Assistant Professor of Medicine. Johns Hopkins University

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The Medication Reconciliation Dilemma

• May 24, 2007
• Eric E. Howell, MD
• Assistant Professor of Medicine
• Johns Hopkins University, School of Medicine
• Johns Hopkins Bayview Medical Center
• Brian Clay, MD
• Assistant Professor of Medicine
• Division of Hospital Medicine
• UC San Diego

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Objectives

• Learn the impact of medication reconciliation (or
  lack thereof) on patients
• Identify the potential weaknesses in current
  medication reconciliation processes
• Demonstrate a knowledge of current options,
  option strengths and option limitations

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Outline for Today

• Setting the stage
• Review the Data
• SHM Survey (Brian Clay)
• JHBMC Med Rec Experience
• Discuss Resources Available
• Conclusions
• Discussion

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Adverse Drug Event (ADE) Case Files

• 80 y.o. man admitted from home to hospital
• Meds changed, including start of ramipril
• On DC summary amaryl listed, not ramipril
• Physician did not reconcile meds on DC

http//www.dhmh.state.md.us/
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ADE Case Files

• Pt discharged
• Later he is found obtunded
• Found to be hypoglycemic and readmitted
• Pt died a few days later from injuries

http//www.dhmh.state.md.us/
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What Happened?

• Swiss Cheese Model of Major Errors

Amaryl transcribed
DC meds not reviewed
Outpt doc unaware of change
Admission
Sentinel Event
Pt/care giver does not review meds
Reason J. Human error models and management.
BMJ. 2000320768-770.
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Background on Adverse Events (AE) and ADEs

• Recall that 20 of pts have AE on DC1,2
• Most AEs are Preventable or Ameliorable (about
  1/3 for each)
• Majority (66-72) of AEs are ADEs

1) Forester, Arch Int Med. 2006166565-71 2)
Forester, Ann Intern Med. 2003138161-167
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ADEs are Common!

• As early as 1995 ADEs thought to be1
• Common- 6.5
• Preventable- up to 42
• Studies continue to support ADEs as 2,3,4
• Common- 11
• Preventable (Ameliorable)- 27 (33)

• 1) Bates, JAMA. 199527429-34.
• 2) Forester, JGIM. 200520317-23
• 3) Forester, CMAJ. 2004170345-9
• 4) Schnipper, Arch Intern Med. 2006166565-71

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How Can ADEs Be Reduced?

• Adverse Drug Events are reduced when medications
  are explained (reviewed)1,2,3

1) Bates, JAMA. 1995 Jul 5274(1)29-34. 2)
Schnipper, Arch Intern Med. 2006 Mar
13166(5)565-71 3) Forester, Arch Int Med.
2006166565-71
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IOM To Err is Human

• 1999- Institute of Medicines (IOM) report
• 98,000 deaths annually in hospitals
• 1.5 Million Potential ADEs (1/day/pt)
• 9000 deaths from adverse drug events
• Most errors are system based, not due to reckless
  individuals

http//www.nap.edu/openbook.php?isbn0309068371
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Background
The IOM report and other data spur action by the
Institute for Healthcare Improvement (IHI)
6 changes that save lives Deployment of Rapid
Response Teamsat the first sign of patient
decline Delivery of Reliable, Evidence-Based
Care for Acute Myocardial Infarctionto prevent
deaths from heart attack Prevention of Adverse
Drug Events (ADEs)by implementing medication
reconciliation Prevention of Central Line
Infectionsby implementing a series of
interdependent, scientifically grounded steps
called the Central Line Bundle Prevention of
Surgical Site Infectionsby reliably delivering
the correct perioperative antibiotics at the
proper time Prevention of Ventilator-Associated
Pneumoniaby implementing a series of
interdependent, scientifically grounded steps
called the Ventilator Bundle
Some is not a number soon is not a time
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Background
The IOM report and other data spur action by the
Institute for Healthcare Improvement (IHI)
Prevention of Adverse Drug Events (ADEs)by
implementing medication reconciliation
Some is not a number soon is not a time
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Institute for Healthcare Improvement (IHI)

• Reconciliation A process of identifying the most
  accurate list of all medications a patient is
  takingincluding name, dosage, frequency, and
  routeand using this list to provide correct
  medications for patients anywhere within the
  health care system
• Requires comparing the patients list of current
  medications against the physicians admission,
  transfer, and/or discharge orders

http//www.ihi.org/NR/rdonlyres/598D427A-4BDA-419D
-91B5-B836D23A6F1D/0/CampaignOverview101105.ppt35
8,9,Prevent Adverse Drug Events by Implementing
Medication Reconciliation
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Background
The IOM report and other data spur action by the
Joint Commission
2005 patient safety Goals Goal 8 Accurately
and completely reconcile medications across the
continuum of care. Goal 8A During 2005, for
full implementation by January 2006, develop a
process for obtaining and documenting a complete
list of the patients current medications upon
the patients admission to the organization and
with the involvement of the patient. This process
includes a comparison of the medications the
organization provides to those on the list. Goal
8B A complete list of the patients medications
is communicated to the next provider of service
when it refers or transfers a patient to another
setting, service, practitioner or level of care
within or outside the organization.
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Joint Commission (JC)

• Medication reconciliation is the process of
  comparing a patient's medication orders to all of
  the medications that the patient has been taking.
  This reconciliation is done to avoid medication
  errors such as omissions, duplications, dosing
  errors, or drug interactions. It should be done
  at every transition of care in which new
  medications are ordered or existing orders are
  rewritten. Transitions in care include changes in
  setting, service, practitioner or level of care.
• This process comprises five steps 
• 1) develop a list of current medications
• 2) develop a list of medications to be prescribed
• 3) compare the medications on the two lists
• 4) make clinical decisions based on the
  comparison
• 5) communicate the new list to appropriate
  caregivers and to the patient.

• http//www.jointcommission.org/PatientSafety/Natio
  nalPatientSafetyGoals/05_hap_npsgs.htm

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Joint Commission (JC) Data

• 2005 Develop Process for Medication
  Reconciliation
• Compliance
• 99.7
• 2006 Full implementation of Med Reconciliation
• Compliance
• 62

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2006 SHM MeetingMedication Reconciliation Survey

• Brian Clay, MD
• Assistant Professor of Medicine
• Division of Hospital Medicine
• UC San Diego

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2006 SHM MeetingMedication Reconciliation Survey

• Survey placed in all attendees meeting materials
  (approximately 800)
• Questions regarding demographics, institutional
  characteristics, process steps, and barriers to
  implementation
• 295 surveys returned

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2006 SHM MeetingMedication Reconciliation Survey

• Majority (90) of institutions represented served
  adult population
• Multiple hospital types represented
• Academic tertiary care center (23)
• Community teaching hospital (29)
• Private community hospital (43)

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2006 SHM MeetingMedication Reconciliation Survey

• Implementation stage varied
• Fully implemented (48)
• Partially implemented (35)
• Still in planning stages (11)
• Hospitalist involvement varied
• Active role in design/implementation (36)
• Peripheral role/consultation (24)
• Not involved (31)

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2006 SHM MeetingMedication Reconciliation Survey

• Format
• Paper (47)
• Computer (11)
• Combined (31)
• Measurements
• Measuring compliance (42)
• Measuring outcomes (22)

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2006 SHM MeetingMedication Reconciliation Survey

• Process Steps
• Physician roles
• Reconciling medications
• Updating discharge medication list
• Communicating med information to next provider
• Nursing or shared (RN/MD) roles
• Obtaining home medication list
• Documenting home medication list
• Providing discharge med information to patient

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2006 SHM MeetingMedication Reconciliation Survey

• Barriers to Implementation
• Patients do not know medications (87)
• Medication list not available (80)
• No access to outside records (63)
• Formulary differences (59)
• Process takes too long (53)
• Hospital systems are cumbersome (52)
• Potential impact
• 58 of those surveyed feel medication
  reconciliation will have a positive impact

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2006 SHM MeetingMedication Reconciliation Survey

• Community teaching hospitals and private
  hospitals more likely to have med recon
  implemented compared to academic centers (57,
  49 vs. 35, p 0.007)
• However, academic centers more likely to use
  computer systems to do med recon (27 vs. 9, 7,
  p 0.005)

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2006 SHM MeetingMedication Reconciliation Survey

• Obtaining and documenting pre-admission
  medications
• Academic centers more a physician
  responsibility
• Community teaching hospitals and private
  hospitals more a nursing responsibility
• Most common response was a shared responsibility

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2006 SHM MeetingMedication Reconciliation Survey

• Reconciling medications with admission orders
• Physician responsibility at all sites
• Striking lack of pharmacist involvement
• Obtaining/documenting meds 5
• Reconciling meds 6
• Discharge instructions 2

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2006 SHM MeetingMedication Reconciliation Survey

• Conclusions
• Shared responsibility model is common
• Multiple barriers to full implementation
• Underutilization of pharmacists
• Hospitalists have played a prominent role in
  design and implementation
• Much more opportunity for hospitalist leadership
  in this area

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Johns Hopkins Bayview

• Medication Reconciliation Dilemma

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JHBMC and the Medication Reconciliation Dilemma

• 2004
• Just starting to address issue
• Faculty staff unaware/uninterested in problem
• JHBMC did a FEMA Improve work flow through paper
  tools

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JHBMC and the Medication Reconciliation Dilemma

• 2004-2005
• Hospital leadership partners with several
  cooperative physicians to champion cause
• Hospital leadership engages physician leadership,
  get buy-in on problem
• Interdisciplinary meetings begin
• New paper process simplifies and streamlines
  med-rec process

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JHBMC and the Medication Reconciliation Dilemma

• Process has
• Admit sheet to list outpt meds
• DC Sheet with
• Place designating meds reconciled
• Check boxes for no change, stop and new
• Check box to designate pt education occurred
• Sheets side-by-side capability

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JHBMC and the Medication Reconciliation Dilemma

• Paper discharge list an instant success
• Admit sheet for meds used intermittently
• Need both components to be successful
• Bottom Line
• Developing process was easy,
• multiple barriers made implementation hard

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Overcoming Barriers PDSA

• Got stakeholders together
• Identified Barriers
• Form not in chart
• Avg doc not engaged
• Pt health literacy
• Took extra doc time
• Popular HP med list used

modified from The Foundation of Improvement by
Thomas W. Nolan et. al
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Overcoming Barriers PDSA

• Developed Solution
• Educated Unit Secs
• QI team showed data met freq
• XXXX
• Improved w/avail forms
• Placed big USE MED REC LIST sticker over HP
  med area!
• SUCCESS!

• Identified Barriers
• Form not in chart ?
• Avg doc not engaged ?
• Pt health literacy ?
• Took extra doc time ?
• Popular HP med list ?

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JHBMC Future Direction Electronic Medication
Reconciliation
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JHBMC Future Directions

• Current electronic format has potential
• Ambulatory list can be selected for in-pt use
• Admission/hospital/discharge meds on one screen
• May condense duplicate lists nursing MD

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JHBMC Future Directions

• Current electronic format drawbacks
• Lists are not side-by-side making
  reconciliation challenging Structure of
  electronic format does not always facilitate
  workflow
• Not sure how admission list will get populated
• Docs still using HP to document meds??

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Resources Available

• http//macoalition.org/
• JCs Dr. Croteau (executive director for pt
  safety initiatives) reports JC gets information
  and support from the macoalition

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www.hospitalmedicine.org
Information in the SHM resource rooms
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• http//macoalition.org/Initiatives/RMToolkit.shtml
  
• Implementation Guide for Safe Practices (A
  Resource Book of Materials)
• Overview
• Safe Practice Recommendations
• Implementation Strategies
• Toolkits

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What do most med recon forms have in common?

• Some indication that the medication was
  reconciled
• A list of potential sources for the list
  (patient, records, etc)
• A way to indicated that specific medications were
  changed from admission
• Separate spaces for med, dose, route, freq, time
  last taken
• Most have started with an existing model and
  modified it for their institutions needs

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www.hospitalmedicine.org

• Information in the SHM resource rooms
• Toolkits
• QI Educational Material

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• SHM Resource Rooms
• Toolkits
• Sample Forms

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• SHM Resource Rooms
• Toolkits
• Sample Forms
• Workbook on implementation

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• SHM Resource Rooms
• Toolkits
• Sample Forms
• Workbook on implementation
• Web Community (ask the expert)

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• SHM Resource Rooms
• Excellent QI Overview
• Very thorough Slide Show

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• SHM Resource Rooms
• Excellent QI Overview
• Very thorough Slide Show
• Extensive workbooks on how to effect change

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A Few words about QI

• Sound QI principles make success much, MUCH more
  likely!
• Consider doing a FEMA

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A Few Words About FEMA
Process Step 1
Process Step 2
Process Step 3
Process Step 4
Failure Mode
Failure Mode
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A Few (more) Words about QI

• Engage Administration
• This is a team effort
• Dont let perfection stand in the way of good
• Measure and change based on the outcomes

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Summary

• Medication Reconciliation has significant
  potential to improve patient safety
• Medication Reconciliation is complex!
• Electronic solutions still in infancy
• Implementation require sound QI methods
• Physician champion
• Well coordinated team effort (including
  physician)
• Rapid cycle change (PDSA)
• Evaluation method

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Summary

• Dont re-invent the wheel, lots of good stuff out
  there already
• Dont let perfection get in the way of good
• I have heard that surveyors raise the bar over
  time!

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Other Resources

• Joint Commission Web link
• http//www.jointcommission.org/
• IHI weblink
• http//www.ihi.org/ihi

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More to Come.

• Medication Reconciliation Conference in the Works
• New Medication Reconciliation Survey due out soon