Transcript National Patient Safety Goals

Medication Reconciliation
The content of this presentation is the property of the Joint Commission
International Commission on Patient Safety. For reference only. No part
of this presentation is to be republished without permission.
Presenters
Carol Wagner
Executive Director,
Patient Safety
WSHA
Sharon I. Eloranta,
MD
Qualis Health
Richard J. Croteau, MD
Executive Director for
Patient Safety Initiatives
Joint Commission
International Commission
for Patient Safety
Steven M. Riddle,
BS Pharm, BCPS
Lead Pharmacist,
Medication Utilization
and Quality
Improvement
Harborview Medical
Center
Joint Commission International Center for Patient Safety
Outline
• Importance of medication
reconciliation for patient safety
• Requirements and survey process
• Key steps and effective strategies
• Best examples from around the
country
Joint Commission International Center for Patient Safety
Sentinel Event Experience to
Date
Of 3548 sentinel events reviewed by the Joint Commission,
January 1995 through December 2005:
464
455
444
358
269
189
138
121
109
94
67
66
65
58
651
inpatient suicides
events of surgery at the wrong site
operative/post op complications
events relating to medication errors
deaths related to delay in treatment
patient falls
deaths of patients in restraints
assault/rape/homicide
perinatal death/injury
transfusion-related events
= 3548
infection-related events
deaths following elopement
fires
anesthesia-related events
“other”
Joint Commission International Center for Patient Safety
RCAs
Sentinel Event Alert
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Potassium chloride
Policy issues
Policy issues
Policy issues
Policy issues
Wrong site surgery
Suicide
Restraint deaths
Infant abductions
Transfusion errors
High Alert Medications
Op/post-op complications
Impact of SE Alert
Fatal falls
Infusion pumps
Proactive risk reduction
Home fires (O2 therapy)
Kernicterus
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
Look-alike, sound-alike drugs
Kreutzfeldt-Jakob disease
Medical gas mix-ups
Needles & sharps injuries
Dangerous abbreviations
Wrong-site surgery #2
Ventilator-related events
Delays in treatment
Bed rail deaths & injuries
Nosocomial infections
Surgical fires
Perinatal deaths
Anesthesia awareness
Kernicterus #2
PCA by proxy
Intrathecal vincristine
Medication reconciliation
Wrong route / wrong tube
Joint Commission International Center for Patient Safety
Joint Commission International Center for Patient Safety
National Patient Safety Goals
• Each year, a set of Goals will be
identified from topics published in
Sentinel Event Alert
• A small number of specific
requirements for each of the Goals
will be identified for survey the
following year
Joint Commission International Center for Patient Safety
National Patient Safety Goals
• The Goals and their requirements
will be published by mid-year
• Selection of the Goals and
requirements will be guided by a
panel of experts: the Sentinel Event
Advisory Group
Joint Commission International Center for Patient Safety
The Joint Commission 2006
National Patient Safety Goals
1. Patient identification
2. Communication among caregivers
3. Medication safety
4. Wrong-site surgery
Universal Protocol
5. Infusion pumps
6. Clinical alarm systems
7. Health care-associated infections
8. Medication reconciliation
9. Patient falls
10. Flu & pneumonia immunization
11. Surgical fires
12. NPSG implementation by network components
13. Patient involvement
14. Pressure ulcers
Joint Commission International Center for Patient Safety
The JCAHO 2006
National Patient Safety Goals
Goal #8: Accurately and completely
reconcile medications across the
continuum of care.
Joint Commission International Center for Patient Safety
The JCAHO 2006
National Patient Safety Goals
Requirement #8.a.
• Implement 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.
Joint Commission International Center for Patient Safety
The JCAHO 2006
National Patient Safety Goals
Requirement #8.b.
• A complete list of the patient's
medications is communicated to the
next provider of service when it
refers or transfers a patient to
another setting, service, practitioner
or level of care within or outside the
organization.
Joint Commission International Center for Patient Safety
Why Is Medication
Reconciliation Important?
• The most frequently occurring type of
medical error:
– Medication errors
• The most frequently cited category of root
causes for serious adverse events:
– Ineffective communication
• The most vulnerable parts of a process:
– Links between the steps (the “hand-offs”)
• Medication reconciliation addresses all
of these
Joint Commission International Center for Patient Safety
“Medications” Include:
• Prescription
medications
• Radioactive
medications
• Sample medications
• Vitamins
• Respiratory
therapy-related
medications
• Nutriceuticals
• Parenteral nutrition
• Over-the-counter
drugs
• Blood derivatives
• Vaccines
• Diagnostic and
contrast agents
• Intravenous solutions
(plain or with
additives)
• Any product
designated by the
FDA as a drug
Joint Commission International Center for Patient Safety
Steps in the Reconciliation
Process
1. Develop a complete and accurate
list of the patient’s medications
2. Compare (reconcile) the listed
medications with any new orders
for medications
– Omission
– Duplication
– Interaction
– Name/dose/route confusion
Joint Commission International Center for Patient Safety
Steps in the Reconciliation
Process
3. Update the list as orders change
during the episode of care
4. Communicate the updated list to
the next provider(s) of care (See
PC.15.10—PC.15.30)
Joint Commission International Center for Patient Safety
Joint Commission International Center for Patient Safety
When Should Reconciliation
Occur?
• Whenever the organization …
“… refers or transfers a patient to
another setting, service, practitioner,
or level of care within or outside the
organization.”
Joint Commission International Center for Patient Safety
When Should Reconciliation
Occur?
• At a minimum …
– Any time the organization requires that
orders be rewritten
– Any time the patient changes service,
setting, provider or level of care and
new medication orders are written
• For transitions not involving new
medications or rewriting of orders,
the organization determines whether
reconciliation must occur.
Joint Commission International Center for Patient Safety
Where Should Reconciliation
Occur?
• Goal #8: Accurately and
completely reconcile medications
across the continuum of care.
• Includes all settings of care and any
transitions between them …
whenever medications are used.
– Inpatient
– Outpatient
– Emergency department
– Imaging services
Joint Commission International Center for Patient Safety
Whose list is it, anyway?
Requirement #8.b.
• A complete list of the patient's
medications is communicated to
the next provider of service when
it refers or transfers a patient to
another setting, service,
practitioner or level of care within
or outside the organization.
Joint Commission International Center for Patient Safety
Whose list is it, anyway?
What’s on the list?
• All the medications the patient is to
be taking after discharge, including
dosage, frequency, and route.
Who gets the list?
• The next provider of care
• The patient
Joint Commission International Center for Patient Safety
Discharge Orders, Instructions,
Lists
Discharge orders:
• Directed to other caregivers
(treatments, Rx)
• Blanket orders (“resume all …”) are
prohibited
Discharge instructions:
• Directed to the patient (self-care)
• “Resume home meds” is permitted
Joint Commission International Center for Patient Safety
Discharge Orders, Instructions,
Lists
Discharge list of medications:
• Complete list of continuing
medications
• This is not an order; previous
medications do not need to be
reordered
Joint Commission International Center for Patient Safety
For more information:
The Joint Commission Web Site:
www.jcaho.org
Joint Commission International Web
Site: www.jcrinc.com
Joint Commission International
Center for Patient Safety:
www.jcipatientsafety.org
My e-mail address: [email protected]
Joint Commission International Center for Patient Safety
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