Spotlight Case September 2007

1. Spotlight Case September 2007 Medication Reconciliation: Whose Job Is It?

2. Source and Credits • This presentation is based on the September 2007 AHRQ WebM&M Spotlight Case • See the full article at http://webmm.ahrq.gov • CME credit is available • Commentary by: Eric G. Poon, MD, MPH, Harvard Medical School • Editor, AHRQ WebM&M: Robert Wachter, MD • Spotlight Editor: Tracy Minichiello, MD • Managing Editor: Erin Hartman, MS

3. Objectives At the conclusion of this educational activity, participants should be able to: • Appreciate the prevalence and impact of medication discrepancies at the times of transition in the health care system • List barriers to successful medication reconciliation • Understand best practices for reconciling medications

4. Case: Medication Reconciliation A woman with a history of seizures was scheduled for repair of a prolapsed rectum. Consultation prior to surgery listed her medication as “Neurontin 250 mg.” When admitted for surgery, the patient reported to the anesthesiologist that she took Zarontin (ethosuximide) 250 mg twice daily. This was recorded on her pre-anesthesia care record, where Neurontin had been entered and crossed out. The admitting note listed current medications as “See her list.” Post-operatively, the patient was prescribed Neurontin (gabapentin) 250 mg twice daily.

5. Complexity of Transitions in Care • Multiple handoffs among health care providers • Numerous changes to the patient’s therapeutic plan • Intended medication regimen before, during, and after hospital stay often a point of confusion

6. Medication Regimen Confusion • Multiple changes to medication regimens • Discontinuity of care • Short hospitalizations • Inadequate patient education See Notes for references.

7. Impact of Medication Discrepancies • More than 50% of admitted patients have at least one discrepancy between medication history obtained by admitting clinicians and actual pre-admission regimen • 27%-59% of these have potential to harm • Discrepancies are most common drug-related problems at time of discharge • Cause half of all preventable adverse drug events 30 days after discharge See Notes for references.

8. Medication Reconciliation • As defined by the Institute for Healthcare Improvement (IHI): • Medication reconciliation is a process of identifying the most accurate list of all medications a patient is taking—including name, dosage, frequency, and route—and using this list to provide correct medications for patients anywhere within the health care system Getting Started Kit. IHI Web site.

9. Medication Reconciliation in Hospitalized Patients • For patients admitted to hospital, this process involves comparing patient’s current list of medications against the physician’s admission, transfer, and/or discharge orders • Recent Joint Commission mandate for all health care organizations to “accurately and completely reconcile medications across the continuum of care” See Notes for references.

10. Case: Medication Reconciliation (cont.) When the order for gabapentin 250 mg twice daily was received in the pharmacy, it was entered as “gabapentin liquid” (gabapentin is not available in tablet/capsule strengths that would allow a 250 mg dose). The pharmacist dispensed gabapentin liquid 250 mg/5 mL with a note in the pharmacy computer record to indicate “dispense size = 120 mL.” This comment is necessary so that the pharmacy knows how much was dispensed.

11. Case: Medication Reconciliation (cont.) This comment also appears on the prescription label and in the electronic medication administration record (EMAR). The hospital had recently implemented a new EMAR system, and there was no way to suppress this information from appearing on the EMAR. The nurse caring for the patient misinterpreted the EMAR and gave an excessive amount of the gabapentin liquid on two consecutive evenings (the exact amount was not documented).

12. Case: Medication Reconciliation (cont.) The patient told the nurse that the amount of medicine seemed more than usual. Shortly thereafter, the patient became lethargic and couldn’t walk. The pharmacist determined that the gabapentin liquid had been refilled earlier than expected and that an overdose had occurred. Although the overdosage was noted at that time, the administration of the incorrect drug (Neurontin, instead of Zarontin) was not recognized until several weeks later when the event was investigated in more detail.

13. What Went Wrong? • Pre-operative consultant obtained wrong pre-admission medication list (PAML) from patient • Consultant failed to verify medication history by contacting primary care physician, neurologist, or pharmacist, or by accessing outpatient medical record or pharmacy dispensing record • Although anesthesiologist corrected medication history, the clinician writing inpatient medication orders was not alerted about the correction

14. What Went Wrong? (cont.) • The admitting physician and nurse failed to review the anesthesiology records or reconfirm the PAML with the patient • The pharmacist probably did not have access to amended medication list that anesthesiologist had generated • The ordering physician and dispensing pharmacist both failed to question the unusual dose of Neurontin

15. Medication Reconciliation: Challenges • Providers piece together medication history using information from multiple, often imperfect, sources: • Patient, caregiver, primary care physician, medical specialists, outpatient medical records, hospital discharge summaries, community pharmacies • Many disciplines involved, often with divergent expectations about who is responsible for reconciling medications and how it should be done ISMP Medication Safety Alert! Acute Care Edition. July 13, 2006.

16. Best Practices in Medication Reconciliation • Given the number of disciplines involved in the medication-use process, robust medication reconciliation process should include participation by physicians, nurses, and pharmacists • Process for medication reconciliation must be clearly defined by a multi-disciplinary team and responsibilities for each component of the process assigned to the parties involved See Notes for references.

17. Best Practices in Medication Reconciliation (cont.) • No single universal process will meet needs of all patients entering a hospital • Limited number of different processes will likely need to be developed based on patient population and point of entry into hospital • Successful implementation will require significant training, education, and support from clinical leaders • Willingness to engage in continuous improvement and monitoring for compliance are likely success factors See Notes for references.

18. Best Practices in Medication Reconciliation—Patient Education • Patients should participate in the medication reconciliation process • Encourage patients to keep an up-to-date list of medications and understand why they take each • During the discharge process, medical staff should ensure that patients are educated about any changes in medication regimen See Notes for references.

19. Information Technology • For health care systems with access to reliable sources of patients’ medication history in electronic format, an electronic tool could facilitate verification of medication history and construction of PAML • Electronic PAML could be shared across multiple disciplines and inform decision making of physicians, nurses, and pharmacists during admission and discharge processes

20. Information Technology (cont.) • For hospitals with computerized physician order entry (CPOE) systems, electronic PAML can also facilitate • Ordering inpatient medications during admission • Construction of the post-hospitalization medication list during discharge • However, no amount of technology can replace a well-designed process Poon EG, et al. J Am Med Inform Assoc. 2006;13:581-592.

21. Resources for Developing Medication Reconciliation Programs • IHI. Getting Started Kit: Prevent Adverse Drug Events (Medication Reconciliation) How-to Guide • http://www.ihi.org/IHI/Topics/PatientSafety/MedicationSystems/ • Massachusetts Coalition for Prevention of Medical Errors. Reconciling Medications: Recommended Practices • http://www.macoalition.org/documents/RecMedPractices.pdf See Notes for references.

22. Take-Home Points • Failure to reconcile medications during transitions of care accounts for many preventable adverse events • To design a robust medication reconciliation process, first define steps involved and decide who should be responsible for each step • A reliable medication reconciliation system requires a multi-disciplinary approach, often with participation of physicians, nurses, and pharmacists across the continuum of care

23. Take-Home Points (cont.) • A one-size-fits-all approach is unlikely to work, even for the same hospital • Information technology can facilitate medication reconciliation if it is devised to support a well-designed process