Transcript Lessons Learnt from Medication Reconciliation Activities Using

Event Analysis
Lessons learnt from Medication Reconciliation activities using
Event Analysis to improve medication safety
Evonne Fong, Dale Mitchell, Stephen Lim
Pharmacy Department
Background
Medication Reconciliation (MR) since 2007 at AHS
?? How and what to measure??

SQuIRe
•
•
Compliance with MR processes on admission, transfer and discharge
Varying results
• Admission: approximately 50% of patients with MR done within 24 hours
• Discharge: approximately 70% of patients with discharge reconciliation done

KPIs
What we found:
• 17.2 medication errors per 100 medications a patient takes
• 58.4 drug errors per 100 high risk patients
Where to next?? … High 5s
 AHS joined WHO’s High 5’s Project in
2009
• Global patient safety collaboration
• Australia’s project: Assuring Medication
Accuracy at Transition Points of Care
 Benefits….
• New measures
• High 5s MR 1-4
• **Event Analysis**
New High 5’s measures
1. Percent of patients with meds reconciled within 24 hours of
admission
2. Mean number of outstanding undocumented intentional
medication discrepancies per patient
3. Mean number of outstanding UNINTENTIONAL medication
discrepancies per patient
4. Percent of patients with at least ONE outstanding
unintentional discrepancy
Event Analysis (EA)
 Unprecedented opportunity to
obtain and analyse findings from
around the world regarding safety
and effectiveness of SOP
• Contributing factors
• Any specific system changes needed
Unique? Similar? Why?
Event Analysis (EA)
Includes:
•
•
•
•
Description of event
Analysis of cause and effect
Identification of contributing factors
Recommended improvements in
processes/systems
• Documentation of findings and
recommendations
Example – Ian’s Story
Day 1:
 Admitted to ED on 22/5/2013 (Wednesday)
 Admission reason: mechanical fall for investigation and
rehabilitation + ?UTI
 PMH: HTN, Parkinson’s Disease, neuropathic pain, depression
 Pt unable to give accurate medication history
 Pt transferred to acute medical unit
 MO writes up medications on chart
 Patient’s mobility assessed on the day of admission by physio
Example – Ian’s Story
Day 2:

Patient transferred to General Medical ward
•
Physio notes state decreased mobility and increased tremor
Day 3:

reviewed by Consultant and Medical Officer.
•
Noted decreasing mobility and worsening of tremor
•
MO calls pharmacy and requests review of medications
•
Notes state:
• “review of medications, discuss with GP about meds, ?Neurologist
involved in patient care; ?Increase dose and add medications”
Ian’s Story
Day 3:
After phone call from MO, a pharmacist reviews patient.

Patient poor historian; pharmacist phones wife and uses Webster pack to
obtain BPMH

When comparing BPMH to med chart, multiple discrepancies identified:
•
Omitted levodopa/carbidopa CR 200/50mg nocte
•
Omitted mirtazapine 30mg nocte
•
Omitted pregabalin 25mg nocte
•
Omitted quetiapine 50mg nocte
•
Omitted amlodipine 10mg nocte
•
Incorrect timing for patients other Parkinson’s medication

MO informed  correct meds and times charted 56 hours post admission

Mobility and condition improved; patient discharged
Event Analysis
 Incident reported by pharmacist doing BPMH
 Decision made to complete EA
 Concise EA completed by team:
• Chief Pharmacist
• Clinical Pharmacist
• Medical Officer
• Safety and Quality Unit Project Officer
Event Analysis

Event Details
•
•
•

Patient details
Narrative of what happened
Medications involved
Classification of extent of harm to the patient
Event Analysis
Contributing Factors



Education and Training
•
MO unable to collect BPMH accurately despite having Webster Pack. Did not know how
to decipher medication details from Webster Pack
•
Missed the 10pm “slot”
Staffing
•
Patient initially admitted to AMU for 24 hrs before transfer to medical ward. AMU does
not have allocated clinical pharmacist  Med Rec not completed within 24 hrs.
•
Gen Med pharmacist on leave; another pharmacist went to see pt when requested by Dr
Patient
•
Patient poor historian
Primary Contributing Factors

Education and Training
Event Analysis
 Measurable actions/changes for hospital
Conclusion
 Event analysis beneficial as a “fact finding” tool
• Used to seek and investigate patient safety
problems to identify if there are problems with
the SOP and to identify cause and effect
• Multidisciplinary approach
• Less labour/resource intensive than RCA
• Measurable actions and changes to implement
to improve patient safety