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Medication Reconciliation Exceeding Expectations.ppt

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					Medication Reconciliation

  What is it?
  Why should we do it?
  How can it be done?
What is Medication Reconciliation?

 • A process for obtaining and documenting
   an accurate list of current medications
   – Must involve the patient

 • Compare to what is ordered

 • Reconcile discrepancies
   – Eliminate unintended discrepancies
Why Medication Reconciliation?

JCAHO 2006 Patient Safety Goal
100K Lives Saved Campaign

Patient Safety!
  Prevent Adverse Drug Events
Adverse Drug Reactions/Event
      Literature Review
    Incidence of Adverse Drug
 Reactions in Hospitalized Patients

 Incidence of serious ADR:
    – 4.7% of admissions due to ADR
    – 2.1% had ADR while hospitalized
    – 0.13 to 0.19% were fatal




Lazarou J et al JAMA 1998;279:1200-1205
    Adverse Drug Reactions as
  Cause of Admission to Hospital

 • ADR’s caused 6.5% of admissions

 • 0.15% were fatal

 • Most ADR’s were considered “avoidable”



Pirmohamed M et al. BMJ 2004;329:15-19
 Adverse Drug Events after Discharge


• Incidence of ADE was 13%
    – 25% preventable

    – 38% ameliorable




Forster AJ et al. Ann Intern Med 2003;138161-167
         Adverse Drug Events in
            Ambulatory Care
• 25% with ADE
• 13% were serious
• 11% were preventable
• 28% were ameliorable
• 14% required visit to clinical facility (i.e. ER)

Gandhi et al N Engl J Med 2003;348:1556-64
     Summary of ADE Literature
• Evident that ADE’s are:
  – common
  – can be serious, life-threatening, or fatal
  – many are preventable or ameliorable
  – occur across the continuum of health care

• Medication errors are leading cause
  – Most common type of error affecting patient care
Medication Reconciliation Literature

JAMA 1997;277:301
   – 46% of med errors occur on admit or discharge
JCOM 2002;8:27
   – 60% of med errors occur when pts admitted, transferred, or
     discharged
   – Reconciliation ’d errors by 70%
Arch Int Med 2005;165:424
   – Med recon prevented 8 potentially severe ADE in 3 month period
Am J Health-Syst Pharm 2004;61:1689
   – 22-59% of all medication discrepancies could result in pt harm
Arch Int Med 2005;165:424
   – Medication discrepancies lead to greater use of hospital services
    How Did We Begin?

• HFMEA Interdisciplinary Workgroup
  formed as a result of significant ADR
• JCAHO mandate announced
• Flowcharting found current process:
  – Inconsistent, error-prone, reactive rather
    than proactive
• Needs Re-Design
       Where Did We Go?:
        Med Recon Study

• Baseline: Measured current process
  – Accuracy of electronic profile
  – Frequency of medication histories obtained
    on admit
  – Rate of unintended discrepancies

• Pilot “Recon Program” implemented and
  measured
                Methods

• Pharm Resident interviewed patient
  within 24-48 hours after admit
• Obtained true med list
• Compared this list versus the electronic
  profile and initial admit orders
• Clarified discrepancies as “intended”
  versus “unintended” by interviewing
  prescriber
   Current System                  Pilot Reconciliation

       Patient admitted                  Patient admitted


                                 RPh notified, reviews med profile
     MD: performs H&P             Enters reconciliation note with
     obtains med history             revised med list into CPRS
  Uses electronic med profile

                                   MD: performs H&P, reviews
                                   revised med list with patient;
    MD orders medications          adds addendum to document
                                             changes

RPh monitors for discrepancies
   after medications ordered         MD orders medications
RPh must decide if intended or   RPh monitors for discrepancies
  unintended, then contact MD       after medications ordered
        for clarification
RESULTS
Electronic Profile Discrepancies
80%          74%

70%

60%

50%                                              45%

40%                            33%                                  33%
30%

20%

10%

 0%
      Any Discrepancy   Taking Med: Not   On Profile: Not   Taking different
                           on Profile         taking             dose
Obtaining a Medication History


    Baseline                 48%




 Recon Pilot



           20%   30%   40%   50%   60%   70%   80%
Obtaining a Medication History


    Baseline                 48%




 Recon Pilot                                   75%




           20%   30%   40%   50%   60%   70%    80%
Patients with Unintended Discrepancy

                              60%
   Patient with Discrepancy




                              50%
                                               38%
                              40%

                              30%
                                                                    46%
                              20%
                                                                                    68%
                              10%

                              0%
                                    Any Discrepancy         Omission        Commission
                                                 Baseline   Recon Program
                    Discrepancies per Patient

              1.6
              1.4
              1.2
Per Patient




              1.0
              0.8
              0.6
              0.4
              0.2
              0.0
                                Any Discrepancy

                           Baseline   Recon Program
        Pharmacy Drug Admit List
           (Reconciliation Note)
•   Cleans up electronic profile to user-
    friendly version
•   Pharmacist highlights potential problems
    before orders written
    –   Expired meds patient possibly still taking
    –   Active meds not filled recently
    –   Remote electronic data from other VA’s
    –   Highlights ½ tab and multiple tab directions
Drug....................................                   Last
                 Rx #                Stat Qty   Issued     Filled      Rem
WARFARIN (COUMADIN) NA 5MG TAB
                 6494490A A 36                 06/21/2005 09/01/2005 (4)
 SIG: TAKE ONE AND ONE-HALF TABLETS BY MOUTH EVERY MONDAY &
    FRIDAY AND TAKE ONE TABLET ALL OTHER DAYS OF THE WEEK, OR AS
    DIRECTED BY WARFARIN CLINIC, TO PREVENT BLOOD CLOTS
  Provider: PHYSICIAN,NAME                    Cost/Fill: $ 4.61
AMIODARONE HCL (SANDOZ) 200MG TAB
                 6419532 A 65                 12/27/2004 08/29/2005 (4)
 SIG: THEN TAKE ONE TABLET EVERY DAY
   Provider: PHYSICIAN,NAME Cost/Fill: $ 9.62
FUROSEMIDE 40MG TAB
                 6647405 A 270                 08/19/2005 08/20/2005 (3)
 SIG: TAKE TWO TABLETS BY MOUTH EVERY MORNING
  Provider: PHYSICIAN,NAME Cost/Fill: $ 3.78
GLIPIZIDE 5MG TAB
                 6618894 A 180                 07/22/2005 07/22/2005 (3)
 SIG: TAKE ONE TABLET BY MOUTH TWICE A DAY
  Provider: PHYSICIAN,NAME Cost/Fill: $ 2.34
SPIRONOLACTONE 25MG TAB
                 6543181 A 90                 05/04/2005 05/05/2005 (3)
 SIG: TAKE ONE TABLET BY MOUTH EVERY DAY
  Provider: PHYSICIAN,NAME A Cost/Fill: $ 16.07
SPIRONOLACTONE 25MG TAB
                 6530353 DC 45                 04/23/2005 04/24/2005 (3)
 SIG: TAKE ONE-HALF TABLET BY MOUTH EVERY DAY
 Provider: PHYSICIAN,NAME Cost/Fill: $ 8.04
Drug                                                        Last      Refills
                                                  Qty       Filled    Remaining
AMIODARONE HCL (SANDOZ) 200MG TAB                 65        08/29/2005 (4)
  TAKE ONE TABLET EVERY DAY
DIGOXIN (LANOXIN) 0.125MG TAB                     90         04/04/2005 (3)
  TAKE ONE TABLET BY MOUTH EVERY DAY
FUROSEMIDE 40MG TAB                               270        08/20/2005 (3)
  TAKE TWO TABLETS BY MOUTH EVERY MORNING
GLIPIZIDE 5MG TAB                                 180        07/22/2005 (3)
  TAKE ONE TABLET BY MOUTH TWICE A DAY
LISINOPRIL 40MG TAB                               90         03/31/2005 (3)
  TAKE ONE TABLET BY MOUTH EVERY DAY
SPIRONOLACTONE 25MG TAB                           90         05/05/2005 (3)
  TAKE ONE TABLET BY MOUTH EVERY DAY
WARFARIN (COUMADIN) NA 5MG TAB                    36         09/01/2005 (4)
  Per Warf Clinic note 10/3/05: Takes 7.5 mg on Mon and Fri, 5mg rest of week
   Expired: Meds Patient May Still Be Taking
ATORVASTATIN CALCIUM 80MG TAB                30                   06/14/2005 (9)
  TAKE ONE TABLET BY MOUTH EVERY MORNING
     expired: 08/11/2005
MIRTAZAPINE 30MG TAB                         30                   06/05/2004 (5)
  TAKE ONE TABLET BY MOUTH AT BEDTIME
     expired: 09/06/2005

The following meds have not been filled recently. Please verify if patient is still taking:
Lisinopril last filled in March

Please note, patient on amiodarone and digoxin – significant interaction and no digoxin
    levels noted. Consider checking level.

    SIGNED: RPH
O   Meds/OTCs patient is taking, that are not on the above list.




O   I plan to hold the following meds for now, will re-evaluate future
    use.



O   Intentional dose changes upon admit.



O   Meds on the above list patient no longer takes. D/C from
    outpatient profile.



O   Medication List as listed above is accurate and should continue.
                Conclusions:
• Electronic profile not accurate
  – creates false sense of security
• Obtaining medication history is not routine
• Current system
  – Does not meet JCAHO standard
  – Catches discrepancies after meds ordered
  – Ability to reconcile is inconsistent
• Pilot Reconciliation Program
  –   Proactive
  –   Improves obtaining medication history
  –   Significantly reduced discrepancies prior to orders
  –   Meets JCAHO standard

				
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