umass memorial medical center medication reconciliation eric alper, m.d., patient safety officer

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3. 3 Medication errors based on chart review

4. 4 Examples of errors No orders for needed home meds Surgeon inadequately addressing meds for chronic conditions Failure to restart meds at transfers Doubling up (brand/generic combinations, formulary substitutions)

5. 5 Problem identified Home med lists not systematically collected In multiple places in the chart, often incomplete or discordant Inadequate processes to compare list of pre-admit medications to orders Lots of similar evidence on NEED from EVERY hospital�s risk assessment/baseline data collection efforts. For example: In a fairly significant review of almost 600 records, we found that only 38% of our medication orders at admission were complete. (OSF Healthcare) A multidisciplinary check of medication orders for pediatric cancer patients revealed that 42% of the orders being reviewed needed to be changed (Dana Farber). Variances between medication orders and information from patient/guardian or prescription labels on the container 30% of the time. A home medication omitted from admission orders was the most common error and incorrect dosages ordered in admission orders also exceeded errors attributable to errors in information obtained from the patient/family (Children�s-San Diego) In our pre-intervention data 37% of discharge medication lists were missing a medication that the patient had been taking prior to admission, was not recorded on the admission medication list, did not receive in the hospital, and should have been prescribed at discharge (34/91); 49% of discharge medication orders had one or more unaccounted for discrepancies from the patient�s actual home medication regimen (MA hospital) 40% of charts ignored patient�s medications that benefit mental health (Zoloft, Wellbutrin, Haldol) in one week of auditing charts on one unit (Cambridge HA) Lots of similar evidence on NEED from EVERY hospital�s risk assessment/baseline data collection efforts. For example: In a fairly significant review of almost 600 records, we found that only 38% of our medication orders at admission were complete. (OSF Healthcare) A multidisciplinary check of medication orders for pediatric cancer patients revealed that 42% of the orders being reviewed needed to be changed (Dana Farber). Variances between medication orders and information from patient/guardian or prescription labels on the container 30% of the time. A home medication omitted from admission orders was the most common error and incorrect dosages ordered in admission orders also exceeded errors attributable to errors in information obtained from the patient/family (Children�s-San Diego) In our pre-intervention data 37% of discharge medication lists were missing a medication that the patient had been taking prior to admission, was not recorded on the admission medication list, did not receive in the hospital, and should have been prescribed at discharge (34/91); 49% of discharge medication orders had one or more unaccounted for discrepancies from the patient�s actual home medication regimen (MA hospital) 40% of charts ignored patient�s medications that benefit mental health (Zoloft, Wellbutrin, Haldol) in one week of auditing charts on one unit (Cambridge HA)

6. 6 �Reconciling Medications� A systematic process of creating the most complete & accurate list possible of every patient�s pre-admission medications 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. RECONCILIATION: marriage counselors & Catholic church Medication reconciliation is the act of comparing the medications the patient has been taking with the medications currently ordered. This allows the caregiver to identify medications that may need to be continued or discontinued or require dose or frequency adjustments based on the patient's changing condition. **To assure that patients receive appropriate meds while hospitalized **To accurately document medication history Medication Coordination Form [BI] Preadmission Medication List Verification and Order Form [UMass] Half form under header �Home Medication List� other half �Verification� Systematic identification of discrepancies (list vs orders), w/ reconcile = resolving those discrepancies LEADERSHIP voice: see Mission Statements Provide very clear directions on your goals for your organization for ensuring that all information on patients� medications is available in one highly visible place in the patient chart and new medication orders are always checked against that list RECONCILIATION: marriage counselors & Catholic church Medication reconciliation is the act of comparing the medications the patient has been taking with the medications currently ordered. This allows the caregiver to identify medications that may need to be continued or discontinued or require dose or frequency adjustments based on the patient's changing condition. **To assure that patients receive appropriate meds while hospitalized **To accurately document medication history Medication Coordination Form [BI] Preadmission Medication List Verification and Order Form [UMass] Half form under header �Home Medication List� other half �Verification� Systematic identification of discrepancies (list vs orders), w/ reconcile = resolving those discrepancies LEADERSHIP voice: see Mission Statements Provide very clear directions on your goals for your organization for ensuring that all information on patients� medications is available in one highly visible place in the patient chart and new medication orders are always checked against that list

7. 7 Our Engagement with Medication Reconciliation Began early �03 Joined IHI IMPACT Mass Coalition convened Collaborative

8. 8 Process Designed pilot form Designed pilot process Multiple tests of change and revisions Gradually increased scope Broad education Meetings Internal Publications Measurement

9. 9 Process: Wrote policy Endorsement by Clinical Performance Improvement committee and Medical Staff Executive committee Revised related documentation Admission orders Nursing Admission database Reviewed Medication reconciliation form Completed Medication reconciliation form Discharge instruction module Continued Measurement Continued revision Shared

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17. 17 Percent ADE(s) Pilot and System

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19. 19 Patient Discharge Instructions

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24. 24 Shared our form and our experience: MA Coalition meetings IHI 100K Lives calls Visited local hospitals Spoken directly to VHA members (in Northeast, Connecticut, Pennsylvania, Central, Central Atlantic, Pacific, Michigan, Southwest regions)

25. We (at UMass Memorial and MA Coalition) have led the country on this important means of improving patient safety

26. 26 This project: Crossed the whole organization Required the knowledge and focus of thousands of individuals Required repeated process redesign at multiple levels Has helped to start changing culture around patient safety

27. 27 In conclusion, In this age of public reporting� We all have �green dots� and �red dots�� At UMass Memorial, we are always striving to deliver safe, high quality care and to be leaders where we can Especially at this time, UMass Memorial genuinely appreciates this recognition as we try to continually improve health care for the people of Central MA and the Commonwealth