Transcript Medication Reconciliation July 12, 2005 Glenn Billman, M.D., Medical Safety Officer, Children’s Hospitals and Clinics of Minnesota.

Medication Reconciliation
July 12, 2005
Glenn Billman, M.D.,
Medical Safety Officer, Children’s Hospitals and Clinics of
Minnesota
First, do no harm….
2
The Issue:
“Medicine used to be simple,
ineffective and relatively safe.
“Now it is complex, effective,
and potentially dangerous.”
Sir Cyril Chantler
3
Our Challenge :
Optimal care for patients requires totally
effective communication regarding
medication use among numerous people of
varying disciplines in multiple locations over
time including the families themselves.
4
Our Aim: Implement Medication
Reconciliation
Implement a Process that will ensure that
patients and their caregivers possess the
most accurate, and up to date medication
list possible
5
Definition 1:
Medication Reconciliation
Reconciliation is the process of comparing
what medication the patient is taking at the
time of admission or entry to a new setting
or level of care, with what the organization
is providing (admission or new medication
orders) to avoid errors such as conflicts or
unintentional omissions.
6
Definition 2:
Medication Reconciliation
 All medications appropriately and
consciously continued, discontinued,
or modified at all transitions of
care.
7
Why Should We Do This?

140 discrepancies in 81 patients (1.7/pt)




65 omissions
59 wrong dose/frequency
16 wrong drug
32.9% discrepancies rates as potentially
moderate harm; 5.7% severe harm
Arch Intern Med, Feb 2005
8
Why Should We Do This?

Ineffective medication reconciliation
upon hospital admission


up to 50% of medication errors
up to 20% of future ADEs
9
Why Should We Do This?
Because It’s Doable !
1) Increased Percent of Patients That
Completed Medication Coordination
90
80
70
60
50
40
Baseline
Percent
100
w
w
w
w
30
20
10
0
Time
10
100
Why Should We Do This?
Because It Works !
90
80
Percent
70
60
50
Discrepancies, All Types And
Sources
40
30
Baseline
Discrepancies, Patient Related
20
10
0
Baseline
Cycle 1
Cycle 2
Cycle 1
Cycle 2
Why Should We Do This?
Because It Works !
Number Of Days Between ED Visits By Hem/Onc
4) An Increase
In
The
Number
Of
Days
Patients Related To ADE's
Between ED Visits Related To ADE’s
70
Number of Days Between ADE's
60
50
Medication Coordination
Parent Education
ADE Monitoring
Potentially Preventable
40
ADE
30
Non-Preventable ADE
20
10
0
11/5/01
11/25/01
12/15/01
1/4/02
1/24/02
2/13/02
Date
3/5/02
3/25/02
4/14/02
5/4/02
12
Why Should We Do This?
Efficiency !
Improve
Discharge
Medication
List
Improved
Accuracy of
Medication
List
Improve
Ambulatory
Medication
List
Improve
Admission
Medication
List
13
Why Should We Do This?
It’s Cost Effective !
High
Do
First
Dedicated Unit
Pharmacist
Diagnosis
Specific Medication
Order Sets Reconciliation
Pharmacist
Patient
Interview
Pharmacy
Managed
Protocols
Pharmacist
Order Entry
Impact
on ADE
Investing In
Safety CPOE
Bar Code
Reconciliation
Automated
ADE
Monitoring
Zero Tolerance
Ordering Standards
Preprinted
Order Forms
Pocket
Formulary
Low
Medication
Competency
Testing
Low
Intervention
Database
Don’t Bother
Cost To
Implement
High
14
2005 NPSG Goal 8:
Medication Reconciliation

Accurately and completely reconciles
medications across the continuum of care

8a: During 2005, for full implementation by
January 2006, develop 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.
15
2005 NPSG Goal 8:
Medication Reconciliation

Accurately and completely reconciles
medications across the continuum of care

8b: A complete list of the patient’s medications
is communicated to the next provider of service
when it refers or transfers the patient to
another setting, service, practitioner, or level of
care within and outside the organization.
16
Medication Reconciliation Is A Tool
To Help Bridge Gaps That Occur At
Transitions and Transfers of Care

Process steps:





The medication history is completed
The physician reviews and acts upon
each medication
The medication orders are written
A 2nd person reviews medication history
That 2nd person resolves discrepancies
17
Reconciliation
Virtually all hospitals who have
successfully addressed
admission reconciliation have
created a special form as part
of the solution. These forms
pretty much look alike.
18
Allergies: Drug/Foods
Do you have a latex allergy or sensitivity?  Yes  No  Unsure
If yes, describe type of reaction:______________________________
Are you allergic to iodine?  Yes  No
Are you allergic to dyes?  Yes  No
Reactions/Side Effects
Height: Actual________cm
Weight: Actual________kg
Information Source:
 On No Medications at Home
 Unable to Obtain Medication History—Reason:
 Patient  Spouse  Wallet Card
 Brought meds from home
 Other (Specify)_______________________
Home Medications on Admission
(Prescriptions, OTC, Herbals, Patches, Inhalers, Eye Drops & Supplements)
Physician Medication
Orders on Admission
(Check Only One)
Drug Name
Initials
Dose
Route
Freq
Last Taken
Date/Time
Order
Unchanged
Change
(Use Order
Sheet)
DO NOT
ORDER

































Person(s) Gathering Medication History:_____________________________________Date/Time____________________
_____________________________________ Date/Time____________________
Ordering Physician Signature: _____________________________________________Date/Time_____________________
 Sent to Pharmacy
19
Children's Hospital San Diego
1
Medication Coordination Form
Instructions: Please Com plete Item s 1 - 10
Addressograph Stamp
2
3
8
9
10
Admit Date:
Time:
List All Medications Identified by
Patient, Family, Prescription
bottle,or M.D. order.
Do All
Medication
Elem ents
Match?
Drug… … … .Dose… Freq… .Route… ...
YES
Last Dose
Signature of RN(s) reconciling m edications:
Did you identify and correct a discrepancy? Yes
Adm inistrative Data Screen Com pleted by :
5
4
NO
If "No", which
elements require
review?
Drug
Dose
7
6
Freq
Route
M.D.
Please Explain How The
Reviewer Discrepancy Was Resolved
Initials
_________________________ Initials___________
Date:_____________Tim e:________________
___________________ _____
Date:_____________Tim e:________________
No
Initials___________
Patient Related?
___________________ _____
Yes
Initials___________
No
Order Related? Yes
No
Date:_____________Tim e:________________
What is included?





Current home meds / OTC / Herbals,
including dose, route & frequency
Time of last dose
Source of the information
The medications ordered at admission
An Assessment of patient compliance
21
There is no perfect
medication list.
Quit thinking there is.
Do not be paralyzed by trying
to perfect the list.
Steve Meisel, PharmD
22
Who uses the form?



The nursing staff or pharmacist use the form to
collect information at admission.
The physician uses the form as a reference
and/or order when writing initial orders for
medications. In some cases the form itself
serves as the order form, thereby obviating the
need to rewrite orders.
Both physicians and nurses use the form
throughout the patient’s stay as a reference.
23
Source of the information





The patient/family
The patient’s pharmacy
Previous medical records
The patient’s medication bottles
The physician’s office
24
A completed Medication List
is only the Half Way Point.
Reconciliation is real work!
25
A Big Problem Is Often Just Getting
An Accurate Medication List







Patient brings in incorrect list.
Patient does not take what is marked on
bottle.
Patient does not know what is on and
family, pharmacy not available.
Wrong name of med on ED sheet.
Med bottles don’t jive with what the patient
says.
Patient is unable to tell you. No family
available. MD on call does not know either.
Can’t call the pharmacy “after hours”.
26
Medication Coordination Flowsheet
Call M.D.
(Adapted from the work of Roger Resar, M.D.)
Pt. Admitted
Yes
Reconciled
Is time of last
dose in question
No
No
Yes
Is this a 24 hour
Med?
Nurse completes
Med Coordination
Data Sheet
Yes
Yes
Can clinic chart or
other sources be
obtained in 24 hours
No
Is the medication list
from an external source
available?
Physician orders with
drugs, dosages, and
times are assembled
No
Does clinic chart
or other external
source reconcile?
No
No
Call M.D.
Yes
Does this confirm
drug and dose?
No
Can Pharmacy reconcile
drug and dose?
Yes
No
Reconciled
Can patient or family give
accurate, confirming data?
Is time of last dose
in question
Yes
No
Yes
No
Stop. Use this
information
Reconciled
Call M.D.
27
The Intent and Value of
Medication Reconciliation Is
In Having An Accurate
Medication List.
28
Transfer Reconciliation



Critical especially upon transfer in and out
of intensive care and other specialty units
As much as 60% of the care plan after
transfer may be different than what the
physician expects
Can utilize internal computer systems to
facilitate, but there must be an active
decision to continue, discontinue, or modify
each line item
29
Transfer Reconciliation

Automatic stops of certain criticalcare-specific drugs (e.g. dopamine)
are acceptable provided those stop
orders appear in the medical record.


? Benzodiazepines
Requirement to re-write all orders
upon transfer introduces new
opportunities for error
30
31
Discharge Reconciliation


The patient’s reconciled list of
admission medications is compared
against the physician’s discharge
orders along with the last day’s MAR.
The lists can either come from the
computer system or be integrated
with the original admissions list.
32
33
34
To Be Successful:



Put the patient first (this isn't
someone else's job)
You need to have some good change
methodology to be able to develop a
good product
You need to use this to replace
something else i.e. medication history
in nursing data base
35
To Be Successful:

Understand Your Processes
Process flow
 Data flow
 Roles and responsibilities
 Procedures

Build Incrementally – Start Small
 Leadership Support is Critical
 Project champions

36
To Be Successful:

You must have organization
alignment (physician, nursing,
pharmacy, administration)





Process Owner and Sub-Process Owners
A champion for the entire process
Have a good education program
when rolling it out
Appropriately Resource the project
You Need To Start!
37
Questions / Comments/
Discussion
38
Contact Information
Contact Glenn Billman:
[email protected]