Transcript MedRec LTC Education PowerPoint Presentation

Implementing Medication Reconciliation
in Long-Term Care O’Connell
Date: April 14, 2008
by Bonnie Walker
Risk Manager /Patient Safety Advisor
Safer Health Care Now!
• National Canadian Patient Safety Campaign!
• National Steering Committee - Canadian Patient Safety
Institute (CPSI)
• Purpose:to help teams,hospitals develop skills/capacity
to make quality improvements and monitor their
performance
• Provide ideas, supports and resources to hospital teams
across the country with the goal of providing safer care.
• Focus is harm reduction and improving care processes
and outcomes for patients, families and caregivers
•
•
•
•
Canadian Adverse Events Study
7.5% of all hospital admissions are associated
with an adverse event (2000)
36.9% of which were deemed preventable
Translates to 70,000 preventable adverse
events per year
Contributing to between 9,000 and 24,000
preventable deaths in Canada (2000)
Adverse Events in Canadian Hospitals (Baker, R. & Norton, P. et al (2004))
The Evidence
• Many patients (37% on average) had drug omissions at
admission.
Cohen J, Wilson C, Ward F. Pharmacy in Practice 1998;13-6.
• Many patients (70%) not receiving medication
instructions at discharge.
Alibhal SMH, Han RK, Naglie G. J Gen Intern Med 1999;14:610-616.
• Medication histories are often incorrect or complete:
- 25% of Rx. Medications not listed
- 61% of patients have 1+ med not listed
Lau HS et al. Br J Clin Pharmacol 2000; 49:597-603.
The Evidence
• Chart reviews have revealed that over half of all hospital
medication errors occur at the interfaces of care
Rozich et al., J. Clin Outcomes Manage. 2001; 8(10):27-34)
J Clin Outcomes Manage 2001;8:27-34
• Implementation of medication reconciliation along with
other interventions decreased the rate of medication
errors by 70% and adverse drug events by 15%, over a
seven month period.
Whittington J, Cohen H. OSF healthcare’s journey in patient safety. Qual Manag Health Care
2004;13(1):53-59
The Evidence
• A successful medication reconciling process reduces
work and rework
- reduced nursing time at admission by over 20 minutes per
patient
- reduced pharmacists time at discharge by over 40
minutes
Rozich,JD, Howard RJ,Justeson JM, Macken PD, Lindsay ME,Resar RK. J Quality Saf. 2004: 30(1):5-14
SHN Improvement Initiatives:
–
–
–
–
–
–
–
–
–
Medication Reconciliation
Acute Myocardial Infarction (AMI)
Surgical Site Infection (SSI)
Rapid Response (RRT)
Central Line Infection
Ventilator Associated Pneumonia (VAP)
Falls LTC
MRSA
DVT
Medication Reconciliation
As of March 2008:
 240 healthcare organizations and 885
teams enrolled nationwide (325 Med Rec Teams)
 26 districts / organizations enrolled from Atlantic
Canada
Medication Reconciliation
• Goals:
– The primary goal of medication reconciliation in long-term
care is to eliminate undocumented intentional
discrepancies (documentation errors) and unintentional
discrepancies (medication errors:omissions, additions etc.)
by reconciling all medications, at all interfaces of care, for
all residents.
– Improve the process of obtaining, updating and
communicating a complete Best Possible Medication
History (BPMH)
• The primary emphasis is to create systems of care that
dramatically reduce the number of Adverse Drug Events
through the reconciliation of medications.
Medication Reconciliation Measures of Success
1.
# of undocumented intentional discrepancies
(documentation accuracy).
2.
# of unintentional discrepancies (medication error).
3.
% of residents that are reconciled.
What is Medication Reconciliation?
• A process in which medications are compared at
interfaces of care:
 Admission
 Transfer
 Discharge
• Discrepancies are identified and reconciled with
physician
• Intervention minimizes patient harm from unintended
discrepancies
ISMP Canada 2005
What is Medication Reconciliation?
• “a formal process of obtaining a complete and accurate
list of each patient’s current home medications-including
name, dosage, frequency and route- and comparing the
physician’s admission, transfer, and/or discharge orders
to that list. Discrepancies are brought to the attention of
the prescriber and, if appropriate, changes are made to
the orders. Any resulting changes are documented.”
ISMP Canada 2005
What’s a BPMH?
(Best Possible Medication History)
• Documentation of all medications that a resident has been
taking previously including drug name, dose, frequency and
route.
•
•
•
•
•
Obtaining BPMH
Community pharmacy
Review medication lists, MARs, vials
Interview resident and /or family
Consult notes from referring physician
H&P
•
•
•
Obtaining BPMH
Nursing/pharmacist (referral) to collect
information at admission
Physician-as a reference and/or order when
writing initial orders for medications
Physicians/nurses/pharmacists throughout the
resident’s stay as a reference
Western Regional Integrated Health Authority
Site:
For O’Connell LTC / DVA Unit Use Only!
O’Connell LTC
O’Connell DVA
MEDICATION HISTORY
ADMISSION MEDICATION ORDERS
Patient Label/Addressograph
**Keep this form with the Physician Orders**
This form is intended to serve as the pre-admission medication list as well as the physician’s admitting orders for preadmission medications. New medication prescribed on admission should be written on the physician’s order sheet.
Source of Medication Information (Check ALL that apply)
 Review of patient/resident medication list
 Review of medication vials
 Review previous hospital records
 Family Physician list
 Patient/resident recall
 Family/caregiver recall
 MAR from another facility
 Other:__________________
 Community pharmacy list Pharmacy Name:______________________
kg
cm
□
□
□
□
□
Best Possible Medication History (BPMH):
□ Epilepsy
□ Anxiety
□ Depression
Physician Admission Orders:
To complete upon admission
BPMH obtained by:
__ Date/Time: __________
BPMH obtained by:
_________Date/Time: __________
Additional Medications Identified After BPMH Taken
( Please Fax Additions to Pharmacy.)
Hold
Change
Continue
Verified/In
iitial
Dosing
Interval
Route
Dose
(List all prescriptions and regularly
taken OTC & PRN medications prior
to admission).
□ CRF
□ R.Arthritis
□ ARF
□ O.Arthritis
□ COPD □ NIDDM
□ IDDM
Allergies:
Include regular and PRN medication taken at previous care setting
Medication Name & Strength
□ PVD
□ CVA
□ HTN
□ MS
IHD
AFiB
CHF
Dyslipidemia
Other:
Discontinue
Weight:
Height:
Diagnosis: (check all that apply)
Reason for Change/Hold/Discontinuation
Date/Time: _________
Date/Time: _________
Prescribing Physician:
Prescribing Physician:
Orders for additional Medications,
identified after initial BPMH
completed, to be written on
Routine Physician Order pink sheet.
Additions to BPMH obtained by:
Date/Time: _________________________________________
NOTE: all addition preadmission medications received after the initial BPMH has
been completed must have those orders written on the routine Physician Orders sheet.
Please fully complete additional forms, if additional space is needed to accommodate number of medications
Risk Score :
(see tool form #
) Pharmacy Consult Recommended
Reason for Referral:
NOTE: Always fax Risk Tool to Pharmacy whether Pharmacy is consulted or not.
Disposition of Patient’s Medication on Admission:
 Locked up in nursing unit  Brought to hospital. Sent home with:
Original Copy – On Chart
Copy – to Pharmacy
 Not brought to hospital
Fax to Pharmacy: Pages(s)
of
.
 No
Form #
 Yes
• Virtually all hospitals
who have
successfully
addressed admission
medication
reconciliation have
created a special form
as part of the solution!
Completing the Medication History /
Admission Orders form!
Western Regional Integrated Health Authority
Site:
For O’Connell LTC / DVA Unit Use Only!
O’Connell LTC
O’Connell DVA
MEDICATION HISTORY
ADMISSION MEDICATION ORDERS
Patient Label/Addressograph
**Keep this form with the Physician Orders**
This form is intended to serve as the pre-admission medication list as well as the physician’s admitting orders for pre-admission
medications. New medication prescribed on admission should be written on the physician’s order sheet.
Source of Medication Information (Check ALL that apply)
 Review of patient/resident medication list
 Review of medication vials
 Review previous hospital records
 Family Physician list
 Patient/resident recall
 Family/caregiver recall
 MAR from another facility
 Other:__________________
 Community pharmacy list Pharmacy Name:______________________
kg
cm
□
□
□
□
□
Best Possible Medication History (BPMH):
□ Epilepsy
□ Anxiety
□ Depression
Physician Admission Orders:
To complete upon admission
Hold
Change
Continue
Verified/In
iitial
Dosing
Interval
Route
Dose
(List all prescriptions and regularly
taken OTC & PRN medications prior
to admission).
□ CRF
□ R.Arthritis
□ ARF
□ O.Arthritis
□ COPD □ NIDDM
□ IDDM
Allergies:
Include regular and PRN medication taken at previous care setting
Medication Name & Strength
□ PVD
□ CVA
□ HTN
□ MS
IHD
AFiB
CHF
Dyslipidemia
Other:
Discontinue
Weight:
Height:
Diagnosis: (check all that apply)
Include all sources
required to thoroughly
complete the BPMH.
Reason for Change/Hold/Discontinuation
Include history of
illnesses.
BPMH obtained by:
__ Date/Time: __________
BPMH obtained by:
_________Date/Time: __________
Additional Medications Identified After BPMH Taken
( Please Fax Additions to Pharmacy.)
Date/Time: _________
Date/Time: _________
Prescribing Physician:
Prescribing Physician:
Orders for additional Medications,
identified after initial BPMH
completed, to be written on
Routine Physician Order pink sheet.
Additions to BPMH obtained by:
Date/Time: _________________________________________
NOTE: all addition preadmission medications received after the initial BPMH has
been completed must have those orders written on the routine Physician Orders sheet.
Please fully complete additional forms, if additional space is needed to accommodate number of medications
Risk Score :
(see tool form #
) Pharmacy Consult Recommended
Reason for Referral:
NOTE: Always fax Risk Tool to Pharmacy whether Pharmacy is consulted or not.
Disposition of Patient’s Medication on Admission:
 Locked up in nursing unit  Brought to hospital. Sent home with:
Original Copy – On Chart
Copy – to Pharmacy
 Not brought to hospital
Fax to Pharmacy: Pages(s)
of
.
 No
Form #
 Yes
Note height and
weight and known
allergies.
Western Regional Integrated Health Authority
Site:
For O’Connell LTC / DVA Unit Use Only!
O’Connell LTC
O’Connell DVA
MEDICATION HISTORY
ADMISSION MEDICATION ORDERS
Patient Label/Addressograph
Continue to Complete by:
**Keep this form with the Physician Orders**
This form is intended to serve as the pre-admission medication list as well as the physician’s admitting orders for pre-admission
medications. New medication prescribed on admission should be written on the physician’s order sheet.
Source of Medication Information (Check ALL that apply)
 Review of patient/resident medication list
 Review of medication vials
 Review previous hospital records
 Family Physician list
 Patient/resident recall
 Family/caregiver recall
 MAR from another facility
 Other:__________________
 Community pharmacy list Pharmacy Name:______________________
kg
cm
□
□
□
□
□
Best Possible Medication History (BPMH):
□ Epilepsy
□ Anxiety
□ Depression
Physician Admission Orders:
To complete upon admission
BPMH obtained by:
__ Date/Time: __________
BPMH obtained by:
_________Date/Time: __________
Additional Medications Identified After BPMH Taken
( Please Fax Additions to Pharmacy.)
Hold
Change
Continue
Verified/In
iitial
Dosing
Interval
Route
Dose
(List all prescriptions and regularly
taken OTC & PRN medications prior
to admission).
□ CRF
□ R.Arthritis
□ ARF
□ O.Arthritis
□ COPD □ NIDDM
□ IDDM
Allergies:
Include regular and PRN medication taken at previous care setting
Medication Name & Strength
□ PVD
□ CVA
□ HTN
□ MS
IHD
AFiB
CHF
Dyslipidemia
Other:
Discontinue
Weight:
Height:
Diagnosis: (check all that apply)
Reason for Change/Hold/Discontinuation
NOTE: all addition preadmission medications received after the initial BPMH has
been completed must have those orders written on the routine Physician Orders sheet.
Please fully complete additional forms, if additional space is needed to accommodate number of medications
Risk Score :
(see tool form #
) Pharmacy Consult Recommended
Reason for Referral:
NOTE: Always fax Risk Tool to Pharmacy whether Pharmacy is consulted or not.
Disposition of Patient’s Medication on Admission:
 Locked up in nursing unit  Brought to hospital. Sent home with:
Original Copy – On Chart
Copy – to Pharmacy
Signature,date and time
when BPMH is completed.
To be done within 24 hrs.
Date/Time: _________
Date/Time: _________
Prescribing Physician:
Prescribing Physician:
Orders for additional Medications,
identified after initial BPMH
completed, to be written on
Routine Physician Order pink sheet.
Additions to BPMH obtained by:
Date/Time: _________________________________________
List name, dose, route,
frequency for each
medication.
 Not brought to hospital
Fax to Pharmacy: Pages(s)
of
.
 No
Form #
 Yes
Obtain physicians intention
to continue, change,
discontinue or hold. Obtain
reason.
Western Regional Integrated Health Authority
Site:
For O’Connell LTC / DVA Unit Use Only!
O’Connell LTC
O’Connell DVA
MEDICATION HISTORY
ADMISSION MEDICATION ORDERS
Patient Label/Addressograph
**Keep this form with the Physician Orders**
• Continue to Complete by:
This form is intended to serve as the pre-admission medication list as well as the physician’s admitting orders for pre-admission
medications. New medication prescribed on admission should be written on the physician’s order sheet.
Source of Medication Information (Check ALL that apply)
 Review of patient/resident medication list
 Review of medication vials
 Review previous hospital records
 Family Physician list
 Patient/resident recall
 Family/caregiver recall
 MAR from another facility
 Other:__________________
 Community pharmacy list Pharmacy Name:______________________
kg
cm
□
□
□
□
□
Best Possible Medication History (BPMH):
□ Epilepsy
□ Anxiety
□ Depression
Physician Admission Orders:
To complete upon admission
Hold
Change
Continue
Verified/In
iitial
Dosing
Interval
Route
Dose
(List all prescriptions and regularly
taken OTC & PRN medications prior
to admission).
□ CRF
□ R.Arthritis
□ ARF
□ O.Arthritis
□ COPD □ NIDDM
□ IDDM
Allergies:
Include regular and PRN medication taken at previous care setting
Medication Name & Strength
□ PVD
□ CVA
□ HTN
□ MS
IHD
AFiB
CHF
Dyslipidemia
Other:
Discontinue
Weight:
Height:
Diagnosis: (check all that apply)
Obtain physician
admission orders for pre
admission medications.
Reason for Change/Hold/Discontinuation
Indicate risk score for
pharmacy referral.
BPMH obtained by:
__ Date/Time: __________
BPMH obtained by:
_________Date/Time: __________
Additional Medications Identified After BPMH Taken
( Please Fax Additions to Pharmacy.)
Date/Time: _________
Date/Time: _________
Prescribing Physician:
Prescribing Physician:
Orders for additional Medications,
identified after initial BPMH
completed, to be written on
Routine Physician Order pink sheet.
Additions to BPMH obtained by:
Date/Time: _________________________________________
NOTE: all addition preadmission medications received after the initial BPMH has
been completed must have those orders written on the routine Physician Orders sheet.
Please fully complete additional forms, if additional space is needed to accommodate number of medications
Risk Score :
(see tool form #
) Pharmacy Consult Recommended
Reason for Referral:
NOTE: Always fax Risk Tool to Pharmacy whether Pharmacy is consulted or not.
Disposition of Patient’s Medication on Admission:
 Locked up in nursing unit  Brought to hospital. Sent home with:
Original Copy – On Chart
Copy – to Pharmacy
 Not brought to hospital
Fax to Pharmacy: Pages(s)
of
.
 No
Form #
 Yes
Indicate disposition of
residents medications.
Western Regional Integrated Health Authority
Site:
For O’Connell LTC / DVA Unit Use Only!
O’Connell LTC
O’Connell DVA
MEDICATION HISTORY
ADMISSION MEDICATION ORDERS
Patient Label/Addressograph
**Keep this form with the Physician Orders**
• Continue to Complete by:
This form is intended to serve as the pre-admission medication list as well as the physician’s admitting orders for pre-admission
medications. New medication prescribed on admission should be written on the physician’s order sheet.
Source of Medication Information (Check ALL that apply)
 Review of patient/resident medication list
 Review of medication vials
 Review previous hospital records
 Family Physician list
 Patient/resident recall
 Family/caregiver recall
 MAR from another facility
 Other:__________________
 Community pharmacy list Pharmacy Name:______________________
kg
cm
□
□
□
□
□
Best Possible Medication History (BPMH):
□ Epilepsy
□ Anxiety
□ Depression
Physician Admission Orders:
To complete upon admission
Hold
Change
Continue
Verified/In
iitial
Dosing
Interval
Route
Dose
(List all prescriptions and regularly
taken OTC & PRN medications prior
to admission).
□ CRF
□ R.Arthritis
□ ARF
□ O.Arthritis
□ COPD □ NIDDM
□ IDDM
Allergies:
Include regular and PRN medication taken at previous care setting
Medication Name & Strength
□ PVD
□ CVA
□ HTN
□ MS
IHD
AFiB
CHF
Dyslipidemia
Other:
Discontinue
Weight:
Height:
Diagnosis: (check all that apply)
Note additional preadmission medications
identified after 24 hrs here.
Reason for Change/Hold/Discontinuation
Sign, date and time
additional medications
noted.
BPMH obtained by:
__ Date/Time: __________
BPMH obtained by:
_________Date/Time: __________
Additional Medications Identified After BPMH Taken
( Please Fax Additions to Pharmacy.)
Date/Time: _________
Date/Time: _________
Prescribing Physician:
Prescribing Physician:
Orders for additional Medications,
identified after initial BPMH
completed, to be written on
Routine Physician Order pink sheet.
Additions to BPMH obtained by:
Date/Time: _________________________________________
NOTE: all addition preadmission medications received after the initial BPMH has
been completed must have those orders written on the routine Physician Orders sheet.
Please fully complete additional forms, if additional space is needed to accommodate number of medications
Risk Score :
(see tool form #
) Pharmacy Consult Recommended
Reason for Referral:
NOTE: Always fax Risk Tool to Pharmacy whether Pharmacy is consulted or not.
Disposition of Patient’s Medication on Admission:
 Locked up in nursing unit  Brought to hospital. Sent home with:
Original Copy – On Chart
Copy – to Pharmacy
 Not brought to hospital
Fax to Pharmacy: Pages(s)
of
.
 No
Form #
 Yes
Ensure orders for additional
medications are noted on routine
Physician Order pink sheet.
Western Regional Integrated Health Authority
Patient Label/Addressograph
For LTC O’Connell / DVA Unit Use Only!
• Complete Risk Score:
Risk Score /Pharmacy Referral
**Keep this form with the Physician Orders**
Patient / Resident Medication Risk Assessment Tool
(circle all applicable factors)
Age
Number of Medications
Prior to Admission
High Risk Medications
Prior to Admission
0 – 64 years
0
65 – 80 years
1
>80 years
2
0-1
0
2-4
2
5-7
3
8 or more
6
Antiseizure
3
Anticoagulant
3
More than two cardiovascular
medications.
5
Diabetic Medications (oral+/- insulin)
Has the patient been transferred from ALC unit?
Is the reason for admission clearly drug-related
(e.g. drug toxicity, non-compliance, polypharmacy)?
Total Score
2
Automatic
Referral to
Pharmacy
Automatic
Referral to
Pharmacy
Examples of medications for each
medication category:
Antiseizure: e.g. carbamazepine,
phenytoin, valproic acid &
divalproex sodium.
Anticoagulants: e.g. warafin, low
molecular weight heparin (e.g.
tinzaparin, dalteparin, enoxaparin),
heparin. Not ASA.
Cardiovascular Medications:
e.g. blood pressure meds, cholesterol
meds, digoxin, amiodarone, daily
ASA, clopidogrel, diuretics.
Do not count anticoagulants as a
cardiovascular medication.
If total score is > or = to 10,
referral to Pharmacist is
recommended.
Original (white) – Patient’s / Resident’s Chart
Faxed copy - In-hospital Pharmacy
NOTE: Always ( whether high or low score) fax the completed Risk Score tool to Pharmacy.
Form #
Score all categories and
add final risk score.
Fax all completed risk
scores to Pharmacy!
Medication History Taking
Include:
• Current home medications including dose,route and
frequency
• Medications ordered at admission
• Continue,start, stop
• Time of last dose
• Source of the information
• Assessment of patient compliance
• OTC’S and herbals (organization decision)
Medication History Taking
Interview:
•
•
•
Encourage questions from the resident / patient
Encourage bringing medications and use of
medication wallet card or home list
Prompt regarding non-pill dosage forms and PRNs
– Creams, drops, inhalers, spray, samples
Medication History Taking
Interview:
•
•
•
•
•
Balance open-ended questions with yes/no questions
Nonbiased questions
No leading questions
Vague responses may indicated non-adherence
Avoid medical jargon
Medication History Taking
Interview Questions:
•
•
•
•
•
Do you have any allergies to medication? Describe
the reaction.
What medication were you taking prior to admission?
Did a doctor change the dose or stop any of your
medication recently?
Have you changed the dose or stopped any of your
medication recently?
Have you recently started any medications?
Medication History Taking
Interview Questions:
• Have any of your medications been causing side
effects?
• When you feel better, do you sometimes stop taking your
medication?
• Sometimes if you feel worse when you take your
medication, do you stop taking it?
• Are the pills in the bottle the same as what is on the
label?
• Have you changed your daily routine to accommodate
your medication schedule?
Medication Reconciliation Process Flow Map
Admission to Healthcare Facility
Best Possible
Medication History
(BPMH)
Admission
Medication Orders
(AMOs)
Compare
IMPROVE WITH:
Standardized Admission
Documentation
Discrepancies
Identified
Yes
No further action
required at admission
No
Documented in
chart or obvious
due to patient’s
clinical condition?
Intentional
Discrepancy
Yes
Ensure medication
reconciliation at
Transfer and
Discharge. See
Chapters 3 & 4 in
GSK
No
Ask prescriber
if intentional?
Yes, Intentional
discrepancy
Document
No
IMPROVE WITH:
Better training in
medication history
Patient awareness
Backup process for
complicated patients
– pharmacistconducted history
IMPROVE WITH:
Standardized Admission
Documentation
Reconcile
(correct)
Source: SHN Medication
Reconciliation Getting Started
Kit (2007)
Why Medication Reconciliation?
•
•
•
•
Medication reconciliation fits with culture of safety
and optimal patient / resident care
Medication reconciliation evidence has shown
reduced medication discrepancies
Medication reconciliation will save time for nurses,
physicians, and pharmacists
Already take a medication history: now we are doing
it on one form and it will be easier to find
Why Medication Reconciliation?
• Will know that a medication change is intentional (rather
than wonder if there was a transcription error or a
missed order), and be able to advise the patient /
resident and family members accordingly
• It will be easy to find the at-home medication list in order
to reconcile on transfer / discharge as all preadmission
medications will be on the new admission form
• Outcomes from the changes with medication
reconciliation are being monitored for improvements
Questions