Transcript SHM Med Con talk - Society of Hospital Medicine

The Medication Reconciliation
Dilemma
May 24, 2007
Eric E. Howell, MD
Assistant Professor of Medicine
Johns Hopkins University, School of Medicine
Johns Hopkins Bayview Medical Center
Brian Clay, MD
Assistant Professor of Medicine
Division of Hospital Medicine
UC San Diego
Objectives:
Learn the impact of medication
reconciliation (or lack thereof) on patients
Identify the potential weaknesses in
current medication reconciliation
processes
Demonstrate a knowledge of current
options, option strengths and option
limitations
Outline for Today
Setting the stage
Review the Data
SHM Survey (Brian Clay)
JHBMC Med Rec Experience
Discuss Resources Available
Conclusions
Discussion
Adverse Drug Event (ADE) Case
Files*
80 y.o. man admitted from home to hospital
Meds changed, including start of “ramipril”
On DC summary amaryl listed, not ramipril
Physician did not reconcile meds on DC
* http://www.dhmh.state.md.us/
ADE Case Files*
Pt discharged
Later he is found obtunded
Found to be hypoglycemic and readmitted
Pt died a few days later from injuries
* http://www.dhmh.state.md.us/
What Happened?
Swiss Cheese Model of Major Errors
DC meds not reviewed
Outpt
doc
unaware
of
change
Sentinel
Event
Amaryl
transcribed
Admission
Pt/care giver does not
review meds
Reason J. Human error: models and management. BMJ. 2000;320:768-770.
Background on Adverse Events
(AE) and ADEs
Recall that ~ 20% of pts have AE on DC1,2
Most AEs are Preventable or Ameliorable
(about 1/3 for each)
Majority (66-72%) of AEs are ADEs
1) Forester, Arch Int Med. 2006;166:565-71
2) Forester, Ann Intern Med. 2003;138:161-167
ADEs are Common!
As early as 1995 ADEs thought to be1 :
Common- 6.5%
Preventable- up to 42%
Studies continue to support ADEs as 2,3,4:
Common- 11%
Preventable (Ameliorable)- 27% (33%)
1) Bates, JAMA. 1995;274:29-34.
2) Forester, JGIM. 2005;20:317-23
3) Forester, CMAJ. 2004;170:345-9
4) Schnipper, Arch Intern Med. 2006;166:565-71
How Can ADEs Be Reduced?
Adverse Drug Events are reduced when
medications are explained (reviewed)1,2,3
1) Bates, JAMA. 1995 Jul 5;274(1):29-34.
2) Schnipper, Arch Intern Med. 2006 Mar 13;166(5):565-71
3) Forester, Arch Int Med. 2006;166:565-71
IOM: To Err is Human
1999- Institute of Medicine’s (IOM) report
98,000 deaths annually in hospitals
1.5 Million Potential ADEs (1/day/pt)
9000 deaths from adverse drug events
Most errors are system based, not due to
reckless individuals
http://www.nap.edu/openbook.php?isbn=0309068371
Background
The IOM report and other data spur
action by the Institute for Healthcare
Improvement (IHI):
6 changes that save lives
Deployment of Rapid Response Teams…at the
first sign of patient decline
Delivery of Reliable, Evidence-Based Care for
Acute Myocardial Infarction…to prevent deaths
from heart attack
Prevention of Adverse Drug Events (ADEs)…by
implementing medication reconciliation
Prevention of Central Line Infections…by
implementing a series of interdependent,
scientifically grounded steps called the “Central
Line Bundle”
Prevention of Surgical Site Infections…by
reliably delivering the correct perioperative
antibiotics at the proper time
Prevention of Ventilator-Associated
Pneumonia…by implementing a series of
interdependent, scientifically grounded steps called
the “Ventilator Bundle”
“Some is not a number; soon is not a time”
Background
The IOM report and other data spur
action by the Institute for Healthcare
Improvement (IHI):
Prevention of Adverse Drug Events (ADEs)…by
implementing medication reconciliation
“Some is not a number; soon is not a time”
Institute for Healthcare
Improvement (IHI)
Reconciliation: A process of identifying the most
accurate list of all medications a patient is
taking—including name, dosage, frequency, and
route—and using this list to provide correct
medications for patients anywhere within the
health care system
Requires comparing the patient’s list of current
medications against the physician’s admission,
transfer, and/or discharge orders
http://www.ihi.org/NR/rdonlyres/598D427A-4BDA-419D-91B5B836D23A6F1D/0/CampaignOverview101105.ppt#358,9,Prevent Adverse Drug Events by Implementing Medication
Reconciliation
Background
The IOM report and other data spur
action by the Joint Commission:
2005 patient safety Goals:
Goal 8:
Accurately and completely reconcile medications across the
continuum of care.
Goal 8A:
During 2005, for full implementation by January 2006,
develop 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.
Goal 8B:
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 (JC)
Medication reconciliation is the process of comparing a patient's
medication orders to all of the medications that the patient has been
taking. This reconciliation is done to avoid medication errors such as
omissions, duplications, dosing errors, or drug interactions. It should
be done at every transition of care in which new medications are
ordered or existing orders are rewritten. Transitions in care include
changes in setting, service, practitioner or level of care.
This process comprises five steps:
1) develop a list of current medications
2) develop a list of medications to be prescribed
3) compare the medications on the two lists
4) make clinical decisions based on the comparison
5) communicate the new list to appropriate caregivers and to the patient.
•http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/05_hap_npsgs.htm
Joint Commission (JC) Data
2005 Develop Process for Medication
Reconciliation
Compliance:
99.7%+
2006 Full implementation of Med
Reconciliation
Compliance:
62%
2006 SHM Meeting
Medication Reconciliation Survey
Brian Clay, MD
Assistant Professor of Medicine
Division of Hospital Medicine
UC San Diego
2006 SHM Meeting
Medication Reconciliation Survey
Survey placed in all attendees meeting
materials (approximately 800)
Questions regarding demographics,
institutional characteristics, process steps,
and barriers to implementation
295 surveys returned
2006 SHM Meeting
Medication Reconciliation Survey
Majority (90%) of institutions represented
served adult population
Multiple hospital types represented
– Academic tertiary care center (23%)
– Community teaching hospital (29%)
– Private community hospital (43%)
2006 SHM Meeting
Medication Reconciliation Survey
Implementation stage varied
– Fully implemented (48%)
– Partially implemented (35%)
– Still in planning stages (11%)
Hospitalist involvement varied
– Active role in design/implementation (36%)
– Peripheral role/consultation (24%)
– Not involved (31%)
2006 SHM Meeting
Medication Reconciliation Survey
Format
– Paper (47%)
– Computer (11%)
– Combined (31%)
Measurements
– Measuring compliance (42%)
– Measuring outcomes (22%)
2006 SHM Meeting
Medication Reconciliation Survey
Process Steps
– Physician roles
Reconciling medications
Updating discharge medication list
Communicating med information to next provider
– Nursing or “shared” (RN/MD) roles
Obtaining home medication list
Documenting home medication list
Providing discharge med information to patient
2006 SHM Meeting
Medication Reconciliation Survey
Barriers to Implementation
– Patients do not know medications (87%)
– Medication list not available (80%)
– No access to outside records (63%)
– Formulary differences (59%)
– Process takes too long (53%)
– Hospital systems are cumbersome (52%)
Potential impact
– 58% of those surveyed feel medication
reconciliation will have a positive impact
2006 SHM Meeting
Medication Reconciliation Survey
Community teaching hospitals and private
hospitals more likely to have med recon
implemented compared to academic
centers (57%, 49% vs. 35%, p = 0.007)
However, academic centers more likely to
use computer systems to do med recon
(27% vs. 9%, 7%, p = 0.005)
2006 SHM Meeting
Medication Reconciliation Survey
Obtaining and documenting pre-admission
medications
Academic centers: more a physician
responsibility
Community teaching hospitals and private
hospitals: more a nursing responsibility
Most common response was a “shared”
responsibility
2006 SHM Meeting
Medication Reconciliation Survey
Reconciling medications with admission
orders
– Physician responsibility at all sites
Striking lack of pharmacist involvement
– Obtaining/documenting meds: 5%
– Reconciling meds: 6%
– Discharge instructions: 2%
2006 SHM Meeting
Medication Reconciliation Survey
Conclusions
– “Shared” responsibility model is common
– Multiple barriers to full implementation
– Underutilization of pharmacists
– Hospitalists have played a prominent role in
design and implementation
Much more opportunity for hospitalist leadership in
this area
Johns Hopkins Bayview
Medication Reconciliation
Dilemma
JHBMC and the Medication
Reconciliation Dilemma
2004:
– Just starting to address issue
– Faculty & staff unaware/uninterested in
problem
– JHBMC did a FEMA: Improve work flow
through paper tools
JHBMC and the Medication
Reconciliation Dilemma
2004-2005:
– Hospital leadership partners with several
cooperative physicians to “champion” cause
– Hospital leadership engages physician
leadership, get buy-in on problem
– Interdisciplinary meetings begin
– New paper process simplifies and streamlines
med-rec process
JHBMC and the Medication
Reconciliation Dilemma
Process has:
– Admit sheet to list outpt meds
– DC Sheet with:
Place designating meds “reconciled”
Check boxes for “no change”, “stop” and “new”
Check box to designate pt education occurred
– Sheets “side-by-side” capability
JHBMC and the Medication
Reconciliation Dilemma
Paper discharge list an instant success
Admit sheet for meds used intermittently
Need both components to be successful
Bottom Line:
Developing process was easy,
multiple barriers made implementation hard
Overcoming Barriers: PDSA
Got stakeholders together
Identified Barriers:
Form not in chart
Avg doc not engaged
Pt health literacy
Took extra doc time
Popular H&P “med list” used
modified from: The Foundation of Improvement by Thomas W. Nolan et. al
Overcoming Barriers: PDSA
Identified Barriers:
Form not in chart 
Avg doc not engaged 
Pt health literacy 
Took extra doc time 
Popular H&P “med list” 
Developed Solution:
Educated Unit Sec’s
QI team showed data met
freq
XXXX
Improved w/avail forms
Placed big “USE MED REC
LIST” sticker over H&P
med area!
SUCCESS!
JHBMC Future Direction: Electronic
Medication Reconciliation
JHBMC Future Directions
Current electronic format has potential:
– “Ambulatory list” can be selected for in-pt use
– Admission/hospital/discharge meds on one
screen
– May condense “duplicate” lists: nursing & MD
JHBMC Future Directions
Current electronic format drawbacks:
– Lists are not “side-by-side” making
reconciliation challenging: Structure of
electronic format does not always facilitate
workflow
– Not sure how admission list will get populated
– Docs still using H&P to document meds??
Resources Available
http://macoalition.org/
JC’s Dr. Croteau (executive director for pt safety
initiatives) reports JC gets “information and
support” from the macoalition
www.hospitalmedicine.org
Information in the SHM “resource rooms”
http://macoalition.org/Initiatives/RMTool
kit.shtml
Implementation Guide for Safe Practices
(A Resource Book of Materials)
Overview
Safe Practice Recommendations
Implementation Strategies
Toolkits
RUN DATE:
RUN TIME:
RUN USER:
LOCATION:
ROOM-BED:
Holyoke Hospital LIVE ADM
MEDICATION RECONCILIATION FORM
NAME:
AGE/SEX:
ADMITTED
ATTENDING:
PAGE 1
ACCOUNT NO:
MEDICAL RECORD NO:
ADMISSION ASSESSMENT
DRUG
DOSE
ROUTE
FREQ
Written on
Admission
MD
Contacted
Result of
MD Contact:
Med Ordered
[ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
[ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
[ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
[ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
[ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
[ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
[ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
[ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
[ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
[ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
[ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
[ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
[ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
[ ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No
Additional information:
Herbal/Homeopathic remedies:
Disposition of patient's medications upon admission:
Comments: (If MD did not order med after call/notification - - state why) _______________
_______________________
Nurse's Signature
ATTENTION PHYSICIAN
Please Reconcile Meds
PATIENT NAME:
UNIT NUMBER:
PREADMISSION MEDICATION LIST
VERIFICATION AND ORDER FORM
(Medication Reconciliation)
Allergies:
LIST BELOW ALL OF THE PATIENT’S MEDICATIONS PRIOR TO ADMISSION INCLUDING OTC AND HERBAL MEDS
NEW MEDICATIONS OR MEDICATION CHANGES SHOULD BE WRITTEN ON ADMISSION ORDERS
Source of Medication list: (check all used)
Patient medication list
Patient/Family recall
Pharmacy _________________
Primary care physician list / PCHIS
Previous discharge paperwork
Medication Administration Record from facility
Other: _______________________________
CHECK HERE IF THIS IS AN ADDENDUM TO OR
REVISION OF PREVIOUSLY COMPLETED
MEDICATION LIST
CIRCLE C to continue OR
DC to discontinue
MEDICATION HISTORY RECORDED/VERIFIED BY:
DATE RECORDED:_________________________________
MEDICATION NAME
(WRITE LEGIBLY)
DOSE
(mg, mcg, )
_____________________
ROUTE
(PO, GT,
SC, IV)
FREQUENCY
LAST DOSE
DATE/TIME
PHYSICIAN PHYSICIAN
ORDER
ORDER
Continue
on
Admission
Continue
on
Transfer
COMPLETE
On
Discharge
1.
C
DC
C DC
2.
C
DC
C DC
3.
C
DC
C DC
4.
C
DC
C DC
5.
C
DC
C DC
6.
C
DC
C DC
7.
C
DC
C DC
8.
C
DC
C DC
9.
C
DC
C DC
10.
C
DC
C DC
11.
C
DC
C DC
12.
C
DC
C DC
13.
C
DC
C DC
14.
C
DC
C DC
C
DC
C DC
15.
Do not scan or take off orders without MD/NP/PA signature
M.D. Signature:____________________________________ Print Name:_______________________________________________
Pager:
Date/Time:
Reviewed and Transcribed
Nurse Signature:____________________________________
Date/Time:________________________
Caritas Norwood Hospital
Norwood, MA
Patient Label
Medication Reconciliation Form
Please complete form to list all medications identified by the patient, family, written medication list, available prescription vial(s).
Drug Allergy:
Reaction:
Drug Allergy:
Reaction:
Drug Allergy:
Reaction:
Drug Allergy:
Reaction:
Prescription (Rx) and Over-the-Counter (OTC) Medications
Medication
Dose
Route
Freq
Time of
last dose
prior to
admission
Ordered on
Admission exactly
as documented
If No, contact MD
Yes
No
Check box to identify field
discrepancy
Med
Dose
Rte
Freq
Results of MD
consult:
Med ordered
clarified
Yes
No
Comments/
changes
COOLEY DICKINSON HOSPITAL
TEST FORM: PREADMISSION
MEDICATION LIST VERIFICATION
Allergies:
List all of the patient’s medications Prior to Admission including OTC and Herbal preparations.
Date Recorded:
Medication Name
(Write Legibly)
Dose
Route
Frequency
Last Taken
Continued on
Admission?
Y or N
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Nurse Comments:
Nurse Signature:
Sources of Information (check all applicable):






Patient’s own medication list
Patient/Family recall
Pharmacy (name & phone):
Physician’s list (name):
Prior hospital records (name facility)
Other (specify):
Alternate Providers
I have reviewed this list:
Physician Signature
Date
 No  Yes: List__________________________________________________________
What do most med recon forms
have in common?
Some indication that the medication was
“reconciled”
A list of potential sources for the list (patient,
records, etc)
A way to indicated that specific medications
were changed from admission
Separate spaces for med, dose, route, freq, time
last taken
Most have started with an existing model and
modified it for their institution’s needs
www.hospitalmedicine.org
Information in the SHM “resource rooms”
Toolkits
QI Educational Material
SHM Resource Rooms
Toolkits:
Sample Forms
SHM Resource Rooms
Toolkits:
Sample Forms
Workbook on implementation
SHM Resource Rooms
Toolkits:
Sample Forms
Workbook on implementation
Web Community (ask the expert)
SHM Resource Rooms
Excellent QI Overview:
Very thorough Slide Show
SHM Resource Rooms
Excellent QI Overview:
Very thorough Slide Show
Extensive workbooks on how to effect change
A Few words about QI…
Sound QI principles make success much,
MUCH more likely!
Consider doing a FEMA
A Few Words About FEMA
Process Step
1
Process Step
2
Process Step
3
Process Step
4
Failure Mode
Failure Mode
Failure Mode
Failure Mode
Failure Mode
Failure Mode
Failure Mode
Failure Mode
Failure Mode
Failure Mode
Failure Mode
Failure Mode
Failure Mode
Failure Mode
Failure Mode
Failure Mode
A Few (more) Words about QI…
Engage Administration
This is a team effort
Don’t let perfection stand in the way of
good
Measure and change based on the
outcomes
Summary
Medication Reconciliation has significant
potential to improve patient safety
Medication Reconciliation is complex!
Electronic solutions still in infancy
Implementation require sound QI methods
–
–
–
–
Physician champion
Well coordinated team effort (including physician)
Rapid cycle change (PDSA)
Evaluation method
Summary
Don’t re-invent the wheel, lots of good stuff
out there already
Don’t let perfection get in the way of good
I have heard that surveyors raise the bar
over time!
Other Resources
Joint Commission Web link:
http://www.jointcommission.org/
IHI weblink:
http://www.ihi.org/ihi
More to Come….
Medication Reconciliation Conference in the Works
New Medication Reconciliation Survey due out soon