Reconciling Medications

1. Reconciling Medications Safe Practice Recommendations and Implementation Strategies

2. 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

3. “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.

4. 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

5. 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]

6. Medication errors based on chart review 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]

7. 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)

8. 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] 

9. 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]

10. The Reconciling Process

11. A process to obtain the best home medication list possible through a defined resource list and active review of the patient’s medical history. Patient Pharmacy Family Patient’s Med List PCP VNA Utilize strategic interviewing practices. Ask open ended questions to obtain info on OTC meds & herbals. THE PROPOSED SOLUTION

12. 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)

13. 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!

14. Getting started • Initiate leadership dialog – resource commitment, regular reporting channels • Form a multidisciplinary team • Risk assessment/baseline measurement • Aim statement, timeline • Pick pilot unit • Begin testing

15. 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.

16. 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

17. 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

18. 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

19. 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...

20. 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

21. 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

22. Implementation Strategies

23. 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)

24. 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

25. 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

26. 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!!

27. 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

28. 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

29. 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)

30. Pilot unit • Mini-team including nurse managers, front-line nurses, MD champion • Project introduction, staff education • Baseline measurement for the unit • Pick reconciling form to test (steal shamelessly...) • Begin testing

31. 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

34. 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

35. 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

37. 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

38. Medication ChecklistHere’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

39. 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

40. Measurement

41. 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

42. # Medications Unreconciled(per 100 Admissions) Luther Midelfort Implementation Impact

43. 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?

44. 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]

45. Is Do discrepa Are Admitting Elements Medication List ncy Meds Data of List Admitting Medication Frequency Frequency No. Admitting Medications Documented on - intention Comments Dose (1) Route (3) Dose (6) Route (8) Addressed By (2) Source Match? Orders (7) 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 Total (5) N or ? Data Source: On: Total (2) Blanks Total (9) N or ? P = patient V = VNA 100 - ED sheet Total (3) Blanks Total (6) Blanks F = family N = Nursing home 200 - RN admission Number of Meds Total (7) Blanks Rx - RX bottle C = Pharmacy 300 - H & PE Total (8) Blanks H = History 400 - PAT form Total ordered meds M = MD office 500 - None Collecting your data

47. 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”

48. 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?

49. 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

50. Beyond Admission and Longer-term Considerations