Western Node Collaborative

1. Western Node Collaborative RIVERVIEW HOSPITAL Medication Reconciliation October 2, 2006 Zaheen Rhemtulla B.Sc. (pharm)

2. Riverview Hospital (RVH) As part of British Columbia Mental Health and Addiction Services and governed under the Provincial Health Services Authority, Riverview Hospital provides specialized tertiary mental health services under 3 core programs: - Adult Tertiary Psychiatric Program (225 inpatient beds + 20 ICU beds) specialized tertiary acute care and rehabilitation services to adults living with a serious mental illness - Geriatric Psychiatric Program (145 inpatient beds) assessment and treatment services for inpatients as well as outpatient consultation services to patients who often have needs relating to end-stage dementing illness with severe chronic psychiatric and medical conditions - Neuropsychiatry Program (49 inpatient beds) care to a specialized group of individuals who have cognitive, affective, and psychotic symptoms associated with brain injuries or disease that are beyond the capacity of acute care hospitals and community-based settings

3. Background Information • Recognizing that Medication Reconciliation is an evidence-based intervention that can prevent a high percentage of medication-related adverse events, Riverview Hospital first convened a MedRec team June 2005 in response to the Safer Healthcare Now Campaign and accreditation requirements. • Having supportive executive sponsorship and leadership buy-in, the project now has a committed team of over 15 members from various disciplines including physicians, nurse clinicians, unit managers, pharmacists, and administrative staff as well as a full-time project leader. The team meet on a monthly basis to discuss the progress of the project which is being piloted on 5 wards throughout the hospital. • Goal for incorporating a medication reconciliation process for all transition points of patient care throughout the hospital stay is December 2006

4. Project Charter Based on studies documenting the high percentage of adverse events occurring in hospitals due to medication errors, particularly at points of transition, Riverview Hospital is focused on providing the best possible care to the patients it serves by developing and implementing procedures and systems that result in better documentation and eliminate unintentional medication discrepancies at interfaces of care.

5. Importance • Efficient transitions in care • Better documentation • Better communication • Better safety • Fewer hospitalizations • Decreased costs • Better patient care

6. Reason to adopt • To provide the best possible care to a very vulnerable patient population (e.g. pt’s with psychosis/Dementia) • Create standardization with all other health-care providers in order to provide “seamless care”.

7. Aims • Reduce the mean number of undocumented intentional discrepancies at admission by 75% from baseline by October 2006 on the 5 pilot wards (2 geriatric wards, 2 adult tertiary care wards, 1 ICU) • Reduce the mean number of undocumented unintentional discrepancies at admission by 75% from baseline by October 2006 on the 5 pilot wards • Increase the medication reconciliation rate (success index) to 100% by October 2006 on the 5 pilot wards

8. Medication Reconciliation Team Riverview Hospital Project Leader: Zaheen Rhemtulla zrhemtulla@bcmhs.bc.ca Administrative Leadership: Marilyn Macdougall mmacdougall@bcmhs.bc.ca Risk Management: Peter Owen powen@bcmhs.bc.ca Clinical Support: Jane Dumontet Pharm.D.jdumontet@bcmhs.bc.ca Dr. Heather Cherneski hcherneski@bcmhs.bc.ca Riola Crawford rcrawford@bcmhs.bc.ca Gail Ancill gancill@bcmhs.bc.ca Lesley Bushell lbushell@bcmhs.bc.ca Richard Sanassy rsanassy@bcmhs.bc.ca Tin Au tau@bcmhs.bc.ca Program Support: Ruby Virani rvirani@bcmhs.bc.ca Valerie Eggen veggen@bcmhs.bc.ca Linda Edwards ledwards@bcmhs.bc.ca Forensic Representatives: Ellen Haworth ehaworth@bcmhs.bc.ca Dave Wharton dwharton@bcmhs.bc.ca

9. Where are we in the process? • Admission: BPMH reconciliation on all admissions to the hospital. This process has detected unintended discrepancies which are resolved in a timely manner. Implementing the use of the Medication History and Admission Orders form on all admissions to pilot ward. • Transfer: Providing a “Medication Review” profile for all internal transfers between wards. The nurse from the receiving ward verifies the profile against the current orders. The verified medication profile is then signed by the physician and a copy is sent to pharmacy for updating. Any discrepancies are dealt with immediately.

10. Where are we in the process? • Discharge Trialing a pharmacy computer generated discharge profile indicating all regularly scheduled medications the patient is to be taking upon discharge. The form is to be verified against current orders and signed by the physician(s) upon discharge. PRN medications are to be written in by the physician only if the patient requires them upon discharge. Included on the discharge profile is the last given and next due date of any long-acting injections. Ensuring all wards are sending a copy of the current MAR from the ward in the discharge package or at discharge, leave or temporary transfer to another facility.

11. Changes Tested • Tested the “pre-printed” Medication History and Admission Orders Form on new admissions to pilot ward. Process involves Admitting sending the same day MAR from previous institution to the pharmacy. Pharmacy enters the MAR onto a Medication History and Admission Orders form and faxes back to ward for physician to reconcile with admitting orders. Any clarifications are done in pharmacy prior to submitting pre-printed order form. • Form is effective in reconciling medications, however, process needs to be built into regular pharmacy and ward routine – ie. Ward needs to notify pharmacy when patient arrives and “pre-printed” form is required; pharmacy needs proper staff trained to complete the form

12. BPMH audits started Pilot admissions form started on one ward – data inconsistencies as many regular staff on vacation Better documentation results in decreased undocumented discrepancies No data collected for Dec and Jan No data collected for April

13. BPMH audits started No data collected for Dec and Jan No data collected for April

14. Pilot admissions form started on one ward – data inconsistencies as many regular staff on vacation Better documentation increases success index BPMH audits started No data collected for April No data collected for Dec and Jan

15. Keys to Success and Lessons Learned • Successes: Leadership buy-in and support, team commitment, funding for project • Barriers: time constraints, individual preferences of methods for documentation, varying needs on individual wards • Lessons Learned: Do as many; Plan, Do, Study, Act (PDSA) cycles as possible

16. Next Steps • Admissions: Trial Medication History and Admissions Form on all admissions one ward at a time to determine if it is universal for all patients Educate staff how to use to utilize form and procedures involved Do audit to see if procedure is effective • Transfers Follow-up for with staff for any issues arising from the new procedure of providing reviews at transfer

17. Next Steps • Discharges Review the results of the trial and expand to all wards. Implement a process of including a patient profile from pharmacy for all discharges. • GOAL Implement a sustainable and effective Medication Reconciliation process at every transition point of patient care

18. Contact Information Zaheen Rhemtulla Project Team Leader/Clinical Pharmacist Riverview Hospital 2601 Lougheed Highway Coquitlam, BC V3C 4J2 604-524-7892 zrhemtulla@bcmhs.bc.ca