Transcript Documenting Medication History: Improving Safety upon

Evaluation of a Medication Reconciliation Process
University of Maryland Medical Center
Hospital for Children
Baltimore, Maryland
Significance
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44,000 - 98,000 Americans die each year as a result of medical
errors
• 8th leading cause of death in the United States
• More deaths than motor vehicle accidents, breast cancer, AIDS
• Cost to hospital is $17 - $29 billion
• Medication errors in our nation's 7,000 hospitals can cost as
much as $15 billion per year
• Accounts for approximately 7,000 deaths and over 770,000
injuries
• 7/100 hospital admissions results in a medication error
The Institute of Medicine Report
To Err Is Human: Building a Safer Health System
Research
• 27% hospital prescribing errors attributed to incomplete
medication histories upon admission
• 67% medication histories erred (n=3755, 22 studies)
• 11-59% clinically important (n=588, 6 studies)
• 10-61% Omission Error
• 13-22% Commission Error
• 60-67% Omission or Commission Error
• Pharmacist-initiated medication histories
• Reduce mortality rate by 128 deaths per hospital annually
• Saves an average of $7 million per hospital annually
Tam, et al. CMAJ 2005;173(5):510-5
Beers MH, Munekata M, Storrie M. J AM Geriatr Soc. 1990;38:1183-7
Bond CA, Raehl CL, Franke T. Pharmacotherapy. 1999;19:556-64
Objectives
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Evaluate the current process for obtaining complete and
accurate medication histories, checking drug interactions,
identifying allergies, updating weight and immunization
information within 24 hours of admission
Determine cost-savings for pharmacy interventions, evidenced
by each potential adverse event avoided
Document and report adverse events associated with
inaccurate or incomplete medication histories
Redesign and implement a standardized process for medication
reconciliation across the continuum of care
Methodology
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Prospective, interventional quality improvement study
Evaluation of the traditional medication history process for
inpatient admissions; excluding emergency department, unit
transfers, hospital discharge, and outpatient clinic
Admissions to The University of Maryland Hospital for
Children Pediatric Intensive Care Unit (PICU) or Intermediate
Care Unit (IMC)
Expected duration of stay  24 weekday hours or  72
weekend hours
Involved pediatric patients and/or families who were able to
provide medication histories
Methodology
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Current Process for Medication Reconciliation
• Patients are accessed and triaged in Emergency Department
• Inpatient admissions are interviewed by admitting physician
• Physician documents patient-specific information and medication
history on standardized admitting triage form
• Nurse clarifies discrepancies or omissions within twenty-four hours of
admission
• Nurse documents information on a standardized nursing form
• Upon inpatient unit transfer, all medications orders are rewritten by
physician, and previous orders are discontinued by pharmacist in the
pharmacy computer system
• Daily MAR printed by pharmacy, and reflects pharmacy order entry
• Upon patient discharge, pharmacy is occasionally contacted for patient
education materials
• No universally-accessible patient record updated with current home and
discharge medications
Phase I: Medication History Audit
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Identify new inpatient admissions via PharmNet® census
Audit physician admitting triage form for incomplete
medication histories
Document physician-obtained medication history on template
form
Notify medical team of omissions in medical information
Phase II: Interview and Intervention
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Identify new inpatient admissions via PharmNet® census
• Audit physician admitting triage form for incomplete
medication histories
• Interview patients and families within 24 weekday/72 weekend
hours (2 attempts)
• Document pharmacist-obtained medication history on template
form
• Notify medical team of discrepancies or omissions in medical
information
• Clarify discrepancies with help of patient and family
• Document interventions in HealthProLink®
• Assign a cost-savings for each intervention
Phase II: Cost Analysis
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$76
$76
$76
$76
$76
$76
$76
$76
$48
$76
Allergy Info Clarified
Allergy Prevented
Dose Evaluation
Drug-Drug Interaction
Patient Medication History
Patients Own Medications Evaluation
Renal Dose Evaluation
Therapeutic Duplication Avoided
Therapeutic Interchange Done
Weight Evaluated
HealthProLink®
Phase II: Cost Analysis
• Cost of ADR ($2,500)
• Difference in overall hospital cost for ADR $5,483
• ADR Prevalence (3%, 1/33 patients)
• Prevalence of serious ADR 6.7%
• Cost Savings through Intervention
• $2,500/33 = $76/intervention/person
• Therapeutic Interchange ($48 Average)
• Assumes 3 days IV therapy avoided
Suh DC, et al. In Ann Pharmacother 2000 Dec;34(12):1373-9
Lazarou, et al. JAMA 1998;279:1200-1205
Results
• Phase I
• 42 charts audited/ 56 inpatient admissions
• Age: 28 days – 20 years
• Average time required for each chart audit: 5 minutes
• Phase II
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46 charts audited/ 74 inpatient admissions
Age: 30 days – 19 years
Average time required for each chart audit: 5 minutes
Pharmacist-initiated patient interviews: 10 interviews
Average time required per interview: 5-15 minutes
Average time required per intervention: 1-60 minutes
Results
Total Number of Home Medications
25
N=88
Number of Patients
20
15
10
5
0
0
1
2
3
4
5
6
7
8
9
Results
N=88
Number of Charts
Missing Patient Information
90
80
70
60
50
40
30
20
10
0
Allergies (17%)
Weight (20%)
Height (74%)
Results
N=209
Number of Medications
Missing Medication Information
200
180
160
140
120
100
80
60
40
20
0
Dose
(26%)
Frequency
(52%)
Route
(73%)
Indication
(84%)
Omission
(12%)
Interventions
• Overall cost-savings $8,126
• Total time required for interventions 11.92 hours
• 128 interventions
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Clarification of allergies/height/weight
Clarification of dosing/frequency/concentration
Formulary interchange
Patient counseling
Noncompliance assessment
Interventions
• 5 Adverse Events
• 1000-fold overdose of clonazepam ordered, due to incorrect
concentration on parent’s home medication list (0.1mg/ml vs.
100mg/ml)
• 5-fold overdose of phenobarbital ordered, due to incorrect
concentration per neurologist (20mg/5ml vs. 20mg/ml)
• Acute withdrawal of medications due to abrupt discontinuation
(fluoxetine, clonidine, quetiapine, dextroamphetamine/amphetamine)
• Physician ordered corticotropin (Acthar® Gel) for treatment infantile
spasm, however cosyntropin (Cortrosyn®) was dispensed x 3 days
• Parents were administering furosemide and spironolactone as premedications for cardiac surgery; doses were exchanged
Barriers and Limitations
• Hospital Admission and Chart Access
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Multiple hospital transfers
English language deficit
Patient absent for procedure, radiology, OR, ECT.
Missing H/P on single-day stay or surgical patient
• Patient-Specific Limitations
• Developmental age
• Developmentally delayed
• Cognitively compromised
• Documentation Tool
• Length of medication history form
• Multiple documentation tools used by health care professionals
• Paper-based process; universal access to information is delayed
Barriers and Limitations
• Admitting Patient Interview
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Time required to thoroughly interview each new admission
Access to family or friends
Patient and family contact information missing, incorrect, or ineffective
Incomplete medical information
Incorrect medical information
Access to outpatient pharmacies and prescription history
• Intervention
• Time requirement for each medication clarification and intervention
• Integration of intervention into patient medical record
• Intervention
• Universally-accessible electronic documentation tool
• Integrate process into admission, unit transfer and hospital discharge
Summary
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Inaccuracies and omissions of medication histories leads to
medication errors inpatient
• The amount of time required to clarify medication
discrepancies contributes to inefficient reconciliation
• Documentation of medication clarifications is lacking
• Documentation is not universally accessible
• Pharmacy interventions contribute to completeness and
accuracy of data, improves patient safety, and has added cost
benefits
• Obtaining complete and accurate medication histories requires
a consistent, multi-disciplinary approach
The Next Step
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Multidisciplinary team of nurses, physicians, information
technology staff, pharmacists, residents, medication safety
representatives collaborating to improve medication
reconciliation process over continuum of care
Determine procedural flow and responsibility for reconciling
medication histories in ER and upon admission inpatient
Development of a patient-friendly medication reconciliation
form, to be piloted in select inpatient units
Coordinate discharge planning and update documentation
Pilot medication reconciliation processes on paper
Integrate reconciliation tools and processes with POE database
The Next Step
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Pharmacy Involvement
• Satellite-based pharmacy support; limited decentralized order entry
• Participate in medication reconciliation process upon inpatient unit
transfer
• Current and accurate list of medications available to transferring
physician on computer order entry system
• Physicians prints active medication list, with option to “continue,”
“continue with modifications,” or “discontinue” active medication upon
unit transfer
• Transfer medication list is faxed to pharmacy for order entry
• New patient MAR printed for receiving nursing unit
Background
• Joint Commission on Accreditation of Healthcare
Organizations National Patient Safety Goals
• Goal 8 - Accurately and completely reconcile medications across the
continuum of care
• 8A - Implement a process for obtaining and documenting a complete
list of the patient’s current medications upon the patient’s admission to
the organization and with the involvement of the patient. This process
includes a comparison of the medications the organization provides to
those on the list
• 8B - A complete list of the patient’s medications is communicated to
the next provider of service when a patient is referred or transferred to
another setting, service, practitioner or level of care within or outside
the organization
Joint Commission on Accreditation of Healthcare Organizations,
2006 National Patient Safety Goals