Transcript et al - Harm Free Care

Rachel Urban
Pharmacist Researcher
Bradford Institute of Health Research/
University of Bradford
[email protected]
Aims
 What exactly is Medicines Reconciliation?
 Definition
 Patient Journey
 Where does it go wrong?
 How can we put it right?
 To look at the evidence and see what’s worked in
practice
 Discuss practical points to successful implementation
Background
What exactly is Medicines
Reconciliation?
IHI Definition
“the process of creating the most accurate list possible of
all medications a patient is taking — including drug
name, dosage, frequency, and route — and comparing
that list against the physician’s admission, transfer,
and/or discharge orders, with the goal of providing
correct medications to the patient at all transition
points within the hospital” (Cambridge, 2008)
Patient enters
hospital
Drug History
Taken, Chart
written
Validation of
Drug History
Medicines
Reconciliation?
Via A&E
Direct to Ward
Pre
admissions
Patient
enters
Hospital
Doctor
Nurse
Pharmacist
Drug history
taken
POD /MDS
Patient
EHR
Discharge info
Community
Pharmacy
NH
GP list
Doctor
Pharmacist
Drug
chart
written
Patient
moves
wards
Drug history
verified
Pharmacist
Technician
Discharge
written
ITC
Home
Care
Home
GP
DN
CP
SS
Care Home
Nurse
Doctor
Pharmacist
Patient
counselled
Patient
Discharged
Discharge
Information
Communicated
Discharge
Information
processed
CP, GP, Admin
Staff
Pharmacist, DN
Where does it go wrong?
 Medication history taking
 Not using all available sources
 Inaccurate prescribing
 Lack of verification by pharmacy staff
 Handover
 Patient counselling
 Communication
 Not knowing what has been stopped and started
 Not knowing why something has been stopped started
 Timeliness of discharge
What’s worked?
Evidence
 Predominantly US studies
 Isolated aspects of process
 Predominantly secondary care
 Admission
 Discharge
 Few primary care
 Care of the Elderly/ A&E
 Role of the Health Care Professional
 Pharmacist
 Nurse
Admission
 A&E
 Prescription chart initiated in A&E (Mills & McGuffie
2010)



MR increased from 50-100%
Rx chart from 6-80%
Prescribing Error rate decreased from 3.3 to0.04
 Encourage Ambulance to bring in PODS (Chan et al
2009, 2010)

Percentage of medicines incorrectly prescribed decreased
from 18.9 to 8.8%
Discharge
 Discharge
 Pharmacist discharge service (de Clifford et al 2009, Morrison
et al 2004 )
 Communication with community Pharmacists

Pegrum et al , Cook 1995
 Identification of discrepancies by CP (Paulino et al 2004)
 Counselling
 Increases number of interventions (Karapinar 2009)
 Patient Information Proforma (Manning et al 2010)
 Decreases number of ADE after discharge (Schnipper 2006)
 Counselling on discharge by Community Pharmacists
(Hugtenburg et al 2009)
Primary Care
 Lack of evidence on Med Rec
 Robust repeat prescribing systems
 Ensure systems for processing information are robust
Standardisation
 Forms/process
 Pre-clinic questionnaire (Tattersall et al 2008)
 Med Rec form (Bedard et al 2010)
 IT
 Kiosk technology for DH taking (Lesselroth et al 2009)
 Nationwide on-line prescription records (Glintborg et al )
 Natural language processing (Cimino et al )
 PAML builder (Turchin et al 2008)
Health Care Professional Role
 Hospital Pharmacist
 Medication History taking (Nester and Hale 2002, McFadzean
1993 Carter et al 2006)
 Presence of pharmacist on post-admission ward rounds
(Fertleman et al 2005)
 Pre-admission clinics (Kwan et al, Dooley et al 2008)
 Community Pharmacist
 Faxing information to community pharmacies (Cook et al
1995, Cook and Choo 1997, Pegrum et al )
 Counselling at discharge by community pharmacists
(Hugtenburg 2009)
 Community liaison pharmacist (Bolas et al 2004)
Education
 Improving education for doctors
 Bray-hall et al 2009, Lindquist et al 2008
 Physician quality officer
 Walsh et al 2011
 American Medical Association 2007 - Physicians Role
in Medicines Reconciliation
 RPSGB – Principles and Responsibilities for
commissioners and providers plus minimum data set.
Common Factors
 Leadership and Support
 MD team
 Simplification and standardisation of process
 Clear policies and procedures
 Visible process
 Clarifying of Roles and Responsibilities
 Reporting and learning from errors
 Education
 Feedback and ongoing monitoring
 Appropriate measures