Transcript Medication Reconciliaton What can we do to ensure it is done?

Jay Ginsberg, MD
Network 1 MAC Representative
Why Reconcile Medications?
 Medication reconciliation is an effective process to
reduce errors and harm associated with loss of
medication information, as patients transfer among
community-based and hospital providers. It may
prevent up to 70% of all potential errors and 15% of all
adverse drug events.
-Joint Commission (2006)
Definition of Medication Error
 A medication error is any preventable event that may
cause or lead to inappropriate medication use or
patient harm while the medication is in the control of
the healthcare professional, patient, or consumer.
-National Coordinating Council for
Medication Error Reporting and Prevention
A Great American Philosopher
If the world was perfect, it
wouldn't be.
Yogi Berra
We don’t want to take this view on
Medication Reconciliation!
Who Thinks Med Reconciliation is
Important?
 Institute of Medicine (1999)
 Joint Commission (2006)
 CMS
 has funded projects to evaluate best practices in
medication reconciliation
 NQF
 Has sponsored studies of medication reconciliation
Medication Statistics
 Medication Related Problems are implicated in 16.1% of
internal medicine ward hospital admissions.
 Nelson, KM; Talbert, RL. Drug-related hospital admissions.
Pharmacotherapy. 1996;16:701–707
 58.9% of admissions could definitely or possibly be
avoided.
 Nelson, KM; Talbert, RL. Drug-related hospital admissions.
Pharmacotherapy. 1996;16:701–707
 Once admitted to the internal medicine ward, greater than
18% of patient deaths can be attributed to one or more
drugs
 Ebbesen, J; Buajordet, I; Erikssen, J; Brors, O; Hilberg, J;
Svaar, H; Sandvik, L. Drug-related deaths in a department of
internal medicine. Arch Intern Med. 2001;161:2317–2323
Medication Statistics
 Adverse drug events contribute to over 100,000 deaths
annually
 Lazarou, J; Pomeranz, BH; Corey, PN. Incidence of adverse drug
reactions in hospitalized patients: a meta-analysis of prospective
studies. JAMA. 1998;279:1200–1205
 25% of ambulatory patients report experiencing at least
one adverse drug event
 Gandhi, TK et al. Adverse drug events in ambulatory care. N Engl J
Med. 2003;348:1556–1564
 The economic burden of MRP on the healthcare system is
estimated to be in excess of $177 billion
 Ernst, FR; Grizzle, AJ. Drug-related morbidity and mortality:
updating the cost-of-illness model. J Am Pharm Assoc(wash).
2001;41:192–9
Dialysis Statistics
 The average dialysis patient takes 6 to 10 medicines a day.
 Curtin RB, Svarstad BL, Keller TH. Hemodialysis patients’
noncompliance with oral medications. ANNA J. 1999;26:307-316.
 Kaplan B, Mason NA, Shimp LA, Ascione FJ. Chronic hemodialysis
patients, part I: Characterization and drug-related problems. Ann
Pharmacother. 1994;28:316-319.
 Szeto et. Al. (Clinical nephrology 2006 vol. 66:4, pp. 256-
262)
 On a-verage, each patient required 4.7 ±1.8 type of
medications
 Average was 10.0 ± 4.9 tablets per day
 15.0% needed at least 7 types of medication
 12.4% had to take more than 15 tablets each day
Is This Important to Dialysis Facilities?
 Informal Survey Conducted by MAC
Is This Important to Dialysis
Facilities?
But:
PubMed search revealed only one
article on medication reconciliation
in dialysis patients
Medication reconciliation in hemodialysis
patients; Ledger S, Choma G
 Evaluation of impact of medication reconciliation and
optimization at the time of patient transfer from an incentre dialysis unit to a satellite dialysis unit
 78.8% of patients had at least one unintended medication
variance
 The majority of unintended variances (56%) were caused
by the physician/nurse practitioner omitting an order for
medication that the patient was taking.
 “In this small study, medication reconciliation was effective
at identifying and rectifying medication errors and
optimizing pharmacotherapy at the time of transfer from
an in-centre hemodialysis to a satellite dialysis unit.”
Health & Safety Survey Project
2006 Survey about Safety Concerns
 Invitations to participate in an anonymous survey sent
to 3,587 patients drawn from a representative national
patient sample
 Network #1 implemented the patient selection and
coordinated survey mailing and responses
 Surveys completed by 1,762 patients
Health & Safety Survey Project
Dialysis Health Professionals
 Invitations to participate in an anonymous web-based
survey widely distributed by RPA, Networks,
Professional Meetings
 Web-based Surveys completed by 649 professionals
Patient Response
Patient Report of Number of Different Daily Medications
50%
45%
Percent Patient Respondents
40%
35%
30%
25%
20%
15%
10%
5%
0%
1 to 5
6 to 10
11 to 15
16 to 20
Number Different Daily Medications
21 or more
Patient Response
40% patients report that they
discuss their meds with their doctor
only “sometimes.”
Health & Safety Survey Project
Professional Survey: Past 3 months
 43% professionals report 1 or more instances of patient
given the wrong medicine or medicine at wrong time
 63% report patients fail to receive 1 of their meds at
times
 37% report that a patient is given wrong dose of a
medication at least once
 Overall 77% staff indicate a patient had a medication
omission or error in past 3 months
What to do?
Considering the large number of medications taken by
the average dialysis patient the problem of medication
errors is a huge one.
The practice of Medication Reconciliation offers the
opportunity to reduce medication errors and thereby
improve patient care.
When is an Accurate Medication
List Important
 “Handoff” from hospital to Chronic Unit
 Patients’ medications are changed in the dialysis unit
 Medications are changed by an outside physician
 In a disaster
Components of Medication
Reconciliation
 Collecting an accurate medication history
 Making certain the medications and the doses are
appropriate
 Educating the Patients about the Medications
 Documenting each change that is made along the way
Collecting an accurate medication
history
 What has been ordered for the patient?
 What is the patient really taking?
Making certain the medications
and the doses are appropriate
 Need list of all medications
 Need accurate information of the patient’s co-
morbidities
Educating the Patients about
Medications
 A 2007 study confirms that medication knowledge of
hemodialysis patients was extremely poor regarding
the name, indication and dosage regimen of their
medications
 BS Sathvik, Seema Mangasuli, MG Narahari, KC Gurudev, G
Parthasarathi Indian Journal of Pharmaceutical Sciences 2007 69:2
232-239
Documenting each change that is
made along the way
 Each “handoff” should include a reconciliation
 Provide health care professionals at each visit by the
patient with an accurate medication list
Current Practices
 Many facilities have computerized medication lists
 How often are they updated?
 Patients are asked to list their medications
 How often are they asked if they understand why they
are asked to take the medications?
 Patients may bring in their pills
 Are they really taking all those pills?
A Great American Philosopher
If you don't know where you
are going, you might wind up
someplace else.
Yogi Berra
Ways Medication Reconciliation
Might Be Improved
 Examples of possible changes in process
 Standardized process for checking medications in a unit

Med checking on a given day each month
 Standardized handoff after hospitalization

Part of accepting a patient back into the unit might be a
requirement that a copy of the med list be faxed
 Review of medication changes after each visit to a
provider

The facility might send a form with the patient to be filled out
by the physician’s office staff with any medication changes
Ways Medication Reconciliation
Might Be Improved
 Accountability
 Medication Coordinator in a facility
 Primary nursing with the requirement that meds be
reconciled
 Education of patients about medications
 Printed materials
 Web sites
 Contests at a facility about common medications
Ways Medication Reconciliation
Might Be Improved
 Since facilities vary so much, no answer is appropriate
for all
 Facilities should be encouraged to do Quality
Assessment and Performance Improvement Projects to
improve Medication Reconciliation
 Medical Advisory Council of the Forum is attempting
to develop tools that can be offered to facilities to help
them develop QAPI projects
Sample Tool
(Developed by Network 11, Modified by MAC)
FACILITY NAME:
PROVIDER NUMBER:
DATE COMPLETED:
TEAM MEMBERS
CONTACT:
Facility
1.
Medical Director
2.
Facility Administrator
3.
Clinical Manager
PROBLEM STATEMENT:
GOAL:
4.
Nephrologists
ROOT CAUSE(S):
5.
RD
1.
6.
SW
2.
7.
PCT
3.
8.
BARRIER(S):
External
1.
1.
2.
2.
3.
3.
METRIC(S)
Preintervention
First
Remeasurement
Second
Remeasurement
Final
Remeasurement
Vascular Surgeon
COMMENTS
Sample Tool
(Developed by Network 11, Modified by MAC)
TASKS
1.
2.
3.
4.
5.
COMMENTS:
RESPONSIBLE
TEAM MEMBER
START DATE
ESTIMATED
COMPLETION
DATE
ACTUAL
COMPLETION
DATE
COMMENTS
(STATUS, OUTCOMES, EVALUATION, ETC.)
A Great American Philosopher
In theory there is no
difference between theory
and practice. In practice
there is.
Yogi Berra
Pitfalls
 Assumption that because the medications have been
reconciled the patient is really taking them
 Changes in formulations
 A brand change of a medication might result in different
absorption that reconciliation would not pick up
 The medication list is only accurate if
 The patient understands what she is taking
 The person taking the information is knowledgeable
and thorough
Medication Reconciliation Summary
Medication Reconciliation is important in providing
quality patient care
2. In dialysis units Medication Reconciliation is
particularly important due to the complexity of the
patients
3. Components of Medication Reconciliation include:
1.
 Collecting an accurate medication history
 Making certain the medications and the doses are
appropriate
 Educating the Patients about the Medications
 Documenting each change that is made along the way
Medication Reconciliation Summary
4. There are several approaches to reducing medication
errors and each facility should develop processes that
best fit
A Great American Philosopher
It gets late early out there.
Yogi Berra