Transcript Medication Reconciliation Beyond Admission Presentation

Continuity of Medication
Management
Medication Reconciliation:
Beyond Admission
Hospital
Presenter
Month YYYY
Continuity is an Issue in Health Care
• 10-67% of medication histories contain at least one error1
• Incomplete medication histories at the time of admission
have been cited as the cause of at least 27% of prescribing
errors in hospital2
• The most common error is the omission of a regularly used
medicine3
• Around half of the medication errors that happen in
hospital occur on admission or discharge4
• 30% of these errors have the potential to cause harm3,5
NSW Examples - Medication Errors
Aspirin and clopidogrel
ceased in ICU and not
recommenced when
patient transferred to
ward
Patient suffered
sudden cardiac
arrest resulting in
death
Patient prescribed
ramipril 1.25mg daily,
medication chart was
rewritten as ramipril
12.5mg daily
Patient suffered presyncopal episode,
was transferred to
HDU and required
noradrenaline
Patient initiated on
new cardiac
medication,
discharged with no
summary or medicine
Patient became
acutely unwell and
was re-admitted
May have
contributed to
patient’s
death
Caused
temporary
harm and
required
intervention
Caused
temporary
harm and
required
intervention
Medication Reconciliation
• A process to reduce adverse medication
events by:
- Ensuring patients receive all intended
medicines
- Mitigating common errors of transcription,
omission, commission and duplication
- Ensuring accurate, current and comprehensive
medication information follows patients on
transfer and discharge
Complete Step 3 and Step 4
at transfers between:
- ICU to ward
- ED to ward
- Ward to ward
- Hospital to hospital
- Hospital to home or
aged care facility
and
- When re-writing or
reviewing medication
charts
NSW Medication Management Plan (MMP)
Facilitates Medication Reconciliation at Transfers
Area to record
medicines taken
prior to
presentation
Know where to find the most accurate list of your patient’s
pre-admission medications, commonly referred to as the
Best Possible Medication History (BPMH)
Contains a list of
the patient’s preadmission
medications for
comparison.
It is available at the
point of care.
Re-Writing or Reviewing Medication
Charts
• Consider re-writing an opportunity to review a
patient’s medications:
- Pre-admission medications with
- Prescribed medications
• Consider:
- Medications to be re-started
- Medications no longer required
- Medications to be adjusted or commenced
• Check:
- New chart with previous chart
- Any changes made have been documented
Change in Clinical Setting / Ward
• Compare:
- Pre-admission medications with
- Prescribed medications
ED
ICU
• Consider:
- Medications to be re-started
Ward 2
- Medications no longer required
- Medications to be adjusted or commenced
• Communicate:
- Medications that are to be continued
- Any changes that have been made
- Any ongoing plan
Ward 1
Hospital to Hospital
• Referring hospital to:
- Communicate
- Medications that are to be continued
- Any changes that have been made
- Any ongoing plan
- Provide a copy of
- Pre-admission medications (to facilitate identification
of changes)
- Prescribed medications (as a reference for the new
treating team)
Hospital to Hospital
• Accepting hospital to:
- Compare
- Medications that are to be continued with previously
prescribed medications and pre-admission medications
- Identify and clarify
- Any changes that have been made
- Any ongoing plan
Hospital to Home or Aged Care Facility
Compare:
- Pre-admission
medications with
- Prescribed
medications
Consider:
- Pre-admission
medications to be restarted
- Prescribed
medications no
longer required
- Medications to be
adjusted or
commenced
MMP
Medication Chart
Hospital to Home or Aged Care Facility
• Communicate to the next care provider and patient:
- Medications that are to be continued
- Any changes that have been made
- Any ongoing plan
Example of a
medication list
for the patient
A Final Check
• Ensure the same medicines information is
provided on the:
-
Discharge summary
Discharge order/prescription
Discharge medicine labels
Patient medication list
• Ensure the patient understands the changes
that have been made
Key Points
• Medication errors and patient harm can be reduced by
reconciling medicines when re-writing medication charts
and at transfers between:
- ICU and ward
- ED to ward
- Ward to ward
- Hospital to hospital
- Hospital to home or aged care facility
• Providing accurate information at transfers/discharge
results in safer ongoing care
References
1. Lee JY, Leblanc K, Fernandes OA, et al. Medication reconciliation
during internal hospital transfer and impact of computerized
prescriber order entry. Ann Pharmacother. 2010;44:1887-1895.
2. Santell JP, Reconciliation failures lead to medication errors. Jt Comm
J Qual Patient Saf. 2006;32:225-229.
3. Elliott RA, Tran T, Taylor SE, et al. Impact of a pharmacist-prepared
interim residential care administration chart on gaps in continuity
of medication management after discharge from hospital to
residential care: a prospective pre- and post-intervention study
(MedGap Study). BMJ Open 2012; 2:e000918.
4. Stowasser DA, Collins DM, Stowasser M. A randomised controlled
trial of medication liaison services – patient outcomes. J Pharm
Pract Res 2002; 32:133-40.