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Measuring the value of medication reconciliation – Part 2 Discharge processes at AHS. Tiing Tiing Chih Yang Liu Dr Stephen Lim (Acknowledgement: all senior pharmacists at AHS). History of Med Rec at AHS. AHS started admission MR in 2007 as part of WA SQuIRe projects
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Measuring the value of medication reconciliation – Part 2 Discharge processes at AHS Tiing Tiing Chih Yang Liu Dr Stephen Lim (Acknowledgement: all senior pharmacists at AHS)
History of Med Rec at AHS AHS started admission MR in 2007 as part of WA SQuIRe projects “M+M” project – medication matching AHS = first hospital to introduce KPIs for Adm Med Rec % of unintentional discrepancies = 17% Ave 17 unintentional discrepancies for 100 meds written i.e. for a patient on 10 medications, 1-2 of the medications will be an unintentional discrepancy
WHO’s High 5s project from 2010 • Benefits = new measures • MR1 • 50% • MR2 • < 0.1 • MR3 • Canadian benchmark 0.3 • AHS: • MR4 • Trending down, last result = 10% • Event Analysis
Event Analysis • Event analysis beneficial as a “fact finding” tool • investigate patient safety problems • to identify if there are problems with the SOP • to identify cause and effect • Multidisciplinary approach • Less labour/resource intensive than RCA • Measurable actions & changes to implement to improve patient safety
It’s discharge time! • DC med rec started late 2007 • Pharmacist involvements: • Med list, CMI • Dispensing • Counselling • Community liaison
Discharge Process Discharge decision made DC script Med chart MMP Pharmacist reconciliation DC Meds Med list CMI Counselling DC liaison
Medication reconciliation on discharge • Proactive model • Patient shows to GP/others • Provide medication list to patient • Decision to discharge patient • Add medication list to discharge summary • Medical officer: • Checks MMP for outstanding issues • Reconciles with medication charts • Signs off NIMC • Writes PBS script for items requiring supply • Pharmacist: Reviews and reconciles : • BPMH (MMP) • Current medication charts • New medicines to start on discharge • PBS prescription • Patient’s Own Medicines • Resolves discrepancies • Communicate D/C summary with • medication list to GP Develop medication list
Discharge summaries at AHS Prior to 2009: Medipal Standalone system “11th hour changes” not communicated Discharge summary sheets Handwritten by dr on pre-printed format Nil or only new meds listed ?? GP liaison ?? Patient copy
Discharge summaries at AHS TEDS (The Electronic Discharge System) implemented in 2009 Pharmacists populate ADR & med list “Import” function allows direct copying of meds from most recent completed TEDS On completion, GP will automatically be emailed
TEDS medication discharge list example • Current and comprehensive list of medicines • Dose changes, indications, explanations of change • Comments section: can use to provide monitoring advice • Includes stopped medications • Includes Allergies/ADRs
Discharge summaries audit Big improvements since TEDS implementation in 2009 QUM 5.3,5.8, 5.9
Discharge Discrepancies Omission Wrong dose Wrong drug Commission ADR
One week DC snapshot Total discharges surveyed = 61 DC reconciliation = 39 (64%) • No active Pcist reconciliation = 22 (36%) • Nil MMP • Low risk pts Pts with discrepancies = 20 (51.3%) Average discrepancies per pt = 0.72 • PBS & legality check • Rx to chart matching • Med list not done by Pcist % incorrect meds per pt = 13% (i.e. at least 1 error per 10 meds taken)
Comparison of Adm & DC MR errors Discharge errors Admission errors
Richard’s discharge Admitted for fast AF, CCF secondary to AF, ? Chest infection Meds on admission: Thyroxine 25microg mane Salbutamol-MDI prn New meds: Digoxin 125microg mane (loading 250microg x 2) Frusemide 40mg mane Metoprolol 12.5mg bd Warfarin + enoxaparin tx dose until INR therapeutic Amoxycillin 500mg tds
Richard’s DC script Warfarin & enoxaparin missing!
Lucy’s discharge Admitting diagnosis: NSTEMI Meds on admission: Allopurinol 100mg mane Methyldopa 250mg bd Paracetamol-SR 1330mg tds New meds started on AMU: Aspirin 100mg mane Ticagrelor 180mg loading then 90mg bd Metoprolol 12.5mg bd DC Rx : frusemide & potassium chloride (Dr thought pt was already taking antiplatelets)
Risk factors contributing to DC discrepancies • Multiple med charts • Nil MMP in place • Brand name confusion • Dr not referring to MMP when doing DC script or summary • Dr from different team handling DC
Challenges for DC med rec • Time / FTE • Nil MMP in place • Dr not contactable to verify discrepancies • Late / urgent discharges
Conclusion • AHS measures coincide with High 5s measures • MR6 • MR6a (% pts whose DC summaries contain a med list) • MR6b (% pts whose DC summaries contain a current, accurate and comprehensive list of meds) • MR6c (No. discrepancies per pt) • MR7 • MR7a (% pts who receive a med list) • MR7b (% pts who receive a current, accurate and comprehensive list of meds) • MR7c (No. discrepancies per pt)