Medication Reconciliation July 12, 2005 by yfr24536

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									 Medication Reconciliation
                    July 12, 2005

                  Glenn Billman, M.D.,
Medical Safety Officer, Children’s Hospitals and Clinics of
                        Minnesota
First, do no harm….
                      2
        The Issue:
“Medicine used to be simple,
ineffective and relatively safe.

“Now it is complex, effective,
 and potentially dangerous.”
          Sir Cyril Chantler



                                   3
Our Challenge :

Optimal care for patients requires totally
effective communication regarding
medication use among numerous people of
varying disciplines in multiple locations over
time including the families themselves.



                                                 4
Our Aim: Implement Medication
           Reconciliation

  Implement a Process that will ensure that
    patients and their caregivers possess the
   most accurate, and up to date medication
                   list possible



                                                5
Definition 1:
Medication Reconciliation
 Reconciliation is the process of comparing
 what medication the patient is taking at the
 time of admission or entry to a new setting
 or level of care, with what the organization
 is providing (admission or new medication
 orders) to avoid errors such as conflicts or
 unintentional omissions.


                                                6
Definition 2:
Medication Reconciliation
 All medications appropriately and
  consciously continued, discontinued,
  or modified at all transitions of
  care.




                                         7
Why Should We Do This?

   140 discrepancies in 81 patients (1.7/pt)
       65 omissions
       59 wrong dose/frequency
       16 wrong drug
   32.9% discrepancies rates as potentially
    moderate harm; 5.7% severe harm

                                  Arch Intern Med, Feb 2005


                                                              8
Why Should We Do This?

   Ineffective medication reconciliation
    upon hospital admission
       up to 50% of medication errors
       up to 20% of future ADEs




                                            9
  Why Should We Do This?
   Because It’s Doable !
1) Increased Percent of Patients That
Completed Medication Coordination
                   100
                   90    Baseline
                   80
                   70
         Percent




                   60                           w
                                                w
                   50
                                                w
                   40
                                                w
                   30
                   20
                   10
                    0
                                           10
                                    Time
                Why Should We Do This?
                  Because It Works !
          100

          90

          80

          70

          60
Percent




          50     Discrepancies, All Types And
                 Sources
          40
                    Baseline
          30
                                                   Discrepancies, Patient Related
          20
                               Cycle 1                  Baseline
          10                             Cycle 2                   Cycle 1   Cycle 2

           0
                                   Why Should We Do This?
                                     Because It Works !
                  In The Number Of Days
4) An IncreasePatients Related To ADE's Hem/Onc
       Number Of Days Between ED Visits By

Between ED Visits Related To ADE’s
                                  70


                                  60        Medication Coordination
                                            Parent Education
   Number of Days Between ADE's




                                  50
                                            ADE Monitoring
                                  40
                                                                                      Potentially Preventable
                                  30
                                                                                      ADE

                                  20
                                                                                      Non-Preventable ADE
                                  10


                                  0
                                  11/5/01    11/25/01   12/15/01   1/4/02   1/24/02          2/13/02   3/5/02   3/25/02   4/14/02   5/4/02

                                                                                      Date
                                                                                                                                        12
Why Should We Do This?
     Efficiency !

     Improve
                                Improve
    Discharge
                               Ambulatory
    Medication
                  Improved     Medication
       List
                 Accuracy of      List
                 Medication
                    List
                  Improve
                 Admission
                 Medication
                    List



                                            13
 Why Should We Do This?
   It’s Cost Effective !
   High             Do                                Investing In
                                 Dedicated Unit
                   First         Pharmacist              Safety CPOE
          Diagnosis                    Pharmacist   Bar Code         Automated
          Specific Medication          Patient      Reconciliation   ADE
          Order Sets Reconciliation    Interview                     Monitoring

Impact           Pharmacy             Pharmacist
                 Managed
on ADE           Protocols
                                      Order Entry


          Zero Tolerance
          Ordering Standards

          Preprinted              Intervention
          Order Forms             Database
                   Pocket
                   Formulary

          Medication

                                                     Don’t Bother
          Competency
   Low    Testing

          Low                          Cost To                                High
                                                                                     14
                                       Implement
      2005 NPSG Goal 8:
    Medication Reconciliation
   Accurately and completely reconciles
    medications across the continuum of care
       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.


                                                           15
          2005 NPSG Goal 8:
        Medication Reconciliation
   Accurately and completely reconciles
    medications across the continuum of care
       8b: A complete list of the patient’s medications
        is communicated to the next provider of service
        when it refers or transfers the patient to
        another setting, service, practitioner, or level of
        care within and outside the organization.




                                                              16
Medication Reconciliation Is A Tool
To Help Bridge Gaps That Occur At
Transitions and Transfers of Care
     Process steps:
         The medication history is completed
         The physician reviews and acts upon
          each medication
         The medication orders are written
         A 2nd person reviews medication history
         That 2nd person resolves discrepancies

                                                    17
Reconciliation

Virtually all hospitals who have
successfully addressed
admission reconciliation have
created a special form as part
of the solution. These forms
pretty much look alike.


                                   18
                                                                         Do you have a latex allergy or sensitivity? Yes No Unsure
                                                                         If yes, describe type of reaction:______________________________
  Allergies: Drug/Foods             Reactions/Side Effects               Are you allergic to iodine?    Yes  No
                                                                         Are you allergic to dyes?     Yes  No

                                                                         Height: Actual________cm
                                                                         Weight: Actual________kg

                                                                         Information Source:   Patient Spouse Wallet Card
On No Medications at Home                                                                     Brought meds from home
Unable to Obtain Medication History—Reason:                                                   Other (Specify)_______________________
                                  Home Medications on Admission                                            Physician Medication
                   (Prescriptions, OTC, Herbals, Patches, Inhalers, Eye Drops & Supplements)               Orders on Admission
                                                                                                               (Check Only One)
                          Drug Name                          Dose   Route     Freq      Last Taken        Order        Change     DO NOT
 Initials                                                                               Date/Time       Unchanged    (Use Order   ORDER
                                                                                                                       Sheet)


                                                                                                                                   
                                                                                                                                   
                                                                                                                                   
                                                                                                                                   
                                                                                                                                   
                                                                                                                                   
                                                                                                                                   
                                                                                                                                   
                                                                                                                                   
                                                                                                                                   
                                                                                                                                   
Person(s) Gathering Medication History:_____________________________________Date/Time____________________            Sent to Pharmacy
                                      _____________________________________ Date/Time____________________
                                                                                                                                            19
Ordering Physician Signature: _____________________________________________Date/Time_____________________
     Children's Hospital San Diego                                                                          1
     Medication Coordination Form
       Instructions: Please Com plete Item s 1 - 10

                                                                                                                       Addressograph Stamp

     Admit Date:                                            4                     5                        6                     7
2    Time:
     List All Medications Identified by               Do All              If "No", which
                                                      Medication
3    Patient, Family, Prescription                    Elem ents
                                                                        elements require             M.D.     Please Explain How The
     bottle,or M.D. order.                            Match?                  review?                Reviewer Discrepancy Was Resolved

     Drug… … … .Dose… Freq… .Route… ...   Last Dose   YES       NO     Drug   Dose    Freq   Route    Initials




8    Signature of RN(s) reconciling m edications:               _________________________ Initials___________          Date:_____________Tim e:________________

                                                                ___________________ _____    Initials___________       Date:_____________Tim e:________________
9
     Did you identify and correct a discrepancy? Yes              No                  Patient Related?           Yes   No         Order Related? Yes        No

10   Adm inistrative Data Screen Com pleted by :                ___________________ _____    Initials___________       Date:_____________Tim e:________________
     What is included?
   Current home meds / OTC / Herbals,
    including dose, route & frequency
   Time of last dose
   Source of the information
   The medications ordered at admission
   An Assessment of patient compliance


                                           21
    There is no perfect
     medication list.

   Quit thinking there is.

Do not be paralyzed by trying
     to perfect the list.
              Steve Meisel, PharmD
                                     22
       Who uses the form?
   The nursing staff or pharmacist use the form to
    collect information at admission.
   The physician uses the form as a reference
    and/or order when writing initial orders for
    medications. In some cases the form itself
    serves as the order form, thereby obviating the
    need to rewrite orders.
   Both physicians and nurses use the form
    throughout the patient’s stay as a reference.


                                                      23
Source of the information
    The patient/family
    The patient’s pharmacy
    Previous medical records
    The patient’s medication bottles
    The physician’s office



                                        24
A completed Medication List
is only the Half Way Point.

Reconciliation is real work!




                               25
A Big Problem Is Often Just Getting
    An Accurate Medication List
      Patient brings in incorrect list.
      Patient does not take what is marked on
       bottle.
      Patient does not know what is on and
       family, pharmacy not available.
      Wrong name of med on ED sheet.
      Med bottles don’t jive with what the patient
       says.
      Patient is unable to tell you. No family
       available. MD on call does not know either.
      Can’t call the pharmacy “after hours”.         26
Medication Coordination Flowsheet
  (Adapted from the work of Roger Resar, M.D.)                                Call M.D.
                                                                   Yes



 Pt. Admitted                                  Is time of last                                  Reconciled
                                                dose in question         No

                                      No

                                                                                                         Yes
                                    Is this a 24 hour      Yes
                                          Med?                                       Yes
 Nurse completes
                                                              Can clinic chart or               Does clinic chart
 Med Coordination
                                                              other sources be                  or other external
 Data Sheet                           No
                                                              obtained in 24 hours               source reconcile?

                                   Is the medication list
                                    from an external source
                                                                                     No                         No
                                        available?
 Physician orders with                                                                              Call M.D.
 drugs, dosages, and
 times are assembled          No                Yes

                                    Does this confirm     No         Can Pharmacy reconcile
                                    drug and dose?                     drug and dose?

                                                                                                  Reconciled
                                                No                                        Yes
 Can patient or family give
 accurate, confirming data?
                                   Is time of last dose
                                       in question               Yes                  No
                     Yes
                                               No                             Call M.D.
            Stop. Use this           Reconciled
             information                                                                                             27
 The Intent and Value of
Medication Reconciliation Is
  In Having An Accurate
     Medication List.



                               28
    Transfer Reconciliation
   Critical especially upon transfer in and out
    of intensive care and other specialty units
   As much as 60% of the care plan after
    transfer may be different than what the
    physician expects
   Can utilize internal computer systems to
    facilitate, but there must be an active
    decision to continue, discontinue, or modify
    each line item
                                                   29
Transfer Reconciliation

   Automatic stops of certain critical-
    care-specific drugs (e.g. dopamine)
    are acceptable provided those stop
    orders appear in the medical record.
       ? Benzodiazepines
   Requirement to re-write all orders
    upon transfer introduces new
    opportunities for error
                                           30
31
    Discharge Reconciliation

   The patient’s reconciled list of
    admission medications is compared
    against the physician’s discharge
    orders along with the last day’s MAR.
   The lists can either come from the
    computer system or be integrated
    with the original admissions list.

                                            32
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         To Be Successful:

   Put the patient first (this isn't
    someone else's job)
   You need to have some good change
    methodology to be able to develop a
    good product
   You need to use this to replace
    something else i.e. medication history
    in nursing data base


                                             35
         To Be Successful:
   Understand Your Processes
      Process flow
      Data flow

      Roles and responsibilities

      Procedures

 Build Incrementally – Start Small
 Leadership Support is Critical

    Project champions


                                      36
           To Be Successful:
   You must have organization
    alignment (physician, nursing,
    pharmacy, administration)
       Process Owner and Sub-Process Owners
       A champion for the entire process
   Have a good education program
    when rolling it out
   Appropriately Resource the project
   You Need To Start!
                                               37
Questions / Comments/
Discussion




                        38
Contact Information


    Contact Glenn Billman:
glenn.billman@childrenshc.org

								
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