Medication Reconciliation

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Medication Reconciliation

• Insert your hospitals name here

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Agenda

• Define the problem
• What is medication reconciliation?
• CheckPoint measure
• Things to consider when developing a process
• Keys to success

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What is the problem?

• Hospitalized patients who experience an adverse
  drug event (ADE) are twice as likely to die as
  those without an ADE
• (JAMA 1997 277301-306)
• The Institute of Medicine has estimated that
  medication errors account for 7,000 deaths
  annually (To Error Is Human building a safer
  health system, 1997, IOM)
• ADEs account for 6.3 of malpractice claims (Arch
  Intern Med. 2002 1622414-2420)

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Where is the problem?

• Chart reviews revealed that 50 of all medication
  errors and 20 of adverse drug events are due to
  poor communication at the interfaces of care
  (Institute for Healthcare Improvement 2005)
• Patient admission to the hospital
• Patient transfer out of specialty units to other
  nursing units
• Patient discharge from the hospital

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Why?

• Interfaces lack a process for comparing the
  patients most current list of medications
  against physician orders for admission, transfer,
  and discharge

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Examples of interface problems

• Physician admission orders read continue home
  meds
• Patients transferring from a critical care
  setting to a nursing unit would still have
  lidocaine drip listed on their medication record
• Patients discharge orders read discharge on
  home meds

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What is Medication Reconciliation?

• A process of identifying the most accurate list
  of medications a patient is taking and using this
  list to provide correct medications for the
  patient anywhere within the health care system

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How Are Medications Reconciled?

1. Verify Collect an accurate medication history
2. Clarify Compare the patients list of current
   medications including name, dosage, frequency,
   and route against the physicians orders. Any
   medication that does not match must be
   reconciled by bringing the discrepancies to the
   attention of the physician
3. Reconcile Document the change or why the
   medication was not ordered to communicate to the
   healthcare team

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When are Medications Reconciled?

• Admission
• The patients home medications are compared to
  the physicians admission medication orders
• Transfer One Unit to Another Unit
• The patients most current medication record is
  compared against the physician's transfer orders
• Discharge
• The patients reconciled list of admission
  medications is compared against the physicians
  discharge orders

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Sample High Level Medication Reconciliation
Process
Patient Profile
HP/Clinic Note/Outpt Pharmacy
Reconciled Admission Med List
Latest MAR
Admission Orders
Reconciled Discharge Med List
Discharge Orders
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Medication Reconciliation is Viewed as a Quality
Measure

• JCAHO 2005 safety goal
• IHI 100K Lives Campaign
• WI Node 100K Lives Web site
• Statewide improvement team (PSW/WHA)
• CheckPoint Error Prevention Measure
• It is the right thing to do, but very challenging
  to implement

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WI Hospital Medication Reconciliation Survey
June 30, 2005
N57 Wisconsin Hospitals
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CheckPoint Scoring

• Each hospital that volunteers to publicly report
  on the medication reconciliation measure will
  have their score posted to the CheckPoint website
  with the other Error Prevention measures
• The medication reconciliation score will consist
  of a composite number ranging from 0-100 points
• The points are cumulative based on the hospitals
  response to 4 components

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4 Components of the Score
Components Response Options Possible Points
1. A written document is developed including all components of the goal Yes or No 10
2. The requirements of the written document are implemented in all relevant patient care areas Yes or No 25
3. A compliance monitoring system is in place with the results periodically reviewed by an oversight committee Yes or No 15
4. Demonstrated Success Rate (DSR) varies by goal Collected Rate 0-50
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Goal 6 DSR Medication Reconciliation

• Number of cases that have a complete
• medication reconciliation form in their
• medical record within 48 hours of admission
• ____________________________________ X 100
• Total number of cases reviewed
  

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What is a complete form?

• All fields required by your hospitals policy are
  complete on the form
• Must include medication name, does, frequency,
  route and reconciliation status
• All medications are reconciled with a
• Medication order OR
• Documentation that the medication was not ordered
  
• All required signature are present
• Must have at least 2 signatures from different
  disciplines

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What Medications are Included?

• All medications on the patients current home
  medication record should be reconciled
• Prescription
• Over-the-counter
• Homeopathic
• Vitamins
• Herbals
• Nutritional supplements
• If your hospital has a policy that excludes OTC,
  homeopathics, vitamins, herbals, or nutritional
  supplements from reconciliation, you may consider
  these medications reconciled

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Reconciliation Definitions

• If a medication is on the patients current home
  record, but no order is written, it is reconciled
  if
• Documentation that it is not being ordered
• Contraindicated for the admitting condition
• If the patient is NPO on admission and no
  medications are ordered, the case is reconciled

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48 Hours

• Use the inpatient admission date and time to
  determine the 48 hour window
• Make sure that the date and time the
  reconciliation was completed is on your
  reconciliation form

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Case Selection

• Minimum number is 75 cases in 6 months
• Inclusion criteria
• All patients admitted for inpatient services
  including admits from the ER and direct admits
• Exclusion criteria
• LOS based on admit date and time of lt48 hours
• Patient unresponsive on admission and you cannot
  obtain a medication history from a competent
  source
• Newborn born during that admission

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CheckPoint Report

• WHA will start reporting the medication
  reconciliation measure March 15, 2006 as part of
  the CheckPoint Error Prevention report
  www.wicheckpoint.org
• The data will be updated every 6 months

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Optional Internal Measures

• Number of reconciled medications
• Number of medication errors after reconciliation
• Number of adverse medication events related to
  non reconciliation
• Number of admissions reconciled

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Things to Consider

• Admission
• Sources of information
• Patient and family (have patient bring meds?)
• Physicians office
• Patients pharmacy
• Past medical record
• Transfer form
• Format?
• What medications are included?
• Who does it?
• Speed and accuracy
• Discrepancies
• What will the process be?
• Who follows up?
• Reconciliation
• Who does it?

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• Transfer
• Compare medication lists before and after a
  transfer or procedure
• Check home meds
• Who does it?

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• Discharge
• Review 3 lists
• Current meds
• Home Meds
• Discharge orders
• Document format
• Who does it?
• Patient Education
• Address hospital formulary changes
• Who gets the discharge medication list?
• Encourage patient to maintain a accurate
  medication list over time

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Team effort, but who does what?

• Physician
• Best knowledge of patient
• Decision maker/write the orders
• Nurse
• Best access to patient and family
• Frequently does the admission history
• Frequently does the discharge education
• Pharmacist
• Best knowledge of drugs and formulary
• Limited patient and family access
• Hosp/community pharmacy interface
• Transfer reconciliation

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• Patient
• Real decision maker
• Variable motivation factors that need to be
  included
• Need tools to keep track of medications
• Administration
• Realize the gravity and challenges of the process
• Prioritize clinical resources
• Culture of patient safety

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Keys to Successful Implementation

• Teamwork!
• Commitment to improve by nurses, pharmacists,
  physicians, and administration
• Baseline and ongoing data collection to track
  progress
• Policies and procedures to govern the process
• Well designed and communicated processes
• Thorough evaluation of existing processes
  including a high level flowchart of the existing
  process to determine where problems exist
• Flowchart new process to assure new problems not
  created and to use as a communication tool

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• Create/adopt forms to document reconciliation at
  admission, transfer and discharge
• May have one or many forms
• Forms may be paper, electronic, or a combination
  of both
• Remember to review computer systems to determine
  if there are links to existing information that
  could be utilize
• Educate staff to assure that everyone understands
  and can use the new process consistently

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Its effective!