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Tips for Implementing Medication Reconciliation

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					                                                                                                 Appendix H

Tips for Implementing Medication Reconciliation

The following outlines the key steps for getting started on implementation of Medication
Reconciliation.
1.       Secure Senior Leadership Commitment
2.       Form a Team
3.       Define the Problem
                 Set Aims (Goals and Objectives)
                 Collect Baseline Data
                 Submit Baseline Data
4.       Start with Small Projects and Build Expertise in Reconciling Medications
5.       Evaluate Improvements Being Made – Collect and Submit Data
6.       Spread


1. Secure Senior Leadership Commitment
    Implementing a successful medication reconciliation process requires clear commitment,
     direction and accountability for outcomes from the highest level of the organization. Visible
     senior leadership support and accountability can help to engage staff, remove obstacles and
     allocate resources enhancing the ability of teams to implement medication reconciliation.
    Actively engage senior leadership by building a business case for medication reconciliation and
     demonstrating the need for ADE prevention and reductions in work and rework. Present
     progress to senior leadership monthly: present data on errors prevented by the medication
     reconciliation process; identify resources needed to be successful.


2. Form a Team
    A team approach is needed to ensure medication reconciliation is completed successfully.
     Teamwork is an integral part of the medication reconciliation process. Medication
     reconciliation is not owned by one discipline. Clinical champions can contribute significantly to
     successful implementation.
    To lead the initiative we recommend the organization identify a multidisciplinary site
     coordination team to coordinate implementation of medication reconciliation and a smaller
     team at the patient care unit level to conduct tests of change on that unit.
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   Representation of the site coordination team could include:
         1.      Senior Administrative leadership (executive sponsor)
         2.      Clinical leaders representing physicians, nursing and pharmacy staff
         3.      Front line caregivers from key settings of care, and from all shifts
         4.      Representatives from other work units or committees whose
                 responsibilities/mandates include the improvement of patient safety (e.g. Patient
                 Safety Officer, representatives from Quality Improvement/Risk Management,
                 Patient Representatives, Pharmacy and Therapeutics committee)
         5.      Patient and/or family member
   Patient involvement, including patient interviews, is critical to the medication reconciliation
    process. The patient is the only constant participant across the system and is critical to the
    success of this major system change.
   On a patient care unit level a small ‘unit team’ is helpful to coordinate and initiate tests of change
    (PDSA cycles) and provide comments to the site coordinating team. Team members could
    include: unit based physician, nurse manager, frontline nurse, pharmacist and patient. Team
    members can communicate in a variety of methods including short stand-up meetings on the
    unit.


3. Define the Problem and Collect Baseline Data
Defining the Problem – Set Aims (Goals & Objectives)
   Setting an aim can assist teams to focus on what they are hoping to achieve when implementing
    medication reconciliation. The aim should be time-specific, measurable and define the specific
    population of patients who will be affected. The following are examples of aims at the
    organizational level:
    1.   Reduce the number of unintentional discrepancies by 75% on a stated number of units by
         (target date)
    2.   Reduce the number of undocumented intentional discrepancies by 75% on a stated number
         of units by (target date)
    3.   Conduct a BPMH and reconcile discrepancies on all patients with greater than 4 medications
         on a stated unit within 24 hours of admission.
   As teams work on different points on the continuum of care for e.g. admission, internal transfer
    and discharge, the aims should be specific to what it is they are hoping to achieve at that point.

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                                                                                                   Appendix H


Collecting Baseline Data
   It is critical to collect baseline data to get a sense of what some of the issues are, at each interface
    of care, in your facility. “Baseline data” reflects the types of discrepancies that exist prior to the
    implementation of the Medication Reconciliation process and will provide the information your
    team needs to build the case for medication reconciliation, and help to identify areas of focus.
   Collect baseline data at the beginning of work in each area. Before starting implementation of a
    new practice it is essential to measure the extent of the defect to be corrected. Not only does this
    data provide the baseline against which to measure the effectiveness of the change, it is evidence
    of the seriousness of the problem to motivate stakeholder involvement.
   A Medication Reconciliation Tool would assist teams in the process of collecting baseline data.
   Use the following criteria to select the group of patients who will participate. Begin:
    1.   Where you think a problem exists. Talk to your colleagues. Review a few charts if needed.
         Do this planning ahead of time to avoid the situation where baseline data collection needs to
         be collected on another population because there is little evidence of a problem with the first
         group.
    2.   Where you think you can make a difference by implementing medication reconciliation.
    3.   Where there is sufficient volume of patients to measure the impact of the improvements you
         are making.
    4.   Where you can engage staff to participate. Work with those who are enthusiastic and
         willing. The sceptics will follow once success is demonstrated.
   The only criterion for exclusion of a patient is that the patient is not prescribed any medications.
   The concurrent method of data collection should be used. Concurrent audits identify patients
    “at hazard” while they are “at hazard” and immediate actions for improvement can be made.
    Concurrent audits also make it easier to distinguish intentional from unintentional discrepancies
    than does a retrospective chart audit.
   Review 10 – 20 patient charts to collect baseline data. Rotate the day and time of data collection
    (ensure your process also samples weekends and night time) in order to assess your current
    process independent of day of week or time of day.


Process for Baseline Data Collection (using admission as the example)
   Allow the normal process of taking a primary medication history (PMH) to occur.

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                                                                                               Appendix H

   To obtain a BPMH, have a registered nurse, pharmacist, trained pharmacy technician or
    physician do one or more of the following, as needed:
    1.   Interview the patient and or family;
    2.   Review medication list and vials;
    3.   Contact the community pharmacist and or referring physician; and/or
    4.   Review the MAR and any additional documentation from the transferring organization or
            unit e.g. discharge summary, progress notes.
   Compare the AMOs with the BPMH to identify any discrepancies.
   Clarify discrepancies with the ordering or most responsible physician or other prescribing
    professional. determine which undocumented intentional discrepancies are and which are
    unintentional discrepancies. These will be recorded on the Individual Medication Reconciliation
    Audit tool in Appendix B and will be submitted in accordance with the evaluation methodology.
   Calculate the Mean Number of Undocumented Intentional Discrepancies (documentation
    error), and the Mean Number of Unintentional Discrepancies (medication error)


4. Start with Small Tests of Change & Build Expertise in Reconciling Medications
   Initially implement a medication reconciliation process on a smaller scale with select groups of
    patients, on select units and during a specific point in the continuum of care to develop forms
    and tools that work in your organization and to gain expertise in the medication reconciliation
    process.
   Consider starting on the unit where you collected your baseline data and involve staff in the
    initiative from the planning stage forward.
   Although medication reconciliation can occur at any of the transition points in care (e.g.,
    admission, transfer, discharge), we suggest that you start at the admission process. If medication
    reconciliation is not done right at admission, you could be continuing your process using
    inaccurate information. As patients may be admitted to the hospital from a number of points,
    consider starting with admissions from one area (e.g. pre-operative screening or the emergency
    department).
   Use a simple process flow diagram to outline the current process in place. Note: keep this
    process simple, its purpose is to identify the sequence of events and who is doing what.
   Adapt and test a medication reconciliation form. Specific sample forms are available in the
    chapters Admission, Transfer and Discharge. The purpose of these forms is to aid in the
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                                                                                              Appendix H

    collection of a best possible medication history (BPMH), to share the information with
    prescribers, and to facilitate reconciliation (the correction of medication orders and
    documentation of prescriber decisions). Many institutions adapt a physician’s order form for
    this purpose and a number of forms have been developed by different organizations. The forms
    will require modifications before use in your institution. As with any changes you make, our
    recommendation is to test the form first on a small scale and modify as needed.


5. Evaluate the Improvements Being Made – Collect Data
   Plot data over time. Much information about a system and how to improve it can be obtained
    by plotting data over time and then observing trends and other patterns. Tracking a few key
    measures over time is the single most powerful tool a team can use and will help them to see the
    effects of the changes they are making. Within your organization we encourage you to use Run
    Charts – described below, to show progress over time.
   Determining if improvement has occurred and if it is lasting, requires observation of patterns
    over time. Run charts are graphs of data over time and are one of the single most important
    tools in performance improvement. Using run charts has a variety of benefits:
                     i.   Run charts help improvement teams formulate aims by depicting how well
                          (or poorly) a process is performing.
                    ii.   They help in determining when changes are truly improvements by
                          displaying a pattern of data that you can observe as you make changes.
                   iii.   Run charts give information about the effectiveness of particular changes
                          and provide direction as you work on improvement and information about
                          the value of particular changes




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                                                                                                       Appendix H

                                                       Sample Run Chart

                                    Mean Number of Unintentional Discrepancies

                          5




                          4
            Mean Number




                          3




                          2




                          1


                                            Goal: 25% of baseline
                          0
                              MAY     JUN        JUL       AUG      SEP   OCT      NOV        DEC



   Seek usefulness, not perfection. Remember, measurement is not the goal; improvement is the
    goal. In order to move forward to the next step, a team needs just enough data to know whether
    changes are leading to improvement.
   Integrate measurement into the daily routine. Look for existing sources of data within your
    organization.
   Useful data is often easy to obtain without relying on information systems. Don’t wait two
    months to receive data from your hospital’s information systems department. Develop a simple
    data collection form, and make collecting the data part of someone’s job. Often, a few simple
    measures will yield all the information you need.
   Use qualitative and quantitative data. In addition to collecting quantitative data, be sure to collect
    qualitative data, which often are easier to access and highly informative. For example, collecting
    and sharing case studies describing errors you have intercepted can be a powerful tool to obtain
    stakeholder involvement. Ask staff how the medication reconciliation process is going or how to
    improve the medication reconciliation or BPMH form. Or, in order to focus your efforts on
    improving a patient’s ability to provide a complete and accurate medication history, ask patients
    and their families about their experience.




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                                                                                               Appendix H


6. Spread
   As experience develops and measurement of the success of your medication reconciliation
    process reflects sustained improvement, the process should be implemented for more patients in
    more areas. Evaluate at each new step before adding more units to the process. Retest the pilot
    process on new units in order to identify any revisions that may be needed. The roll-out across
    an organization requires careful planning to move through each of the major implementation
    phases.
   A key factor for closing the gap between best practice and common practice is the ability of
    healthcare providers and their organizations to spread innovations and new ideas. The IHI’s ‘A
    Framework of Spread: From Local Improvements to System-Wide Change will assist teams to
    develop, test and implement a system for accelerating improvement by spreading change ideas
    within and between organizations. This paper will assist teams to “prepare for a spread;
    establish an aim for spread; and develop, execute, and refine a spread plan.” Some issues that
    need to be addressed in planning for spread include training and new skill development,
    supporting people in new behaviours that reinforce the new practices, problem solving, current
    culture regarding change, degree of buy-in by staff, and assignment of responsibility.


Measuring the Success of Medication Reconciliation

On an ongoing basis progress should be measured to evaluate your medication reconciliation
process.

   10 – 20 charts should be reviewed and data collected each month. Larger organizations may
    choose to review more charts each month depending on patient volumes.

   When collecting monthly data after the baseline audit, thought should be given to the type of
    patient audited – those with a completed medication reconciliation process versus all patients
    regardless if the process was completed. Focusing on patients with a completed process will
    help provide information regarding the impact and effectiveness of the medication reconciliation
    process you have implemented. For a sample data collection tool see Appendix D: Individual
    Medication Reconciliation Audit Tool.




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                                                                                                                   Appendix H

     If measures do not reflect improvement, your team should investigate why (e.g. processes which
      are not working, non-compliance to these processes and/or barriers exist which prevent the
      process from working effectively etc.)


Measuring Discrepancies at Admission
The following table provides discrepancy measure definitions and examples which apply to
medication reconciliation at admission:

    Type                 Definition                                                Example

                         An intentional discrepancy is one in which the            A patient on a maintenance dose of anticoagulant was

    Intentional          prescriber has made an intentional choice to add,         admitted for surgery. The surgeon made the decision to
    Discrepancy          change or discontinue a medication and their choice is    discontinue this medication on admission due to concerns
                         clearly documented. This is considered to be ‘best        about potential perioperative haemorrhage; this decision is
                         practice’ in medication reconciliation.                   clearly documented in the patient’s health record.
    Undocumented
                         An undocumented intentional discrepancy is one in         A patient on a maintenance dose of atenolol for
    Intentional
    Discrepancy          which the prescriber has made an intentional choice to    hypertension was admitted for surgery. The surgeon did
                         add, change or discontinue a medication but this          not order atenolol on admission, due to concerns about
                         choice is not clearly documented.                         perioperative hypotension; however, the reason for not
                         Undocumented intentional discrepancies are a failure to   ordering atenolol was not documented in the medical
                         document. They are not medication errors and do           record.
                         not usually represent an immediate threat to patient
                         safety.
                         Undocumented intentional discrepancies may however
                         lead to confusion, require extra work and may lead to
                         medication errors. They can be reduced by
                         standardizing the method for documenting admission
                         medication orders.




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Unintentional   An unintentional discrepancy is one in which the            A patient on multiple medications was admitted to a
Discrepancy     physician unintentionally changed, added or omitted a       general medicine ward after experiencing a stroke.
                medication the patient was taking prior to admission.       Admission medication orders included digoxin, based on
                Unintentional discrepancies are medication errors           information in a recent volume of the patient's chart. A
                that can lead to ADEs. They can be reduced by               follow-up interview with the patient's family and
                ensuring good training of nurses/ physicians/               community pharmacy revealed that, although the patient
                pharmacists at obtaining in-depth medication histories      had been on digoxin in the past, this medication had been
                and by wisely involving clinicians, frequently              discontinued approximately one month prior to the
                pharmacists to identify and reconcile these                 admission. This information was brought to the attention
                discrepancies. In institutions without access to clinical   of the attending hospital physician and the digoxin was
                pharmacists, reconciliation of discrepancies can be         stopped.
                assigned to other healthcare professionals.
                                                                            A patient with Parkinson's disease was admitted for
                                                                            management of acute pulmonary edema. Based on
                                                                            information on the patient's medication vial, Sinemet
                                                                            200/50 (200 mg/50 mg) PO BID was ordered on
                                                                            admission. A few days later, the patient's family
                                                                            commented that the patient's
                                                                            Parkinson's disease appeared to be worsening. Further
                                                                            investigation revealed that the patient had recently been
                                                                            told by his neurologist to increase his Sinemet dosage to
                                                                            200/50 PO TID. The attending hospital physician was
                                                                            informed and the Sinemet dosage was corrected.




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                                                                                                           Appendix H

Measuring Discrepancies at Internal Transfer (To be addressed in later phases
of implementation)
The following table describes discrepancy measure definitions and how these might apply to
medication reconciliation at internal transfer:

 Type                   Transfer Discrepancies                   Examples
 Intentional            A medication is changed, omitted or      1. An ICU patient is receiving ranitidine for stress ulcer
 Discrepancy            added at transfer and the reason is         prophylaxis – on the transfer orders to the ward,
                        clear (i.e., standard protocol) or          ranitidine is not included as per the standard protocol to
                        clearly documented.                         discontinue prophylaxis upon leaving ICU
                                                                 2.   A ward patient receiving diclofenac is transferred to ICU
                                                                      for the management of upper GI bleeding – the NSAID
                                                                      is not included in the transfer orders and the reason is
                                                                      documented (e.g., suspected bleeding ulcer due to
                                                                      NSAID)
 Undocumented           A medication is changed, omitted or      1.   Paroxetine is ordered for a patient who is moving from
 Intentional            added at transfer and the reason is           ICU to the ward – the patient had not been receiving
 Discrepancy            not clear or there is no related              paroxetine in ICU and it was not documented in the list
                        documentation. Discussion with the            of pre-admission medications – discussion with the
                        prescriber reveals that this is an            prescriber reveals that the patient’s family just mentioned
                        intentional choice.                           that the patient had been taking paroxetine prior to
                                                                      admission
                                                                 2.   A patient who had been receiving ramipril in CCU is
                                                                      ordered losartan on transfer to the ward – discussion
                                                                      with the prescriber reveals that the patient was
                                                                      experiencing a dry cough that may have been related to
                                                                      ramipril
 Unintentional          A medication is changed, omitted or      1.   A CCU patient is being transferred to the cardiology
 Discrepancy            added in the transfer orders and              ward – the transfer orders include atorvastatin 40 mg
                        discussion with the prescriber reveals        daily, instead of the 80 mg daily that was prescribed post-
                        that this is NOT an intentional               MI – discussion with the prescriber reveals that this
                        choice.                                       change was unintentional
                                                                 2.   An orthopaedic surgery patient who was receiving
                                                                      thromboprophylaxis (dalteparin) prior to admission is
                                                                      transferred to ICU for respiratory complications and
                                                                      dalteparin is not included in the transfer orders –
                                                                      discussion with the prescriber reveals that the
                                                                      thromboprophylaxis was to be restarted postoperatively
                                                                      and that this omission was unintentional




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                                                                                                                  Appendix H


Measuring Discrepancies at Discharge (To be addressed in later phases of
implementation)

The primary measure to evaluate the medication reconciliation process at discharge is the percentage
of patients for whom the discharge medication reconciliation process (creation of the Best Possible
Medication Discharge Plan (BPMDP)) was completed.


Experienced medication reconciliation teams may also choose to voluntarily collect specific data on
discrepancies on discharge similar to data collected on admission and transfer.                              This can be
accomplished by comparing the Best Possible Medication Discharge Plan (BPMDP) with the
Discharge Prescription, Discharge Orders and/or Discharge Summary to identify & resolve
discrepancies.

The following table describes discrepancy measure definitions and how these might apply to
medication reconciliation at discharge:

 Type of Discrepancy           Discharge Discrepancies                                            Examples
 Intentional           A medication is changed, omitted or added       Indomethacin newly started for muscle pain upon discharge
 Discrepancy           at discharge and the reason is clear, e.g.      (patient not receiving prior to admission or in hospital).
                       standard protocol, or has been clearly          Rationale for initiation clearly documented in discharge
                       documented.                                     summary.

                                                                       Patient receiving oral antibiotic pre-admission to hospital (noted
                                                                       on BPMH). Course of antibiotics completed while in hospital
                                                                       therefore antibiotic omitted from discharge prescription and
                                                                       rationale clearly documented in discharge summary.
 Undocumented          A medication is changed, omitted or added       Patient receiving ramipril 5 mg po daily at home (noted on
 Intentional           in the discharge orders and the reason is not   BPMH). Upon discharge, the physician intentionally escalated
 Discrepancy           clear and has not been documented.              the dose on the discharge prescription to ramipril 7.5 mg po
                       Discussion with the prescriber reveals that     daily. There is no documentation of the rationale for this change
                       this IS an intentional choice.                  in the medical chart or discharge documentation. A discussion
                                                                       with the prescriber reveals that this is an intentional choice.




 Unintentional         A medication is changed, omitted or added       Patient was stabilized on warfarin 4 mg daily for a new DVT in
 Discrepancy           in the discharge orders and the reason is not   hospital. Warfarin was unintentionally ordered as warfarin 2 mg
                       clear and there is no documentation (actual     on the discharge prescription. A discussion with the prescriber
                       discrepancy). Discussion with the               reveals that this is NOT an intentional choice.
                       prescriber reveals that this is NOT an
                       intentional choice.




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