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]


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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)


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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] 


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More evidence on impact:Johns 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]


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The

Reconciling Process


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A process to obtain the best home medication list possible through a defined resource list and active review of the patient’s medical history.

Patient

Pharmacy

Family

Patient’s Med List

PCP

VNA

Utilize strategic interviewing practices.

Ask open ended questions to obtain info on OTC meds & herbals.

THE PROPOSED SOLUTION


Reconciling process admission l.jpg
Reconciling process: admission through a defined resource list and active review of the patient’s medical history.

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)


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BECOMING A STATEWIDE INITIATIVE through a defined resource list and active review of the patient’s medical history.

  • 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!


  • Getting started l.jpg
    Getting started through a defined resource list and active review of the patient’s medical history.

    • Initiate leadership dialog – resource commitment, regular reporting channels

    • Form a multidisciplinary team

    • Risk assessment/baseline measurement

    • Aim statement, timeline

    • Pick pilot unit

    • Begin testing


    Define aim obtain baseline measure l.jpg
    Define Aim / Obtain Baseline Measure through a defined resource list and active review of the patient’s medical history.

    • 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.


    1 getting the home med list l.jpg
    1. Getting the home med list through a defined resource list and active review of the patient’s medical history.

    What have we learned?

    • Adopt standardized form

    • Share responsibilities, ordering prescriber accountable... crew resource management principles

    • Validate with the patient

    • Don’t let perfection be the enemy of the good


    1 getting the home med list17 l.jpg
    1. Getting the home med list through a defined resource list and active review of the patient’s medical history.

    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


    1 getting the home med list18 l.jpg
    1. Getting the home med list through a defined resource list and active review of the patient’s medical history.

    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


    2 using home list when writing orders l.jpg
    2. Using home list when through a defined resource list and active review of the patient’s medical history.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...


    Project phasing l.jpg
    Project phasing through a defined resource list and active review of the patient’s medical history.

    • 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


    3 identifying reconciling discrepancies l.jpg
    3. Identifying, reconciling discrepancies through a defined resource list and active review of the patient’s medical history.

    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


    Slide22 l.jpg

    Implementation Strategies through a defined resource list and active review of the patient’s medical history.


    Resource requirements l.jpg
    Resource requirements through a defined resource list and active review of the patient’s medical history.

    • During testing/implementation phase

      • Make explicit allocation for those with patient care responsibilities

      • Managers need to pay attention to workloads; don’t 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)


    Post team members encourage input l.jpg
    Post Team Members- Encourage Input through a defined resource list and active review of the patient’s medical history.

    • 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


    Tips for engaging mds l.jpg
    Tips for engaging MDs through a defined resource list and active review of the patient’s medical history.

    • 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 (P&T, Medical Records)

    • Chief Medical Resident on the team, with responsibility to report back to other residents


    Baseline risk assessment l.jpg
    Baseline risk assessment through a defined resource list and active review of the patient’s medical history.

    • Chart review

      • Institution-wide

    • Mini-FMEA, flow charting existing processes

      • Do in conjunction with initial tests of change

    • Just-enough measurement/analysis

      • Don’t get bogged down here!!


    Mission l.jpg
    Mission through a defined resource list and active review of the patient’s medical history.

    • 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


    Choosing where to start l.jpg
    Choosing where to start through a defined resource list and active review of the patient’s medical history.

    • Use risk assessment process

    • Willing volunteers

    • At admission logical place

      • Pros & cons: Med vs Surg units

      • Some success starting @ transfer: ICU, CCU, telemetry units

      • Probably not ED


    Start small focus on one unit l.jpg
    Start small, focus on one unit through a defined resource list and active review of the patient’s medical history.

    • 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)


    Pilot unit l.jpg
    Pilot unit through a defined resource list and active review of the patient’s medical history.

    • 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


    Piloting a reconciling form l.jpg
    Piloting a reconciling form through a defined resource list and active review of the patient’s medical history.

    • 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


    Fundamental ingredients l.jpg
    Fundamental ingredients... through a defined resource list and active review of the patient’s medical history.

    • 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


    Culture l.jpg
    Culture... through a defined resource list and active review of the patient’s medical history.

    • Core issues of teamwork and communi-cation... organizational culture matters

    • Changing the way people do work; every time you try to change behavior, it’s only natural to be met with resistance

      • Recognize that this is HARD;

        Difficult task: but not impossible

      • Unit briefings/pharmacy rounding


    Challenges and barriers l.jpg
    Challenges and barriers through a defined resource list and active review of the patient’s medical history.

    • Time and resources

      • “How can we find the time to do this?”

    • Roles and responsibilities

      • “It’s not my job”

      • “I’m not going to sign that form”

    • Data collection

      • Need data... but don’t let data collection delay testing, overwhelm


    Medication checklist here s how patients can help the medication reconciliation process l.jpg
    Medication Checklist through a defined resource list and active review of the patient’s medical history.Here’s 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


    Staff education l.jpg
    Staff education through a defined resource list and active review of the patient’s medical history.

    • 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


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    Measurement through a defined resource list and active review of the patient’s medical history.


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    Just-enough measurement through a defined resource list and active review of the patient’s medical history.

    • 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


    Medications unreconciled per 100 admissions l.jpg
    # Medications Unreconciled through a defined resource list and active review of the patient’s medical history.(per 100 Admissions)

    Luther Midelfort Implementation Impact


    Baseline data collection l.jpg
    Baseline data collection through a defined resource list and active review of the patient’s medical history.

    • GOAL: Identify current safety risks

      • How complete is info on patient’s 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?


    Example why is it needed l.jpg
    Example: Why is it Needed? through a defined resource list and active review of the patient’s medical history.

    • 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]


    Collecting your data l.jpg

    Is through a defined resource list and active review of the patient’s medical history.

    Do

    discrepa

    Are Admitting

    Elements

    Medication List

    ncy

    Meds

    Data

    of List

    Admitting Medication

    Frequency

    Frequency

    No.

    Admitting Medications

    Documented on -

    intention

    Comments

    Dose (1)

    Route (3)

    Dose (6)

    Route (8)

    Addressed By

    (2)

    Source

    Match?

    Orders

    (7)

    MD? (9)

    List all that apply

    al? Y or

    Y or N or

    Y or N or ?

    No or ?

    ? (4)

    (5)

    1

    2

    3

    4

    5

    6

    7

    8

    9

    10

    11

    12

    Lists Documented

    Total (1) Blanks

    Total (5) N or ?

    Data Source:

    On:

    Total (2) Blanks

    Total (9) N or ?

    P = patient

    V = VNA

    100 - ED sheet

    Total (3) Blanks

    Total (6) Blanks

    F = family

    N = Nursing home

    200 - RN admission

    Number of Meds

    Total (7) Blanks

    Rx - RX bottle

    C = Pharmacy

    300 - H & PE

    Total (8) Blanks

    H = History

    400 - PAT form

    Total ordered meds

    M = MD office

    500 - None

    Collecting your data


    Baseline practical process l.jpg
    Baseline: practical process through a defined resource list and active review of the patient’s medical history.

    • 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”


    Ongoing data collection l.jpg
    Ongoing data collection through a defined resource list and active review of the patient’s medical history.

    • 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

    • DON’T CHEAT:

      • Don’t skip patients without a reconciling form

      • Don’t just look for home med list; the question is, have the home meds been RECONCILED?


    Tips on collecting your data l.jpg
    TIPS on collecting your data... through a defined resource list and active review of the patient’s medical history.

    • 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


    Slide50 l.jpg

    Beyond Admission through a defined resource list and active review of the patient’s medical history.

    and

    Longer-term Considerations


    Reconciling at transfer l.jpg
    Reconciling at Transfer through a defined resource list and active review of the patient’s medical history.

    • 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?


    Reconciling at discharge l.jpg
    Reconciling at Discharge through a defined resource list and active review of the patient’s medical history.

    • 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


    Outpatient settings l.jpg
    Outpatient Settings through a defined resource list and active review of the patient’s medical history.

    • 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.


    Using as an order sheet l.jpg
    Using as an order sheet through a defined resource list and active review of the patient’s medical history.

    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


    Automation l.jpg
    Automation through a defined resource list and active review of the patient’s medical history.

    If you can’t do it on paper,

    don’t 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


    Automation john hopkins icu project l.jpg
    Automation: John Hopkins ICU project through a defined resource list and active review of the patient’s medical history.

    • 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


    Better access to medication histories l.jpg
    Better access to medication histories through a defined resource list and active review of the patient’s medical history.

    • 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


    Better access to medication histories58 l.jpg
    Better access to medication histories through a defined resource list and active review of the patient’s medical history.

    • 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