Spotlight

1. Spotlight Medication Reconciliation With a Twist (or Dare We Say, a Patch?)

2. Source and Credits • This presentation is based on the May 2014AHRQ WebM&M Spotlight Case • See the full article at http://webmm.ahrq.gov • CME credit is available • Commentary by: Janice Kwan, MD, Department of Medicine, University of Toronto • Editor, AHRQ WebM&M: Robert M. Wachter, MD • Spotlight Editor: Bradley A. Sharpe, MD • Managing Editor: Erin E. Hartman, MS

3. Objectives At the conclusion of this educational activity, participants should be able to: • Appreciate that medication discrepancies are common across the care continuum • Define the Best Possible Medication History (BPMH) & how to optimally obtain it • Understand that transdermal patches have a heightened propensity for error • List different approaches for improving medication reconciliation • Describe the overall evidence supporting medication reconciliation

4. Case: Medication Reconciliation An 80-year-old woman with a history of dementia was admitted with abdominal pain and diagnosed with a bowel obstruction secondary to a new diagnosis of colon cancer. She underwent an uncomplicated surgical resection of the colon with relief of the obstruction. Postoperatively she developed confusion and agitation consistent with acute delirium. At this hospital, a geriatric psychiatry consulting service helped manage postoperative delirium. As part of their evaluation, they reviewed the patient's current and prior medications to determine possible triggers and optimize treatment. They spoke directly with the family and reviewed the official medication reconciliation list, which had been performed by a pharmacist at admission.

5. Case: Medication Reconciliation (2) Although the family stated the patient was on a "memory medicine," reconciliation did not include anything for dementia. Based on this discrepancy, the consulting service contacted the outpatient pharmacy and learned the patient was prescribed a cholinesterase inhibitor patch (a medication for dementia), to be replaced weekly. She had not been prescribed the drug during the hospital stay, and the last patch had been placed more than a week earlier. Although many factors likely contributed to postoperative delirium, the geriatrics service felt that abrupt withdrawal of the cholinesterase inhibitor contributed to the episode, making it more severe and prolonged.

6. Background Transitions of care, such as admission to, transfer within, and discharge from the hospital, are vulnerable periods that put patients at increased risk for errors Unintentional changes to patients' medication regimens represent one important category of such errors, which often stem from poor communication and inadvertent information loss Up to 67% of patients have unintentional medication discrepancies during admission to the hospital

7. Background (2) Most unintentional discrepancies are not clinically significant and most patients are not harmed, yet they are still placed at risk Medication reconciliation is formal process for identifying and correcting unintentional medication discrepancies across transitions of care In recent years, we have gained a much more sophisticated understanding of challenges and best practices in medication reconciliation

8. Best Possible Medication History • The Best Possible Medication History (BPMH) is a cornerstone of the medication reconciliation process • The BPMH is comprehensive and includes: • Asystematic process for obtaining a thorough history of all prescribed and non-prescribed medications by using a structured patient and/or family interview • Verification of this information with at least one other reliable source of information

9. This Case • A pharmacist completed an "official medication reconciliation" during a period of care transition • However, the cholinesterase patch was left out of the patient's admission medication list • This omission resulted in unnecessary and preventable injury to the patient • This case also highlights the power of BPMH and verification of information (if possible) • The geriatrics consulting team eventually determined the BPMH in collaboration with the outpatient pharmacist

10. Transdermal Patches • Transdermal patches are used for many medications including opiates, hormonal therapy, nicotine, and cholinesterase inhibitors • These patches may be associated with more errors due to inconsistencies in dosing intervals, in addition to patch design, placement, and identification • This case is a good reminder to always include transdermal medications in the structured medication interview

11. Physician Awareness • Evidence suggests physicians are aware of the need for medication reconciliation • There are many barriers and true robust medication reconciliation often does not happen

12. Approaches to Medication Reconciliation • Performing robust, thorough, and accurate medication reconciliation during transitions in care involves: • Interprofessional collaboration among pharmacists, nurses, and physicians • Integrating medication reconciliation into discharge summaries • Combining reconciliation with medication counseling with patients

13. Approaches to Medication Reconciliation (2) • Medication reconciliation can be "bundled" with other interventions: • Individualized counseling of patients • Coordination of follow-up appointments • Post-discharge telephone calls • Involvement of a care coordinator or nurse discharge advocate

14. Evidence in Support • Systematic reviews have shown medication reconciliation has many potential benefits: • Reducing clinically significant medication discrepancies • Decreasing potential and confirmed adverse drug events • Alone it does not reduce post-discharge utilization but may do so when bundled with other interventions (see above)

15. Patient Safety Goal • Medication reconciliation widely embraced as an important patient safety strategy worldwide • The World Health Organization prioritized it as one of its top five patient safety goals • Multiple national campaigns champion medication reconciliation • The Joint Commission declared it a National Patient Safety Goal in 2005 • Due to concerns over implementation challenges, a modified, more attainable goal was released in 2011: • Maintain and communicate accurate patient medication information across different points of care

16. Pharmacists Are frequently integral to the medication reconciliation process Yet, may not be the best solution: pharmacists often have other essential tasks to carry out Often best to target "high-risk" patients—those most at risk of an adverse drug event during transitions of care

17. Determining High-Risk Patients • Research suggests the following are high risks: • Older age (55–80 years) • Polypharmacy (4–13 medications) • More than 3 comorbid conditions • Not yet clear evidence that using these criteria to identify patients will reduce medication discrepancies • However, such criteria might be a useful starting point to identify highest risk patients

18. Health Information Technology Health information technology (IT) has been lauded as a solution for challenges in medication reconciliation A consensus statement issued by the Society of Hospital Medicine (SHM) highlighted the power of health IT

19. Statement by SHM • The consensus statement by SHM recommended: • An integrated and transferable personal health record • This record must be compatible across all settings (interoperability and accessibility for different systems)

20. Other Uses of Health IT • In addition to personal health records, information technology has been utilized in many different ways to improve the medication reconciliation process: • Tracking medications across sites of care • Allowing for an active comparison of medications and clarification of discrepancies • These IT interventions have shown variable effectiveness in improving medication reconciliation

21. Future for Medication Reconciliation • Medication reconciliation is a widely recommended patient safety strategy • It demonstrates promise for making meaningful improvements in health care quality and safety • Future research should focus on • Determining the highest risk patients • Building tools which allow institutions to identify such patients • Exploring health IT−based interventions

22. Future for Medication Reconciliation (2) Whether medication reconciliation is a high-value patient safety strategy where costs (financial and otherwise) outweigh benefits remains to be seen To date, studies seem to indicate the benefits outweigh the costs This case illustrates the capacity for medication reconciliation to identify and correct unintentional medication discrepancies with potential to prevent patient harm at care transitions when completed appropriately

23. Take-Home Points Transitions of care are vulnerable periods due to poor communication and inadvertent information loss. Unintentional changes to patients' medication regimens are a well-documented category of such errors Medication reconciliation is formal process for identifying and correcting unintentional medication discrepancies across transitions of care Although medication reconciliation has been widely embraced, implementation has been challenging, and its evidence base has been supportive, but not definitive

24. Take-Home Points (2) Targeting this resource-intensive intervention towards patients with high-risk features, such as older age, polypharmacy, or multimorbidity, may improve the effectiveness Transdermal patches have a heightened propensity for error due to inconsistencies in dosing intervals, in addition to patch design, placement, and identification. Remember to include transdermal medications in structured medication interviews