Transcript Slide 1

Medication Reconciliation:
whose job is it anyway?
Why a Multidisciplinary approach?
Limitations identified in ‘pharmacists only’ approach
• Baseline data from June 2010 showed pharmacists could
reconcile medications for 35% of patients within 48 hours
(gold standard is within 24 hours)
• Insufficient pharmacists to complete and sustain medRec
• If pharmacist’s sole focus could compromise other medication
safety activities.
• Gaps in medRec process would occur after hours and
weekends
• Address by targeted intervention of complex patients only?
Initial Training: January 2011
• Pharmacy High 5 team developed a presentation
– Presented to pharmacists and High 5 core group:
• “Train the trainer”
• Best Possible Medication history taking
• Med Rec process
• Compulsory attendance
• Resources provided to train/teach ward staff.
– Training Road shows – ward based training
• Identified unit-specific processes
– Grand/ ICU rounds
Ongoing Training
• JMO, Registrar and Resident training
– Occasional ward based training
– Secured additional training slots in orientation
program
• Medical Intern Pre-registration workshop
• Pharmacist orientation
• New grad nursing awareness training
Patient Safety Culture in our
hospital
2014:
2011:
eMR commenced
in ED
2011:
Multidisciplinary
approach of High 5
Initiative
2010
Patient safety
culture survey:
ED & Geriatrics
(60%)
(~25%)
Patient safety
culture
changed for
the better?
2014 Survey:
Objectives:
Primary:
Do clinicians understand the
importance of Medication
Reconciliation: who, how and
why?
Secondary:
– Were there any barriers to
implementing this change
– Can these barriers be
overcome or resolved?
Question Design
Demographic
Questions
• What is your current staff
position/specialty?
Multiple choice
& ‘Free text’
Questions
• If there is no documented
medication history or MMP in
the patient notes, what would
be your next course of action?
Rating scale
• What impact does the MMP
have on your clinical decision
making?
•Extremely/Very/Moderately/Slightly/
No significant impact
Removed bias
• In your experience, have there
been any barriers to
completing or recording
information on the MMP?
Method
• 2 Study sites: POWH, Redlands
• Study group: Doctors, pharmacists and nurses
• Collected data for 7 days via
– Paper forms
– Email ‘Survey monkey’ link
• Supported by Directors of Clinical
Services/Nursing/Pharmacy
• Survey respondents remained Anonymous
Results: Demographics
Staff position
Approx. Staff
Population
% Response per Discipline
Population
that responded
(%)
n = 138
Doctors (JMOs
& SMOs)
400
49 (12%)
Nursing
1200
65 (5%)
Pharmacists
32
24 (75%)
(n=138)
Pharmacists
17%
Doctors
36%
Nursing
47%
% Response per Specialty
12.4
12.4
12.4
7.4
6.6
6.6
5.8
4.1
0.8
1.7
0.8
1.7
1.7
0.8
1.7
1.7
0.8
2.5
7.4
5
0.8
Results: Education/Training
Answer
Yes
No
Did you receive any
education/training?
62 (46.6)
71 (53.4)
58 (54.7)
48 (45.3)
N = 133 (%)
Was the education given at
orientation sufficient?
N= 106 (%)
• Sample Comments/suggestions:
– “I thought this was the role of the pharmacist? Any training would be
useful” (Intern)
– “Wasn’t able to attend” (Registrar)
– “Online training, inservice, verbal discussion?” (RN)
Who is responsible for completing the
Medication Management Plan (MMP) form?
100
90
80
70
Percentage %
Doctors
60
Pharmacists
50
Accredited Nursing Staff
40
30
Doctors, Pharmacists and Accredited Nursing
Staff
20
Doctors and Pharmacists only
10
0
Doctors' Response
n= 44
Nurses' Response
n= 58
Pharmacists'
Response
n= 23
What do you understand to be the main
reason/s for Medication Reconciliation?
120
Percentage %
100
80
60
Doctors n=40
40
Nurses n=59
20
0
Pharmacists
n=24
Safety Culture
Can you remember when
MedRec helped to pick up a
medication error?
The MMP* helps my team to
make safer medication decisions
for our patients
100
Doctors n=44
Nurses n=54
90
Pharmacists n=22
100
91
93
80
Percentage %
70
60
Doctors n=42
50
Nurses n=57
40
Pharmacists n=22
30
20
9
10
7
0
0
No
Yes
No
Yes
*Medication Management Plan Form = a tool used at POWH
to conduct Medication Reconciliation
Overall Comments
Clinician
Comments
Doctor
MMPs are very useful for JMOs!
A good tool when available in patient notes
It’s a great initiative, please keep it going
Electronic would be great
MMP has no significant impact on admission because it is not
usually done on admission
Nurse
I have found the MMP helpful if I have difficulty reading the
doctor’s handwriting and also for checking that doses are correct
when the charts change over to the next one
Some education would be good so we can use it more effectively
on ward rounds
It’s not the nurse’s role to fill out the MMP form-should be
medical or pharmacist
Pharmacist
MMPs are very useful but time consuming
Only Pharmacists are doing MMPs
Increases workload for pharmacists
Discussion
• Identified barriers:
– Education reaching all stakeholders (frontline up)
– Time
– Documentation (electronic vs paper)
• Identified improvements:
– Patient safety culture awareness
– Multidisciplinary approach identified
• Limitations
Factors identified required for
future success
•
•
•
•
Dedicated resources
Strong multidisciplinary leadership
Physician champion engagement
Software that supports the High 5 SOP
and
• Ongoing comprehensive staff education
plan
• Change readiness of organisation
A Doctor’s perspective
Doctors’ attitudes
• ‘We’re very busy’
• ‘Can’t the pharmacists do it?’
• ‘It means writing everything out multiple times’
• ‘What’s the point of it?’
• ‘Why don’t we just wait until electronic prescribing
comes in?’
Issues
• Capturing the correct audience to educate them that its
everyones responsibility
• We are missing the middle level (staff specialists, VMOs etc)
• IT systems don’t speak to each other (or a mixture of paper
and electronic notes)
• It requires a change in attitude- but support for change
• Senior staff don’t realise the importance of the process
Problem:
• Professional boundaries and established hierarchies may
result in disagreements about where the responsibility for
medicines reconciliation lies
Solution:
• Focus on reducing the risk for patients and increasing the
availability of timely, accurate information
• Any potential professional or hierarchical differences should
be put aside to enable appropriately trained and competent
healthcare professionals to take the lead
Problem:
• Competing demands and the common response that ‘the
problem is too big —‘we don’t know where to start’’can be
overwhelming for staff
• This can lead to delays in getting medicines reconciliation off
the ground
Solution:
• People need to be supported by managers to enable them to
prioritise their workload
• simple structures should be put in place so that medicines
reconciliation becomes part of the organisation—
’s everyday
work
There are no quick fixes, but this is a far from
insurmountable problem
A possible five-level hierarchy approach:
• There are no shortcuts to breaking down silos.
• You can’t fix the environment if the organization doesn’t
understand the problem.
• You can’t improve the development process if the right
environment doesn’t exist to enable healthy guidelines.
• Climb the pyramid brick by brick to the ultimate goal: better
clinical outcomes through true collaboration.
Practicalities
• How do we ensure senior physicians care?
• IIMS categorised into ‘med rec’ errors?
• Statistics on IIMS, Med rec compliance to individual
departments/teams? League tables??
• Grand rounds?
• Presentations of RCAs concerning medication errors?
•
Using Accreditation- Standard 4 as a bargaining chip?
Involving Patients
• The value of involving patients and/or their carers in the
medicines reconciliation process should not be
underestimated
• Patients are a valuable source of information about the
medicines they take and, with support, they can be
encouraged and enabled to take a fuller and more active part
in the process
Organisational approach
• The profile of medicines reconciliation needs to be raised in
all healthcare organisations
• The Chief Executive, senior management lead and board
members of an organisation can help by promoting the
uptake of medicines reconciliation
• Collaborative approach with other Australian hospitals
involved
• Get process right before instituting eMM- detrimental to put
bad stuff into a good system
Guess what?
Its YOUR job!
Acknowledgements
• Survey question design & data collection: Ketty Rivas (Safety
and Health Outcomes Officer) , Selina Boughton (Pharmacist)
• Survey promotion: POWH Pharmacists