Transcript Community Pharmacist Presentation in Ottawa

MedsCheck and Hospital Medication
Reconciliation
Improving Patient Safety
Building the
Community Pharmacy and Hospital Partnership
Ottawa Ontario
Oct. 14, 2008
Margaret Colquhoun
Project Leader ISMP Canada
© Institute for Safe Medication Practices Canada 2007®
ISMP Canada
www.ismp-canada.org
To identify risks in medication use
systems, recommend optimal system
safeguards and advance safe
medication practices.
Work to advance safe medication use.
© Institute for Safe Medication Practices Canada 2008®
Agenda
1. Welcome and Introductions
2. Medication reconciliation
Overview and progress of work in institutions including
discharge medication reconciliation
3. MedsCheck and Medication Reconciliation
Pre-surgical MedsCheck for elective surgical patients –
who, what, how?
4. Planning Together
Summary and next steps
Staying in touch
© Institute for Safe Medication Practices Canada 2008®
Medication Reconciliation
• Formal and consistent process in which most
accurate list of patient’s home medications are
compared at transitions of care: admission,
transfer, discharge, LTC, homecare
• Discrepancies are identified, brought to
attention of physician, required changes are
made and communicated
• Intended to minimize potential patient
harm from unintended discrepancies
© Institute for Safe Medication Practices Canada 2008®
Medication Reconciliation
Is also…
• A high priority objective for all hospitals in Ontario
• A Required Organizational Practice for
Accreditation Canada
• One of the Safer Healthcare Now! Initiatives
• A process that will become the new way…not a
project
© Institute for Safe Medication Practices Canada 2008®
Schematic of Structured, Multidisciplinary Integrated
Medication Reconciliation Strategy
Primary
Medication
History: MD or
RN
ER
Ward
Admission
Reconciliation
BPMH:
Taken by pharmacist
BPMH
medical chart
One history
only
Wong J. Annals of Pharmacotherapy 2008 (in press)
1
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Published Studies: “Unintended Medication
Discrepancies
at the time of Hospital Admission”
• 151 patients
• At least 4 regular prescriptions, admitted to GIM teaching
hospital
• 53.6% of patients at least 1 unintended discrepancy
[95% CI 45.7%-61.6%]
• 46.4% of errors – omitted medication
• Patient Impact : 38.6% had the potential to cause moderate to
severe discomfort or clinical deterioration
•
Cornish P et al. Arch Intern Med 2005:165;424-429
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Published Studies:
“Patient Medication Adverse Events Post
Discharge”
23% of Discharged Patients from a Canadian Hospital
experienced an adverse event – of those 72% were drug related
72%
16%
Threrapeutic Errors
Nosocomial Infections
11%
Adverse Drug event
328 patients who were discharged from a Canadian teaching hospital were studied prospectively in 2002 for 14 weeks. (AJ Forster,et al.,
CMAJ 2004:170(3)345-349.)
Developed by Courtyard-Group for E-Health Conference 2004
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Published Studies: The Case
for Medication Reconciliation
• Many patients (70%) not receiving medication instructions at
discharge
(Alibhai SMH, Han RK, Naglie G. Medication Education of Acutely Hospitalized Older Patients. J Gen Intern
Med 1999 Oct;14: 610-616)
© Institute for Safe Medication Practices Canada 2008®
Stories from Medication Reconciliation
Teams: Medication reconciliation
Failures
• Transplant rejection drugs not
ordered on admission (>48hr delay in
restarting)
• Glaucoma meds missed for 14 days
© Institute for Safe Medication Practices Canada 2008®
Med Rec Admission Failure
• LB was admitted to a medical ward with a
working diagnosis of community acquired
pneumonia
• Appropriate antibiotics & symptom management
ordered & commenced
• 2 days later LB suffered a myocardial infarction
(HR 168)
• Beta-blocker was not continued on admission
© Institute for Safe Medication Practices Canada 2008®
Current Picture
• We do not have seamless communication
systems…………and patients know it
• There is duplication of effort in community
and hospital
• There is potential for unintended adverse
drug events
© Institute for Safe Medication Practices Canada 2008®
Hospital Perspective
What is the patient supposed to be on?
• Patient Interview
• Medical chart
• Labels on Rx Vials
• Medication wallet
• Medication Lists
cards
• Family MD list
• Patient’s own list
Patient’s Actual
Medication Use
• Community pharmacist

Patient’s Prescribed
Medication Regimen
What is the “truth”?
© Institute for Safe Medication Practices Canada 2008®
Community Perspective
What is the patient supposed to be
on?
RX’s from the hospital
• Missing information (medication
name, dose, frequency, quantities
LTD codes)
• Illegible
• Automatic substitutions while in
hospital
• Drugs not covered by ODB or drug
plan
• Section 8’s not applied for
• Knowing which meds were
intentionally discontinued or were
they unintentionally missed
Other sources of
information:
•Patient profile on the
computer (not reflective
of recent changes)
•Patient or agent
(usually know little)
•Hospital Physician
/Nursing station
(impossible to acquire
info)
© Institute for Safe Medication Practices Canada 2008®
MedsCheck
Ontario Ministry of Health and Long-Term Care
• Funded by MOHLTC
• One-on-one 30 minute appointment with the
community pharmacist
• Reviews all the patient’s medications (prescribed
and OTC)
• Helps patients better understand their
medication therapy and ensure that medications
are taken as prescribed.
© Institute for Safe Medication Practices Canada 2008®
Who is eligible for a
MedsCheck?
• All Ontarians are eligible
• Once per year
• No additional cost to client
• Provided they are taking 3 or more
medications for a chronic condition.
• Community Pharmacist is reimbursed for
their professional services.
© Institute for Safe Medication Practices Canada 2008®
MedsCheck
Personal Medication Record
© Institute for Safe Medication Practices Canada 2008®
What’s a MedsCheck Follow-up?
• MedsCheck Follow-up is a program for patients who may
benefit from additional MedsChecks during the annual
timeframe.
• There is no limit to the number of Medscheck Follow-ups
provided they meet the following criteria:
 A planned hospital admission (e.g. elective surgery)
 A physician or registered nurse in the extended class (RN[EC])
request
 A recent discharge from hospital (within 2 weeks)
© Institute for Safe Medication Practices Canada 2008®
Overview of MedsCheck/Medication
Reconciliation Pilot
To facilitate the linkage of the MedsCheck
program in community pharmacies with
the medication reconciliation process in
hospitals in communities across Ontario.
© Institute for Safe Medication Practices Canada 2008®
Pilot Objectives
To Improve :
• Communication of medication information
• Continuity of care for the patient/client at
transitions of care.
• Accuracy of medication ordering
• Efficiency by reducing re-work
© Institute for Safe Medication Practices Canada 2008®
Linking MedsCheck to MedRec Pilot
ISMP Canada 2008
• 14 hospitals
• Pre-admission surgical clinic - elective patients
• Requesting patients to arrange a MedsCheck 1-2 weeks prior
to their pre-admission clinic appointment
• Create the Best Possible Medication History (BPMH) in
hospital using MedsCheck as the primary source of
information
• Collect data - time to complete BPMH and quality of
MedsCheck
© Institute for Safe Medication Practices Canada 2008®
Our Initial Focus: Pre Surgical Admission Reconciliation
1
Pre-op
Appointment
1
Day of
Surgery
OR
2
•Prevent failure to restart
home meds following
discharge and transfer
•Prevent duplicative
therapy at discharge (i.e.
brand/generic, formulary
substitutions)
1
Surgical Unit
2
Home
•
Prevent inadvertent
omission of needed
home meds
•
Prevent errors
associated with
orders having
incorrect doses or
dosage forms
2
Transfer Units (Rehab)
Co-ordination Process Flow
Patient gets
a MedsCheck 2 weeks
before pre-op clinic date
Surgeon asks
Pt to get a
MedsCheck
UPDATE:
Hospitals:
• Booklets
• Phone reminders
• Pamphlets
• Calling/Faxing
their pharmacies
• Hip/Knee
binders
• Verbal reminders
POST-OP
Surgeon reviews
and orders meds
using BPMH
Discharge
MedRec
Pt brings
MedsCheck and
vials
to pre-op clinic date
BPMH created using
MedsCheck plus 1 other
source
BPMH is updated
Patients sees
community
pharmacist for
MedsCheck
Follow-up
Day Surgery nurse
reviews
medication
list with patient
on day of surgery
Supports for Hospitals
• Checklists
• Revised sample forms
• Data collection tools pre and post
MedsCheck
• Community pharmacists BPMH
presentations and meetings such as this
one
• Sharing teleconferences
© Institute for Safe Medication Practices Canada 2008®
Sample: My Total Joint
Replacement Passport
My Total Joint Replacement Passport
Please use this passport to record the dates for all of your appointments and other activities. The next
page explains each appointment / activity in more detail.
My surgeon is Dr. _________________________. His/her office will contact me with my surgery date.
My family member/friend who will assist me throughout my joint replacement is:
_______________________.
He/she can be reached at: _________________.
Appointment/Activity
Used with permission from Markham
Stouffville hospital
1.
Date of surgery
2.
Preoperative assessment
3.
Appointment with your family doctor
4.
Appointments with specialists
5.
MedsCheck appointment with your community
pharmacist (if you are on 3 or more prescribed meds)
6.
Community Care Access Centre (CCAC) visit or Outpatient
Physiotherapy postoperative appointment
7.
Discharge date from hospital
8.
Staples/clip removal date
9.
Anticoagulation therapy stop date
10.
Appointment with your surgeon for postoperative follow-up
visit
11.
Transportation
Bring this passport with you to all appointments.
Date
Sample: Forms and Applications
The forms and applications must be completed before your
preoperative visit to the hospital. If you have any questions, it
is fine to contact your surgeon’s office for assistance.
These forms must be brought with you to your preoperative
assessment visit at the hospital:
•
•
•
•
History and Physical Form
Anesthesia Patient Questionnaire
Inpatient Rehabilitation Application
MedsCheck from your community pharmacist if you are
on 3 or more prescribed medications
© Institute for Safe Medication Practices Canada 2008®
Sample: Surgical Assessment
Clinic (SAC) Checklist
Surgical Assessment Clinic (SAC)
Appointment Checklist
What to Bring with You
The forms given to you with this guide are to be brought in with you to the SAC
appointment or returned prior to the appointment. If you have mailed or faxed
these forms, you must ensure they reach the hospital before this appointment.
Rehabilitation Application – completed by you.
The Anesthesia Patient Questionnaire – completed by you.
History and Physical form – completed by your family physician.
Copies of any recent blood work or diagnostic tests that you have had done
outside of Markham Stouffville Hospital.
All medications you are taking at home in their original containers with the
labels (include prescription eye drops and creams, herbal and over-thecounter medications).
MedsCheck from your community pharmacist if you are on
Used with permission from Markham
Stouffville hospital
3 or more prescription medications.
A snack and drink as you will be at the hospital for 4-5 hours; this is
particularly important if you have diabetes.
A family member, friend, or caregiver who will be helping you after surgery.
Translator - If your primary language is not English, please arrange to
have a translator with you for all your appointments including on the day of
your surgery.
Bring this patient guide with you. Your orthopedic team will
review your passport with you to ensure you are completing
all of your presurgical preparations correctly.
© Institute for Safe Medication Practices Canada 2008®
Coordinating MedsCheck and Medication
Reconciliation in Ontario will:
Positively impact the entire continuum of patient care:
• Seamless transfer of information
• Support patients to take/receive medications correctly
and appropriately during transitions in care.
• Reduce the potential for medication errors/adverse
drug events
• Improves efficiency and accuracy
© Institute for Safe Medication Practices Canada 2008®
Coordinating MedsCheck and
Medication Reconciliation in Ontario will:
• Develop and strengthen the relationship between
patients and their community pharmacist.
• Improve patients understanding of their medications
by reviewing them in the community and again in
hospital at discharge.
• Encourage hospital and community pharmacies to
work more closely together to improve
communication and patient care.
© Institute for Safe Medication Practices Canada 2008®
Hospital Roles
• Change processes to direct patients to book a
MedsCheck prior to pre-admission clinic date.
• Surgeons, pre-admit nurses, forms and tools
• Pilot hospitals have resources to share E.g Checklist
• Train preadmission staff to ask for a MedsCheck
by name when doing BPMH and use it.
• Further implement discharge medication
reconciliation
© Institute for Safe Medication Practices Canada 2008®
Community Pharmacists
Role
• Book MedsCheck for pre-admission clinic patients
when they ask or if contacted by the hospital
• Perform MedsCheck
• Record all the medications the patient is actually taking. If it
differs from the prescribed instructions then document the
discrepancy in comments section.
• Include all current prescription and over-the-counter
medications. (aspirin, iron, potassium)
• Ask about medications dispensed from other pharmacies.
• Perform Follow-up MedsCheck at Discharge within 2
weeks
© Institute for Safe Medication Practices Canada 2008®
Innovations we’ve heard about hospitals
• Using SPEP students to follow patient from SAC visit to admission
• Using volunteers to phone patients to remind them to get a
MedsCheck
• Phoning/faxing pharmacies (with the patient’s permission) to
inform them of the patients who are having a surgery and their preadmission clinic date
• Writing articles in local paper about this new initiative to inform
patients
• Faxing community pharmacies a form to fax back so that it is
completed in the hospital format as that you would use in hospital.
(Note: some community pharmacies are using electronic version)
• Working with community pharmacists on discharge med rec form.
© Institute for Safe Medication Practices Canada 2008®
Innovations we’ve heard
about……community
• Designated MedsCheck day - considered a viable
business plan that pays for itself
• SPEP Students - good educational experience
• Scheduling daily time for MedsCheck
• BPMH training (Enhancing MedsChecks)
• Accommodating patients who cannot get a
MedsCheck from their own pharmacy
© Institute for Safe Medication Practices Canada 2008®
Making it Happen
• What are the barriers in hospitals?
• What are the barriers in community to
accommodating more patients for a MedsCheck
or complying with patient/hospital request to
book a MedsCheck?
• How can we work together?
© Institute for Safe Medication Practices Canada 2008®
Conclusion
We have opportunities
in Ontario to help
us overcome the
challenges of medication
information transfer
© Institute for Safe Medication Practices Canada 2008®
Questions
mcolquhoun or [email protected]
© Institute for Safe Medication Practices Canada 2008®