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					Reconciling Medications


    Safe Practice Recommendations
                  and
       Implementation Strategies
 Medication Safety Facts

 Medication errors account for more than
 7,000 deaths annually
 Approx. two out of every 100 patients
 admitted to the hospital will experience
 a preventable adverse drug event
 Over 12% of patients with an ADE
 within 2 weeks of discharge
 “Reconciling Medications”

A systematic process to reduce the number of
medication events occurring at interfaces of care
Creating the most complete and accurate list possible
of all home medications for each patient and then
comparing that list against the physician‟s admission,
transfer, and/or discharge orders. Discrepancies are
brought to the attention of the physician and, if
appropriate, changes are made to the orders. Any
resulting changes in orders are documented.
RESEARCH:
 Errors that are the result of an omission are often not
  reported as errors, although they may result in an
  adverse outcome for the patient.
 They may manifest themselves as:
      Unexplained elevated lab values
         Due to inaccurate dosing

         Missed medications

      Readmissions due to:
         Doubling up of medications

         Missed medications at discharge

         Contraindication to unknown OTC or herbal meds
 Problem identified

 Info on patients‟ home meds not being
  systematically collected; in multiple places in
  the chart, often incomplete
 Poor or inadequate processes to compare list
  of pre-admit medications to orders
 Research study demonstrated that over half of
  all hospital medication errors occurred at the
  interfaces of care
  [Rozich, Resar 2001]
Medication errors based on
chart review
              9%

                                                       Interface Errors
    14%
                                                       Drug Distribution or
                                                       Documentation Errors
                                                       Allergy Documentation
                                     56%

    21%                                                Others


Source: Luther Midelfort Hospital -- Mayo Health System chart review
           “We found that the list of medications that details current drug use
            was either nonexistent or wrong more than 85% of the time”
                       [Rozich/Resar 2004, p.8]
 Examples of errors

 No orders for needed home meds
 Missed or duplicate doses from inadequate
  records of frequency/last administration time
 Surgeon inadequately addressing meds for
  chronic conditions
 Failure to restart meds at transfers
 Doubling up (brand/generic combinations,
  formulary substitutions)
 Unintended medication
 discrepancies at admission
Studies show over half of patients have
discrepancies between home medications and
medications ordered at admission, many with
potentially serious results
 54% of patients; 39% potentially serious [Cornish
Arch Intern Med 2005]
 More than half; 59% could have caused harm if
the error continued after discharge [Gleason Am Jnrl
H-Sys Pharm 2004]
More evidence on impact:
Johns Hopkins Surgical ICU

 Dramatic reduction in medication errors
 resulted from reconciling:
     Baseline: 31 of 33 (94%) of patients with MD
      changing orders when discrepancies brought
      to their attention
     By week 24, nearly all medication errors in
      discharge orders eliminated
     As a result of routine reconciling, average of
      10 orders per week are changed
                                    [Pronovost, 2003]
       The
Reconciling Process
THE PROPOSED SOLUTION
 A process to obtain the       Patient
  best home medication          Pharmacy
  list possible through a       Family
  defined resource list         Patient’s Med List
  and active review of the      PCP
  patient‟s medical             VNA
  history.
                              Utilize strategic
                               interviewing practices.
                              Ask open ended
                               questions to obtain
                               info on OTC meds &
                               herbals.
Reconciling process: admission
Getting the home med list (at intake)
      Interviewing strategies to promote accuracy
      Input from patient/family/alternative sources
      Outreach: patients arrive with accurate list
Writing medication orders
      Goal: work from accurate home med list
Identify and reconcile discrepancies
Order (no omissions, no duplicates, right med/dose/
              frequency/route)
 Communicate (to next level of service)
BECOMING A STATEWIDE
INITIATIVE
 The Massachusetts Hospital Association in
  collaboration with the Massachusetts Coalition for the
  Prevention of Medical Errors reviewed evidence of
  medication reconciliation to determine:

            Importance – How much can we impact safety?
            Feasibility – Is this a doable process?
            Measurability – Can we monitor our progress?


      Statewide advisory board voted to accept this
       initiative!
Getting started
1) Initiate leadership dialog – resource
   commitment, regular reporting channels
2) Form a multidisciplinary team
3) Risk assessment/baseline measurement
4) Aim statement, timeline
5) Pick pilot unit
6) Begin testing
Define Aim / Obtain Baseline Measure
 Aim:
     To reduce the rate of unreconciled
      medications at admission by 50 % within 9
      months.
 Measure:
     Baseline measurement of 20 charts,
      subsequent measures performed on 30 charts
      per month for the first 3 months after
      implementation of form. Evaluate the
      frequency of the measure after the first three
      months.
1. Getting the home med list

What have we learned?
 Adopt standardized form
 Share responsibilities, ordering prescriber
  accountable... crew resource management principles
 Validate with the patient
 Don‟t let perfection be the enemy of the good
1. Getting the home med list

  Who? Shared responsibilities, always
  someone with sufficient expertise:
 RN who completes the initial admission history
 Pharmacist/pharmacist technician
  [Michels/Meisel 2003; Gleason/Groszek 2004]
 MD if reconciling form not complete when ready
  to write orders
1. Getting the home med list

  What?
 Current home meds
 Include OTCs & herbals
 Dose, frequency, time of last dose
 Optional: route, source of information,
  compliance, purpose
 Many building collection of patient allergies into
  the process
2. Using home list when
writing orders
What have we learned?
 Make highly visible
 Provide access at point when orders are written
 Have reconciling form serve as an order sheet.
  benefits and issues...
Project phasing
 Pilot testing: identify changes, measure to
  know if the changes are an improvement
 Implementation: take a successful change
  and build it into the way the entire pilot
  population/pilot unit does their work
 Spread: replicating a change/package of
  changes beyond the pilot unit into other parts
  of the organization
 Maintain the gains
3. Identifying, reconciling
discrepancies
Who?
   Generally  nursing assigned responsibility
    of comparing the home list to the admit
    orders, identifying variances, and
    reconciling all differences
   Pharmacist involvement can be
    productive, especially for organizations
    with decentralized pharmacy
   Need strategy for handing off any
    unresolved differences at shift change
Implementation Strategies
 Resource requirements

 During testing/implementation phase
     Make explicit allocation for those with patient
      care responsibilities
     Managers need to pay attention to workloads;
      don‟t assign tests to someone overloaded
 Ongoing
     Build into regular workflows
     Collecting home history IS time consuming;
      some have added resources to support that
      (e.g. pharmacy techs)
Post Team Members- Encourage Input
 Contact any of the following Medication
  Reconciliation PI Team members to answer
  any of your questions:

     Melissa Bartick, MD - X9335
     Jennifer Fexis, Quality - X9406
     Darlene Civita, RN ICU- X9350
     Vicky Casto, RN ACU - X9335
     Deb Wilkinson, RPh - X9363
    Tips for engaging MDs
 Personal appeals from VP of Medical Affairs and/or
    Chiefs of services
   Trial with key leaders on each unit; get their input via
    “hallway consultations” not meetings
   Identified “Ambassadors” from engaged hospitalists;
    they then educated others
   Developed into CME risk program
   MDs from key committees (P&T, Medical Records)
   Chief Medical Resident on the team, with
    responsibility to report back to other residents
 Baseline risk assessment

Chart review
   Institution-wide
Mini-FMEA, flow charting existing
 processes
   Do in conjunction with initial tests of
    change
Just-enough measurement/analysis
   Don‟t get bogged down here!!
Mission
 Every patient will receive all medications they
 have been taking at home unless they are
 held/discontinued by their caregiver(s) and
 all new medications as ordered -- correct
 drug, dose, route, and schedule.


The goal of reconciling is to design a process that will ensure
the most accurate patient home medication list available, thus
reducing the number of medication events upon admission,
transfer and discharge
Choosing where to start

 Use risk assessment process
 Willing volunteers
 At admission logical place
   Pros& cons: Med vs Surg units
   Some success starting @ transfer: ICU,
    CCU, telemetry units
   Probably not ED
 Start small, focus on one unit

 Small tests... 1 unit, 1 RN, 1 MD, 1 patient
 Add more staff, more shifts, refining process
  and form
 Keep testing on that one unit until you refine
  the process and can show that it works (test
  on all shifts, patients coming in as direct
  admits, from ED, transfers, etc)
Pilot unit
1) Mini-team including nurse managers, front-
   line nurses, MD champion
2) Project introduction, staff education
3) Baseline measurement for the unit
4) Pick reconciling form to test (steal shamelessly...)
5) Begin testing
Piloting a reconciling form

 Testing; avoid forms committees...
 Simple vs complex
     Reconciling status
     Orders: continue, change, d/c, hold
     Optional: data sources, purpose/indication,
      date/time of last dose, amt of non-compliance
     Columns for reconciling at discharge?
     Signature lines
 Fundamental ingredients...

 Get support of your CEO; cannot do it without
  leadership at the top
 Use data (to motivate, to know if changes are
  leading to improvement)
 Strong representation from leadership of the 3
  key stakeholder groups: MD, RN, pharmacy
 Start small
 Culture...

 Core issues of teamwork and communi-
  cation... organizational culture matters
 Changing the way people do work; every time
  you try to change behavior, it‟s only natural to
  be met with resistance
      Recognize that this is HARD;
       Difficult task: but not impossible
      Unit briefings/pharmacy rounding
 Challenges and barriers

 Time and resources
     “How can we find the time to do this?”
 Roles and responsibilities
     “It‟s not my job”
     “I‟m not going to sign that form”
 Data collection
     Need data... but don‟t let data collection delay
      testing, overwhelm
Medication Checklist
Here‟s how patients can help the „medication reconciliation‟ process:



 Keep an updated list of all medications including herbals,
  vitamins and OTC. Including dosage and reason for taking
  the drug
 Include all allergies and describe reaction
 Include immunization history
 Take the list to all doctor visits and medical testing labs, as
  well as pre-assessment visit for admission or surgery and all
  hospital visits including ER
 When you leave the hospital, be sure to update your list with
  new medications and ask if any medications are duplicated
 Keep this list in with you at all times
 Staff education

 Include staff ed rep on your team
 Create simple template clarifying the steps to
  be taken to complete reconciling
 Lead off with examples of errors from your
  own hospital
 Use front line staff from pilot unit to educate
  staff on subsequent units
 Build into orientation, ongoing staff ed
 Publish your data and progress in your
  organizations newsletter
Measurement
Just-enough measurement
 Core measure
     Percent Medications Unreconciled
 Orders changed, “great catches”, stories
 Measures linked to each test, for example:
     % patients with reconciling form in chart
     RN/MD assessments of process
 Spread: % patients on units w/ reconciling
 Context of institution-wide ADE reduction
                                              0
                                                   50
                                                        100
                                                                      150
                                                                                     200
                                                                                                       250
                                                                                                             300

                                          1/5/98

                                         1/12/98

                                         1/19/98

                                         1/26/98

                                          2/2/98

                                          2/9/98

                                         2/16/98

                                         2/23/98

                                          3/2/98

                                          3/9/98

                                         3/16/98
                                                                                                                   (per 100 Admissions)




                                         3/23/98
                                                                                      Admission




                                         3/30/98
                                                                                      reconciliation




                                          4/6/98

                                         4/13/98

                                         4/20/98
                                                                    Discharge




                                         4/27/98

                                          5/4/98
                                                                    reconciliation




                                         5/11/98

                                         5/18/98

                                         5/25/98

                                          6/1/98

                                          6/8/98

                                         6/15/98
                                                          Transfer
                                                                                                                                          # Medications Unreconciled




                                         6/22/98

                                         6/29/98
                                                          reconciliation




                                          7/6/98
Luther Midelfort Implementation Impact
Baseline data collection

GOAL: Identify current safety risks
   How   complete is info on patient‟s
    pre-admission meds? How hard
    to find? In multiple places?
   How   often are home meds
    omitted from admit orders? not
    re-started after transfer, at
    discharge? duplicate therapies at
    discharge?
  Example: Why is it Needed?

 In a chart review of our admit orders, we
 found an average of over 4 discrepancies
 per patient, with omitted medications the
 most significant error.

 Source: University of Kansas Hospital
          Terry Rusconi [2003]
        Collecting your data
                                                                                                      Is
                                                                                           Do
                                                                                                  discrepa                                                     Are Admitting
                                                                                        Elements
                                                                      Medication List                ncy                                                          Meds
                                          Frequency            Data                      of List              Admitting Medication          Frequency
No.      Admitting Medications   Dose (1)
                                             (2)
                                                    Route (3)        Documented on -              intention                        Dose (6)
                                                                                                                                               (7)
                                                                                                                                                      Route (8) Addressed By   Comments
                                                              Source                     Match?                     Orders                                        MD? (9)
                                                                     List all that apply           al? Y or
                                                                                        Y or N or                                                               Y or N or ?
                                                                                                   No or ?
                                                                                          ? (4)
                                                                                                     (5)


 1


 2


 3


 4


 5


 6


 7


 8


 9


10


11


12
                                                                                         Lists Documented
      Total (1) Blanks                                          Data Source:                    On:                                 Total (5) N or ?
      Total (2) Blanks                            P = patient         V = VNA           100 - ED sheet                              Total (9) N or ?
      Total (3) Blanks                            F = family          N = Nursing home 200 - RN admission                           Total (6) Blanks
      Number of Meds                              Rx - RX bottle      C = Pharmacy      300 - H & PE                                Total (7) Blanks
                                                  H = History                           400 - PAT form                              Total (8) Blanks
                                                  M = MD office                         500 - None                                  Total ordered meds
          A               B                  C                  D                     E                   F              G
                                                                              Number of Admitting
        Chart      Total Admission   Total Blanks (1)       Number of        Meds Not Addressed by   Total Ordered   Total Blanks
1      Review        Medications          (2) (3)        Discrepancy's (5)          MD (9)            Medications     (6) (7) (8)
2           1                    5                 0                     2                       1               5             0
3           2                    1                 3                     1                       1               4             0
4           3                   13                10                     2                       2              11             3
5           4                   10                12                     0                       0               9             0
6           5                    2                 2                     0                       0               7             0
7           6                   10                30                     0                       0               9             0
8           7                   13                13                     2                       0              13             3
9           8                    7                 3                     0                       0               8             0
10          9                    9                 0                     3                       0               8             0
11         10                   10                14                     2                       1              10             2
12         11                   13                 4                     0                       0              19            19
13         12                   10                 0                     0                       0              11             0
14         13                    0                 0                     8                       8               8             0
15         14                   12                23                     4                       5               9             0
16         15                   11                16                    10                       1              10            10
17         16                   15                 6                    11                       0              18             2
18         17                   10                14                    10                       7               3             4
19         18                    9                 4                     3                       1              12             6
20         19                   11                15                     6                      10               6             0
21         20                    2                 2                     1                       1               5             0
22      Sum                    173               171                    65                      38             185            49
23   Summary Statistics - Admit Orders
24   # discrepancy errors: Sum of (5)                                   65
25   # patients: # charts reviewd:                                      20
26   Discrepancy errors/100 admissions:                                325
27   Average error per patient                                        3.25
28
29   Summary Statistics- H & P
30   # reconciliation errors: Sum of (9)                                38
31   # patients: # charts reviewd:                                      20
32   Reconciling errors/100 admissions:                                190
33   Average error per patient                                         1.9
34
35   Summary Statistics - Admit Orders
36   # dose, freq, route omission errors:   Sum of (C)                 171
37   Total admission medications: Sum of (B)                           173
38   Admitting Omission errors?100 admissions                           99
39   Average error per med                                            0.99
40
41   Summary Statistics - H & P
42   # dose, freq, route omission errors:   Sum of (G)                  49
43   Total ordered medications: Sum of (F)                             185
44   Order Omission errors?100 admissions                               26
45   Average error per med                                            0.26
46
 Baseline: practical process
 Multidisiplinary team of reviewers
     RN, MD, Pharm... QI rep to combine
 Minimum 20 charts
     Institution-wide, random or stratify to ensure
      all units represented
     Minimum stay of 3 days
     Can be fruitful to include re-admits
 Find home meds and list on form
 Compare to admit orders
 Identify “unreconciled medications”
  Ongoing data collection
 Need frequent measurement on every unit where you
  are testing: monthly charts to display on unit
 Process: easy for patients where the reconciling form
  has been completed; follow process used in baseline
  data collection when no reconciling form
 DON‟T CHEAT:
      Don‟t skip patients without a reconciling form
      Don‟t just look for home med list; the question is,
       have the home meds been RECONCILED?
  TIPS on collecting your data...
 Share responsibilities, engaging implementers
 Limit sample: 20 charts
 Real-time review: patients on unit for 24 hours
 Establish rules for consistent treatment where judgment
  required (omission or obvious hold or d/c based on patient
  condition; but strategy should encourage increased documentation
  by prescriber)
 Set time limit (when unable to find home meds, use list from
  admit orders and indicate that all are unreconciled)
 Share “Great Catches”: examples of orders changed, errors
  prevented
    Beyond Admission
           and
Longer-term Considerations
 Reconciling at Transfer
 Compare most recent med record (MAR) and home
  med list against transfer orders. Issues:
 Access to reconciling form with home med history at
  point when new orders written
 Need to modify reconciling form to add columns for
  reconciling at transfer?
 Identifying responsibilities of both the transferring and
  the receiving unit
 Embedding into workflow: Who writes transfer
  orders? When? Where?
 Reconciling at Discharge

 Patients especially vulnerable
 immediately post-discharge
   Over 12% of patients with an ADE within
    2 weeks of discharge [Forster 2003]
 Address potential for doubling up based
  on formulary substitutions or other
  brand/generic name confusions
 Prohibit “resume home meds”!!!
 Verification of dosing instructions
 Outpatient Settings

 Applies to settings where the outpatient:
   may receive medication
   where patient's response to treatment might
    be affected by medications they are on
   where a practitioner who can review and
    modify the patient's medications is a part of
    the outpatient service
 Examples include outpatient oncology
  services, GI laboratories, emergency
  department, urgent care clinics, certain
  imaging procedures.
Using as an order sheet
   Proceed with caution, but efficiency gains
 Most MDs find it very helpful; makes their life
  easier, decreases duplication
 Timing: 6-10 months into the process?
 Modifications to reconciling form:
      Add MD signature line(s)
      Columns to indicate “continue” or “discontinue”
      Amendment form
Automation
            If you can’t do it on paper,
              don’t even try it in vapor
 First must have a stable process: adequate
  testing of the form, implementation on
  multiple units
 Careful design required; who enters info, who
  can update/change, may introduce new
  errors
Automation: John Hopkins ICU
project
 Revised form to strike balance between
  burden of data collection and
  comprehensiveness of medication
  information
 Automated process after 48 weeks, paper
  forms converted to electronic form
 Intervention now takes 20 minutes on
  admission and 20 minutes at discharge with
  minimal marginal costs
Better access to medication histories
 Promote patients maintaining medication
  cards
     Provide in ED, at discharge
     Disease specific support groups
     Pharmacy medication review
     Senior center (file of life)
     Partner with PCPs, nursing homes, VNA,
      health plans
Better access to medication histories
 Interview strategies including increased use
  of open ended questions
 Link medications to conditions, prescribing
  physicians
 Checklists of OTCs/herbals and commonly
  missed meds
 Leverage expertise of VNAS
 Shared databases

				
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Description: Nursing Home Resident Interview Template document sample