Title: Medication Reconciliation July 12, 2005
1Medication Reconciliation July 12, 2005
- Glenn Billman, M.D.,
- Medical Safety Officer, Childrens Hospitals and
Clinics of Minnesota
2 3The Issue
- Medicine used to be simple, ineffective and
relatively safe. - Now it is complex, effective, and potentially
dangerous. - Sir Cyril Chantler
4Optimal care for patients requires totally
effective communication regarding medication use
among numerous people of varying disciplines in
multiple locations over time including the
families themselves.
Our Challenge
5Our Aim Implement Medication Reconciliation
- Implement a Process that will ensure that
patients and their caregivers possess the most
accurate, and up to date medication list possible
6Definition 1
- Medication Reconciliation
- Reconciliation is the process of comparing
what medication the patient is taking at the time
of admission or entry to a new setting or level
of care, with what the organization is providing
(admission or new medication orders) to avoid
errors such as conflicts or unintentional
omissions.
7Definition 2
- Medication Reconciliation
- All medications appropriately and consciously
continued, discontinued, or modified at all
transitions of care.
8Why Should We Do This?
- 140 discrepancies in 81 patients (1.7/pt)
- 65 omissions
- 59 wrong dose/frequency
- 16 wrong drug
- 32.9 discrepancies rates as potentially moderate
harm 5.7 severe harm - Arch Intern Med, Feb 2005
9Why Should We Do This?
- Ineffective medication reconciliation upon
hospital admission - up to 50 of medication errors
- up to 20 of future ADEs
101) Increased Percent of Patients That Completed
Medication Coordination
Why Should We Do This?Because Its Doable !
11 Why Should We Do This?Because It Works !
12 Why Should We Do This?Because It Works !
4) An Increase In The Number Of Days Between ED
Visits Related To ADEs
13 Why Should We Do This?Efficiency !
14 Why Should We Do This?Its Cost Effective !
High
Investing In Safety
Do First
CPOE
Dedicated Unit Pharmacist
Automated ADE Monitoring
Bar Code Reconciliation
Diagnosis Specific Order Sets
Pharmacist Patient Interview
Medication Reconciliation
Impact on ADE
Pharmacy Managed Protocols
Pharmacist Order Entry
Zero Tolerance Ordering Standards
Preprinted Order Forms
Intervention Database
Pocket Formulary
Medication Competency Testing
Low
Dont Bother
Low
High
Cost To Implement
152005 NPSG Goal 8 Medication Reconciliation
- Accurately and completely reconciles medications
across the continuum of care - 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.
162005 NPSG Goal 8 Medication Reconciliation
- Accurately and completely reconciles medications
across the continuum of care - 8b A complete list of the patients medications
is communicated to the next provider of service
when it refers or transfers the patient to
another setting, service, practitioner, or level
of care within and outside the organization.
17Medication Reconciliation Is A Tool To Help
Bridge Gaps That Occur At Transitions and
Transfers of Care
- Process steps
- The medication history is completed
- The physician reviews and acts upon each
medication - The medication orders are written
- A 2nd person reviews medication history
- That 2nd person resolves discrepancies
18Reconciliation Virtually all hospitals who have
successfully addressed admission reconciliation
have created a special form as part of the
solution. These forms pretty much look alike.
19(No Transcript)
20(No Transcript)
21What is included?
- Current home meds / OTC / Herbals, including
dose, route frequency - Time of last dose
- Source of the information
- The medications ordered at admission
- An Assessment of patient compliance
22There is no perfect medication list. Quit
thinking there is. Do not be paralyzed by trying
to perfect the list.
Steve Meisel, PharmD
23Who uses the form?
- The nursing staff or pharmacist use the form to
collect information at admission. - The physician uses the form as a reference and/or
order when writing initial orders for
medications. In some cases the form itself
serves as the order form, thereby obviating the
need to rewrite orders. - Both physicians and nurses use the form
throughout the patients stay as a reference.
24Source of the information
- The patient/family
- The patients pharmacy
- Previous medical records
- The patients medication bottles
- The physicians office
25A completed Medication List is only the Half Way
Point.Reconciliation is real work!
26A Big Problem Is Often Just Getting An Accurate
Medication List
- Patient brings in incorrect list.
- Patient does not take what is marked on bottle.
- Patient does not know what is on and family,
pharmacy not available. - Wrong name of med on ED sheet.
- Med bottles dont jive with what the patient
says. - Patient is unable to tell you. No family
available. MD on call does not know either. - Cant call the pharmacy after hours.
27(No Transcript)
28The Intent and Value of Medication Reconciliation
Is In Having An Accurate Medication List.
29Transfer Reconciliation
- Critical especially upon transfer in and out of
intensive care and other specialty units - As much as 60 of the care plan after transfer
may be different than what the physician expects - Can utilize internal computer systems to
facilitate, but there must be an active decision
to continue, discontinue, or modify each line
item
30Transfer Reconciliation
- Automatic stops of certain critical-care-specific
drugs (e.g. dopamine) are acceptable provided
those stop orders appear in the medical record. - ? Benzodiazepines
- Requirement to re-write all orders upon transfer
introduces new opportunities for error
31(No Transcript)
32Discharge Reconciliation
- The patients reconciled list of admission
medications is compared against the physicians
discharge orders along with the last days MAR. - The lists can either come from the computer
system or be integrated with the original
admissions list.
33(No Transcript)
34(No Transcript)
35To Be Successful
- Put the patient first (this isn't someone else's
job) - You need to have some good change methodology to
be able to develop a good product - You need to use this to replace something else
i.e. medication history in nursing data base
36To Be Successful
- Understand Your Processes
- Process flow
- Data flow
- Roles and responsibilities
- Procedures
- Build Incrementally Start Small
- Leadership Support is Critical
- Project champions
37To Be Successful
- You must have organization alignment (physician,
nursing, pharmacy, administration) - Process Owner and Sub-Process Owners
- A champion for the entire process
- Have a good education program when rolling it out
- Appropriately Resource the project
- You Need To Start!
38Questions / Comments/ Discussion
39Contact Information
- Contact Glenn Billman
- glenn.billman_at_childrenshc.org