Transcript BACKGROUND - Minot State University

Reconciling Medications
Safe Practice Recommendations
and
Implementation Strategies
Medication Safety Facts
 Medication errors account for more than
7,000 deaths annually
 Approx. two out of every 100 patients
admitted to the hospital will experience
a preventable adverse drug event
 Over 12% of patients with an ADE
within 2 weeks of discharge
“Reconciling Medications”
A systematic process to reduce the number of
medication events occurring at interfaces of care
Creating the most complete and accurate list possible
of all home medications for each patient and then
comparing that list against the physician’s admission,
transfer, and/or discharge orders. Discrepancies are
brought to the attention of the physician and, if
appropriate, changes are made to the orders. Any
resulting changes in orders are documented.
RESEARCH:
 Errors that are the result of an omission are often not
reported as errors, although they may result in an
adverse outcome for the patient.
 They may manifest themselves as:
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Unexplained elevated lab values
 Due to inaccurate dosing
 Missed medications
Readmissions due to:
 Doubling up of medications
 Missed medications at discharge
 Contraindication to unknown OTC or herbal meds
Problem identified
 Info on patients’ home meds not being
systematically collected; in multiple places in
the chart, often incomplete
 Poor or inadequate processes to compare list
of pre-admit medications to orders
 Research study demonstrated that over half of
all hospital medication errors occurred at the
interfaces of care
[Rozich, Resar 2001]
Medication errors based on
chart review
9%
Interface Errors
14%
56%
21%
Drug Distribution or
Documentation Errors
Allergy Documentation
Others
Source: Luther Midelfort Hospital -- Mayo Health System chart review
“We found that the list of medications that details current drug use
was either nonexistent or wrong more than 85% of the time”
[Rozich/Resar 2004, p.8]
Examples of errors
 No orders for needed home meds
 Missed or duplicate doses from inadequate
records of frequency/last administration time
 Surgeon inadequately addressing meds for
chronic conditions
 Failure to restart meds at transfers
 Doubling up (brand/generic combinations,
formulary substitutions)
Unintended medication
discrepancies at admission
Studies show over half of patients have
discrepancies between home medications and
medications ordered at admission, many with
potentially serious results
 54% of patients; 39% potentially serious [Cornish
Arch Intern Med 2005]
 More than half; 59% could have caused harm if
the error continued after discharge [Gleason Am Jnrl
H-Sys Pharm 2004]
More evidence on impact:
Johns Hopkins Surgical ICU
 Dramatic reduction in medication errors
resulted from reconciling:
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Baseline: 31 of 33 (94%) of patients with MD
changing orders when discrepancies brought
to their attention
By week 24, nearly all medication errors in
discharge orders eliminated
As a result of routine reconciling, average of
10 orders per week are changed
[Pronovost, 2003]
The
Reconciling Process
THE PROPOSED SOLUTION
 A process to obtain the
best home medication
list possible through a
defined resource list
and active review of the
patient’s medical
history.

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Patient
Pharmacy
Family
Patient’s Med List
PCP
VNA
 Utilize strategic
interviewing practices.
 Ask open ended
questions to obtain
info on OTC meds &
herbals.
Reconciling process: admission
Getting the home med list (at intake)

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Interviewing strategies to promote accuracy
Input from patient/family/alternative sources
Outreach: patients arrive with accurate list
Writing medication orders

Goal: work from accurate home med list
Identify and reconcile discrepancies
Order (no omissions, no duplicates, right med/dose/
frequency/route)
 Communicate (to next level of service)
BECOMING A STATEWIDE
INITIATIVE
 The Massachusetts Hospital Association in
collaboration with the Massachusetts Coalition for the
Prevention of Medical Errors reviewed evidence of
medication reconciliation to determine:
 Importance – How much can we impact safety?
 Feasibility – Is this a doable process?
 Measurability – Can we monitor our progress?

Statewide advisory board voted to accept this
initiative!
Getting started
1) Initiate leadership dialog – resource
commitment, regular reporting channels
2) Form a multidisciplinary team
3) Risk assessment/baseline measurement
4) Aim statement, timeline
5) Pick pilot unit
6) Begin testing
Define Aim / Obtain Baseline Measure
 Aim:

To reduce the rate of unreconciled
medications at admission by 50 % within 9
months.
 Measure:

Baseline measurement of 20 charts,
subsequent measures performed on 30 charts
per month for the first 3 months after
implementation of form. Evaluate the
frequency of the measure after the first three
months.
1. Getting the home med list
What have we learned?
 Adopt standardized form
 Share responsibilities, ordering prescriber
accountable... crew resource management principles
 Validate with the patient
 Don’t let perfection be the enemy of the good
1. Getting the home med list
Who? Shared responsibilities, always
someone with sufficient expertise:
 RN who completes the initial admission history
 Pharmacist/pharmacist technician
[Michels/Meisel 2003; Gleason/Groszek 2004]
 MD if reconciling form not complete when ready
to write orders
1. Getting the home med list
What?
 Current home meds
 Include OTCs & herbals
 Dose, frequency, time of last dose
 Optional: route, source of information,
compliance, purpose
 Many building collection of patient allergies into
the process
2. Using home list when
writing orders
What have we learned?
 Make highly visible
 Provide access at point when orders are written
 Have reconciling form serve as an order sheet.
benefits and issues...
Project phasing
 Pilot testing: identify changes, measure to
know if the changes are an improvement
 Implementation: take a successful change
and build it into the way the entire pilot
population/pilot unit does their work
 Spread: replicating a change/package of
changes beyond the pilot unit into other parts
of the organization
 Maintain the gains
3. Identifying, reconciling
discrepancies
Who?
 Generally
nursing assigned responsibility
of comparing the home list to the admit
orders, identifying variances, and
reconciling all differences
 Pharmacist involvement can be
productive, especially for organizations
with decentralized pharmacy
 Need strategy for handing off any
unresolved differences at shift change
Implementation Strategies
Resource requirements
 During testing/implementation phase
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Make explicit allocation for those with patient
care responsibilities
Managers need to pay attention to workloads;
don’t assign tests to someone overloaded
 Ongoing
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Build into regular workflows
Collecting home history IS time consuming;
some have added resources to support that
(e.g. pharmacy techs)
Post Team Members- Encourage Input
 Contact any of the following Medication
Reconciliation PI Team members to answer
any of your questions:
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Melissa Bartick, MD - X9335
Jennifer Fexis, Quality - X9406
Darlene Civita, RN ICU- X9350
Vicky Casto, RN ACU - X9335
Deb Wilkinson, RPh - X9363
Tips for engaging MDs
 Personal appeals from VP of Medical Affairs and/or
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Chiefs of services
Trial with key leaders on each unit; get their input via
“hallway consultations” not meetings
Identified “Ambassadors” from engaged hospitalists;
they then educated others
Developed into CME risk program
MDs from key committees (P&T, Medical Records)
Chief Medical Resident on the team, with
responsibility to report back to other residents
Baseline risk assessment
Chart review
 Institution-wide
Mini-FMEA, flow charting existing
processes
 Do
in conjunction with initial tests of
change
Just-enough measurement/analysis
 Don’t get bogged down here!!
Mission
 Every patient will receive all medications they
have been taking at home unless they are
held/discontinued by their caregiver(s) and
all new medications as ordered -- correct
drug, dose, route, and schedule.
The goal of reconciling is to design a process that will ensure
the most accurate patient home medication list available, thus
reducing the number of medication events upon admission,
transfer and discharge
Choosing where to start
 Use risk assessment process
 Willing volunteers
 At admission logical place
 Pros
& cons: Med vs Surg units
 Some success starting @ transfer: ICU,
CCU, telemetry units
 Probably not ED
Start small, focus on one unit
 Small tests... 1 unit, 1 RN, 1 MD, 1 patient
 Add more staff, more shifts, refining process
and form
 Keep testing on that one unit until you refine
the process and can show that it works (test
on all shifts, patients coming in as direct
admits, from ED, transfers, etc)
Pilot unit
1) Mini-team including nurse managers, frontline nurses, MD champion
2) Project introduction, staff education
3) Baseline measurement for the unit
4) Pick reconciling form to test (steal shamelessly...)
5) Begin testing
Piloting a reconciling form
 Testing; avoid forms committees...
 Simple vs complex
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Reconciling status
Orders: continue, change, d/c, hold
Optional: data sources, purpose/indication,
date/time of last dose, amt of non-compliance
Columns for reconciling at discharge?
Signature lines
Fundamental ingredients...
 Get support of your CEO; cannot do it without
leadership at the top
 Use data (to motivate, to know if changes are
leading to improvement)
 Strong representation from leadership of the 3
key stakeholder groups: MD, RN, pharmacy
 Start small
Culture...
 Core issues of teamwork and communi-
cation... organizational culture matters
 Changing the way people do work; every time
you try to change behavior, it’s only natural to
be met with resistance
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Recognize that this is HARD;
Difficult task: but not impossible
Unit briefings/pharmacy rounding
Challenges and barriers
 Time and resources
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“How can we find the time to do this?”
 Roles and responsibilities
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“It’s not my job”
“I’m not going to sign that form”
 Data collection
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Need data... but don’t let data collection delay
testing, overwhelm
Medication Checklist
Here’s how patients can help the ‘medication reconciliation’ process:
 Keep an updated list of all medications including herbals,
vitamins and OTC. Including dosage and reason for taking
the drug
 Include all allergies and describe reaction
 Include immunization history
 Take the list to all doctor visits and medical testing labs, as
well as pre-assessment visit for admission or surgery and all
hospital visits including ER
 When you leave the hospital, be sure to update your list with
new medications and ask if any medications are duplicated
 Keep this list in with you at all times
Staff education
 Include staff ed rep on your team
 Create simple template clarifying the steps to
be taken to complete reconciling
 Lead off with examples of errors from your
own hospital
 Use front line staff from pilot unit to educate
staff on subsequent units
 Build into orientation, ongoing staff ed
 Publish your data and progress in your
organizations newsletter
Measurement
Just-enough measurement
 Core measure

Percent Medications Unreconciled
 Orders changed, “great catches”, stories
 Measures linked to each test, for example:
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% patients with reconciling form in chart
RN/MD assessments of process
 Spread: % patients on units w/ reconciling
 Context of institution-wide ADE reduction
0
7/6/98
6/29/98
6/22/98
6/15/98
6/8/98
100
6/1/98
Discharge
reconciliation
5/25/98
5/18/98
5/11/98
5/4/98
4/27/98
4/20/98
4/13/98
4/6/98
3/30/98
150
3/23/98
3/16/98
3/9/98
3/2/98
200
2/23/98
2/16/98
2/9/98
2/2/98
1/26/98
1/19/98
1/12/98
1/5/98
# Medications Unreconciled
(per 100 Admissions)
300
250
Admission
reconciliation
Transfer
reconciliation
50
Luther Midelfort Implementation Impact
Baseline data collection
GOAL: Identify current safety risks
 How
complete is info on patient’s
pre-admission meds? How hard
to find? In multiple places?
 How
often are home meds
omitted from admit orders? not
re-started after transfer, at
discharge? duplicate therapies at
discharge?
Example: Why is it Needed?
 In a chart review of our admit orders, we
found an average of over 4 discrepancies
per patient, with omitted medications the
most significant error.
Source: University of Kansas Hospital
Terry Rusconi [2003]
Collecting your data
No.
Admitting Medications
Is
Do
discrepa
Elements
Medication List
ncy
Frequency
Data
of List
Dose (1)
Route (3)
Documented on intention
(2)
Source
Match?
List all that apply
al? Y or
Y or N or
No or ?
? (4)
(5)
Are Admitting
Meds
Frequency
Admitting Medication
Dose (6)
Route (8) Addressed By
(7)
Orders
MD? (9)
Y or N or ?
1
2
3
4
5
6
7
8
9
10
11
12
Total (1) Blanks
Total (2) Blanks
Total (3) Blanks
Number of Meds
Data Source:
Lists Documented
On:
P = patient
V = VNA
F = family
N = Nursing home 200 - RN admission
Rx - RX bottle
C = Pharmacy
H = History
M = MD office
100 - ED sheet
300 - H & PE
400 - PAT form
500 - None
Total (5) N or ?
Total (9) N or ?
Total (6) Blanks
Total (7) Blanks
Total (8) Blanks
Total ordered meds
Comments
A
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
Chart
Review
B
C
Total Admission
Medications
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Sum
Total Blanks (1)
(2) (3)
5
1
13
10
2
10
13
7
9
10
13
10
0
12
11
15
10
9
11
2
173
0
3
10
12
2
30
13
3
0
14
4
0
0
23
16
6
14
4
15
2
171
Summary Statistics - Admit Orders
# discrepancy errors: Sum of (5)
# patients: # charts reviewd:
Discrepancy errors/100 admissions:
Average error per patient
Summary Statistics- H & P
# reconciliation errors: Sum of (9)
# patients: # charts reviewd:
Reconciling errors/100 admissions:
Average error per patient
D
E
F
G
Number of
Discrepancy's (5)
Number of Admitting
Meds Not Addressed by
MD (9)
Total Ordered
Medications
Total Blanks
(6) (7) (8)
2
1
2
0
0
0
2
0
3
2
0
0
8
4
10
11
10
3
6
1
65
65
20
325
3.25
38
20
190
1.9
Summary Statistics - Admit Orders
# dose, freq, route omission errors:
Sum of (C)
Total admission medications: Sum of (B)
Admitting Omission errors?100 admissions
Average error per med
171
173
99
0.99
Summary Statistics - H & P
# dose, freq, route omission errors:
Sum of (G)
Total ordered medications: Sum of (F)
Order Omission errors?100 admissions
Average error per med
49
185
26
0.26
1
1
2
0
0
0
0
0
0
1
0
0
8
5
1
0
7
1
10
1
38
5
4
11
9
7
9
13
8
8
10
19
11
8
9
10
18
3
12
6
5
185
0
0
3
0
0
0
3
0
0
2
19
0
0
0
10
2
4
6
0
0
49
Baseline: practical process
 Multidisiplinary team of reviewers

RN, MD, Pharm... QI rep to combine
 Minimum 20 charts
Institution-wide, random or stratify to ensure
all units represented
 Minimum stay of 3 days
 Can be fruitful to include re-admits
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 Find home meds and list on form
 Compare to admit orders
 Identify “unreconciled medications”
Ongoing data collection
 Need frequent measurement on every unit where you
are testing: monthly charts to display on unit
 Process: easy for patients where the reconciling form
has been completed; follow process used in baseline
data collection when no reconciling form
 DON’T CHEAT:
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Don’t skip patients without a reconciling form
Don’t just look for home med list; the question is,
have the home meds been RECONCILED?
TIPS on collecting your data...
 Share responsibilities, engaging implementers
 Limit sample: 20 charts
 Real-time review: patients on unit for 24 hours
 Establish rules for consistent treatment where judgment
required (omission or obvious hold or d/c based on patient
condition; but strategy should encourage increased documentation
by prescriber)
 Set time limit (when unable to find home meds, use list from
admit orders and indicate that all are unreconciled)
 Share “Great Catches”: examples of orders changed, errors
prevented
Beyond Admission
and
Longer-term Considerations
Reconciling at Transfer
 Compare most recent med record (MAR) and home
med list against transfer orders. Issues:
 Access to reconciling form with home med history at
point when new orders written
 Need to modify reconciling form to add columns for
reconciling at transfer?
 Identifying responsibilities of both the transferring and
the receiving unit
 Embedding into workflow: Who writes transfer
orders? When? Where?
Reconciling at Discharge
 Patients especially vulnerable
immediately post-discharge
 Over
12% of patients with an ADE within
2 weeks of discharge [Forster 2003]
 Address potential for doubling up based
on formulary substitutions or other
brand/generic name confusions
 Prohibit “resume home meds”!!!
 Verification of dosing instructions
Outpatient Settings
 Applies to settings where the outpatient:
 may receive medication
 where patient's response to treatment might
be affected by medications they are on
 where a practitioner who can review and
modify the patient's medications is a part of
the outpatient service
 Examples include outpatient oncology
services, GI laboratories, emergency
department, urgent care clinics, certain
imaging procedures.
Using as an order sheet
Proceed with caution, but efficiency gains
 Most MDs find it very helpful; makes their life
easier, decreases duplication
 Timing: 6-10 months into the process?
 Modifications to reconciling form:
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Add MD signature line(s)
Columns to indicate “continue” or “discontinue”
Amendment form
Automation
If you can’t do it on paper,
don’t even try it in vapor
 First must have a stable process: adequate
testing of the form, implementation on
multiple units
 Careful design required; who enters info, who
can update/change, may introduce new
errors
Automation: John Hopkins ICU
project
 Revised form to strike balance between
burden of data collection and
comprehensiveness of medication
information
 Automated process after 48 weeks, paper
forms converted to electronic form
 Intervention now takes 20 minutes on
admission and 20 minutes at discharge with
minimal marginal costs
Better access to medication histories
 Promote patients maintaining medication
cards
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Provide in ED, at discharge
Disease specific support groups
Pharmacy medication review
Senior center (file of life)
Partner with PCPs, nursing homes, VNA,
health plans
Better access to medication histories
 Interview strategies including increased use
of open ended questions
 Link medications to conditions, prescribing
physicians
 Checklists of OTCs/herbals and commonly
missed meds
 Leverage expertise of VNAS
 Shared databases