Moving Forward with Medication Reconciliation: Tips on Developing

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Moving Forward with Medication Reconciliation
Tips on Developing Implementinga System

• Steve Riddle, BS Pharm, BCPS
• Quality Improvement and Medication Utilization
  Pharmacist
• Harborview Medical Center

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National Efforts for Medication Reconciliation
JCAHO NPSG 8 Accurately and completely
reconcile medications across the continuum of
care.
100K Lives Campaign Prevent Adverse Drug Events
Via Medication Reconciliation
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Medication errors are one of the leading causes
of injury to hospitalized patients.

• Chart reviews reveal that over 50 of all
  hospital medication errors occur at the
  interfaces of care.

Rozich JD, Resar RK. Medication Safety One
organizations approach to the challenge. JCOM
20018(10)27-34.
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First Things First

• Determine processes
• Think about the steps in the process of care.
• Ask the key questions for each step
• Who?
• What?
• Where?
• When?
• How?

• Define roles
• Develop communication methods
• Electronic or paper forms
• Tools
• Design quality measures

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The Med Recon Process
Hospitalization
Transfer
Discharge
Admit
ER
Floor
SNF, ECF, NH
Direct Floor
Unit
Direct ICU
OP Rehab
Special Care
OR
Community Care
Pharmacies
Family
Home Care
MD Offices
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Creating..
a Complete Preadmission Medication List
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Who collects the med list?

• What is your current process of care?
• Who has sufficient expertise? What is their
  availability?
• Pharmacist, Pharmacy Intern or Tech
• Whoever sees patient first Admitting MD or RN
• Admission and/or Preadmit Nurse
• Triage Nurse in ED
• Process will likely require multidisciplinary
  involvement

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How much time does it take to perform
reconciliation?

• Time to perform?
• Average 11 minutes
• Bimodal

• Time saved?
• Reduction of pharmacists time at discharge by 40
  minutes
• Amount of work and rework that is minimized or
  reduced simply by making the process more
  efficient

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When do you collect the med list?

• On admission, or as soon as possible thereafter
• Prior to next prescribed dose
• Max 24 hours Target 6-8 hours 4hrs for
  high risk meds/circumstances
• Dont get into paralysis or make it too
  complicated
• Whenever and however, it should take place early
  enough to improve the safety of medication
  management processes (and hence patient safety).

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Howdo you create the med list?

• Patient can complete a medication questionnaire.
• Include interview questions on back of admit
  forms to assist staff
• Patient brings bag of medications in for ID
• Designated staff call MDs and pharmacies who
  service patient
• Consider MD office file sharing with hospital

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More about the med list

• Target is reasonable completeness accuracy
• Doesnt have to be perfect list
• Dont accept lists without questioning involve
  the patient!
• Understand that the med list is a dynamic
  document
• Only documentation needed is the list
• Make list highly visible, easily available
• Specific location in chart or EMR
• Distinct color of paper

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Reconciling
?
Preadmit Med List
New Orders
Transfer Orders
Discharge Orders
Reconciliation is defined as all medications
appropriately and consciously continued,
discontinued, or modified.
It is up to each organization to determine how
this process takes place.
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Whos involved in reconciliation? Assign
Responsibility!

• Often RN has primary responsibility to ensure
  completion, contacting of MD and passing off
  unreconciled meds at shift change
• Pharmacist is a logical choice but can be any
  clinician/staff with the background and
  experience necessary
• MD Ultimately responsible

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When.. does reconcile occur?

• As soon as a reasonably complete list is
  obtained
• Within a specified timeframe, as determined by
  the organization
• May be delayed in some situations to assure
  provision of appropriate acute care

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Howdoes reconciliation occur?

• Standardized reconciliation form
• Many forms readily available see
• http//www.100kliveswashington.org/changes-ade.htm
  
• Dont use anothers form without reviewing and
  modifying to meet your needs!
• Try to replace another form or task
• Ex Use the reconciliation for orders
• Educate MDs on forms!

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There simply is no perfect medication list. Quit
thinking there is. Do not be paralyzed by trying
to perfect the list.
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Communicating
a complete list of the patient's medications to
the next provider of service
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Who is involved in the Continuum of Care?
Physicians
Hospitals
Family Caregivers
Urgent Care Centers
Patient
Pharmacies
Medical Offices Clinics
Paramedics
Dentists
Extended Care Facilities (NH, Rehab, etc)
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Data has shown that there are unintentional
discrepancies between the medications prescribed
on admission and those taken at home in 25-40 of
hospitalized patients.
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Medication Safety Getting the Patient Involved
Personal Medication Record (PMR) Completed by
patient w/ or w/o healthcare provider assistance
Patient instructed and encouraged to carry
PMR and keep updated

• Patient and staff
• update PMR upon
• Hospital Discharge
• Any medication intervention

Patient takes PMR to all healthcare visits

• Medical Staff use PMR to complete
• medication assessment upon
• Admission to Hospital
• MD Office Visit
• Other Health Appt

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Key Connections in the Community Plan to work
with.

• Physician office managers
• Community pharmacies
• Outpatient surgery centers
• Nursing homes/Assisted Living
• Retirement Centers

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Physician Office Participation

• Supply physician offices with standardized
  medication reconciliation and patient medication
  record (PMR) forms
• Replace their current forms
• Require patients to show PMRs (similar to ID and
  insurance cards) at each visit.

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Tips for Getting Started
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Implementation

• Form an implementation team
• Nursing
• Pharmacy
• Risk Manager
• QI or Patient Safety
• Administration
• Select a champion

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Select A Spokesperson

• KEY LEADER
• Identify a physician (or clinical leader) who
• Understands the process
• Supports a culture of safety
• Is passionate about the process
• PAVING THE WAY
• Supports best practice
• Promotes project through data sharing
• Educates and encourages provider participation

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Key Connections in the Hospital Plan to work
with.

• Hospital Forms Committee
• Surgery
• Employee Health
• Radiology
• Pre-Op Assessment
• ED

• Pharmacy
• Resp Therapy
• Patient procedure schedulers
• Nurse managers
• Discharge planners

and more!
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Think Big!...Start Small

• Focus on admission processes
• Pick a pilot population
• Measure the process (pre/post)
• Develop a plan for spread

Use a validated improvement process!
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Measuring Outcomes and Improvement
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Med Recon Outcomes Measures

• Process indicators
• of unreconciled meds ( success)
• Set goals (determine baseline)
• Outcome measures
• Decrease in ADEs
• Improve systems to eliminate errors

Admission Reconciliation
Discharge Reconciliation
Consider sampling to check progress use 20-30
charts
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Discrepancies per patient
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Discrepancies per order
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Outcomes Clinical/Safety

• Reconciliation decreased the rate of
• medication errors by 70
• adverse drug events by 15
• Obtaining medication histories for the scheduled
  surgical population reduced potential adverse
  drug events by 80 within three months of
  implementation

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SummaryFocus on Key Points in Med Recon Process

• Creating List on Admit
• Reconciling on Admit
• Maintaining list during stay
• Communicating at Discharge

Design a system that assures each of the steps
above happen every time without fail!
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Med ReconCloser to Home.

• PQIP3
• Pharmacist
• Quality
• Improvement
• Project

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Resources, Forms and Tools

• WSPA CD-rom contains slides and some tools
• Washington Network Medication Reconciliation
  contacts
• Steve Riddle (sriddle_at_u.washinton.edu)
• Jeff Rochon (jrochon_at_wsparx.org)
• Nancy West (nancyw_at_qualishealth.org)
• Sharon Eloranta (sharone_at_qualishealth.org)
• Carol Wagner (CarolW_at_wsha.org)
• Websites
• IHI
• www.ihi.org/IHI/Topics/PatientSafety/MedicationSys
  tems/
• JCAHO/Joint Comission for Internatl. Patient
  Safety
• www.jcipatientsafety.org/
• UHC
• http//public.uhc.edu/uhcmail/ihi/mr.htm
• Massachusetts Coalition for the Prevention of Med
  Errors
• www.macoalition.org/initiatives.shtml

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Goals of PQIP3 Phase 1

• Develop consistent, standardized processes of
  care regarding patient medication use.
• Develop a framework for sharing information
  between pharmacies and other health care
  providers.

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Methods of PQIP3

• Assist in development of standardized tools and
  forms for med recon
• Develop a process for providing patients with
  their current medication information

• Develop local and regional partnerships between
• Pharmacies
• Pharmacies and medical offices
• Emphasis on connecting inpatient practice sites
  with community and institutional practices

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Who is PQIP?

• Sponsors WSPA and Qualis Health
• Deaconess
• Whidbey General
• Franciscan Health
• Sacred Heart
• UWMC
• Northwest Hospital

• Yakima Valley Memorial
• Walgreens
• Columbia Valley Community Health
• Harborview Med Center
• SW Med Center

and more!
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Medication Reconciliation Process
Develop Medication List Collect, Verify
Clarify Meds
Admit Reconciliation
How? 1. Compare list to new med orders. Note
any -Duplications -Omissions -Changes
-Formulary substitutions -Holds or DCs
Who? RN Pharmacist MD/provider
How? Use sources of info such as -patient -family
-pt. med list -PCP -Transfer form -Pharmacies
Who? RN Pharmacist Pharmacy Tech. Surgical
RN Preadmit staff MD/Provider
Physician
2. Finalize List (signature)
PHASES
Maintain Update Medication List
ADMISSION
Maintain Update List (Community)
TRANSFER
How? Review current med list on each change in
care for -Duplications-Omissions -Changes
-Formulary substitutions -Holds or DCs
Who? RN Pharmacist MD/provider Unit Secretary
How? Provider patient medication list with
directions to take to all appointments and
providers of care.
DISCHARGE
POST-DISCHARGE
Communicate
Discharge Reconciliation
How? Deliver the discharge med recon list to the
patient the next providers of care,
including -Physicians -Outpt treatment
providers -Pharmacies -Caregivers Family
Who? RN Pharmacist/ Pharmacy MD/provide Dsch
Planner Social Worker
How? 1. Compare home med list to meds at time of
discharge Note any duplications, omissions,
changes, formulary substitutions, holds or DCs.
Explain changes and assure continuity.
Who? RN Pharmacist MD/provider
2. Finalize List (signature)
Physician
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Med Recon Process Mapping Questions

• For each phase of this patients hospitalization
  please complete the Med Recon form and ask
• WHO is responsible for collecting this
  information?
• Clarifying and verifying this information?
• Reconciling?
• WHAT Are the sources of information needed to
  complete this?
• What information do you need (allergies, chronic
  conditions, other medications)
• WHERE Is this information kept? Who has access?
• WHEN Is the time frame for this phase?
• HOW Is this information recorded and maintained
  during the admission? on the permanent record?

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Med Recon FAQs
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What is meant by "patient involvement?"

• The organization asks the patient about their
  current medications.
• When the patient is unable to provide this
  information, the organization should have a
  process to acquire this information.

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What is the timeframe for completing med
reconciliation?

• Can DELAY reconciliation in urgent situations
• PERFORM
• when the patient is stabilized and the
  opportunity to acquire information about the
  patient's most current medications is available.

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Will the Joint Commission be expecting to see a
specific form or document in the chart?
No!

• The patients current medication list must be
  documented and part of the patient's record.
• Organization should specifically define the
  expected time frame for that to occur.
• A surveyor may ask the organization about their
  medication processes.

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Is documentation of the reconciliation required
and what type of documentation is required?

• The only required documentation is the list
  itself.
• It is up to each individual organization to
  decide how to demonstrate that the reconciliation
  process is taking place.
• "How do I know the comparison process is
  consistently happening in my organization?
• Answer this and you are prepared for JCAHO

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What measurement requirements are associated with
the NPSGs?

• In general, there are no prescribed requirements
  for measurement/data collection relating to the
  NPSGs.
• The requirement is only to be in compliance with
  the goals and their specific requirements.
• Any organization who does not have a process in
  place and 100 implemented on surveys after
  January 1, 2006 will be scored as non-compliant

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What is the timeline for implementation?

• 2005 ? Design, planning and initial
  implementation
• 2006 ? Full implementation
• Must design an audit method to assure compliance.