Reconciling Medications

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Reconciling Medications

• Safe Practice Recommendations
• and
• Implementation Strategies

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Medication Safety Facts

• Medication errors account for more than 7,000
  deaths annually
• Approx. two out of every 100 patients admitted to
  the hospital will experience a preventable
  adverse drug event
• Over 12 of patients with an ADE within 2 weeks
  of discharge

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Reconciling Medications

• A systematic process to reduce the number of
  medication events occurring at interfaces of care
• Creating the most complete and accurate list
  possible of all home medications for each patient
  and then comparing that list against the
  physicians admission, transfer, and/or discharge
  orders. Discrepancies are brought to the
  attention of the physician and, if appropriate,
  changes are made to the orders. Any resulting
  changes in orders are documented.

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RESEARCH

• Errors that are the result of an omission are
  often not reported as errors, although they may
  result in an adverse outcome for the patient.
• They may manifest themselves as
• Unexplained elevated lab values
• Due to inaccurate dosing
• Missed medications
• Readmissions due to
• Doubling up of medications
• Missed medications at discharge
• Contraindication to unknown OTC or herbal meds

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Problem identified

• Info on patients home meds not being
  systematically collected in multiple places in
  the chart, often incomplete
• Poor or inadequate processes to compare list of
  pre-admit medications to orders
• Research study demonstrated that over half of all
  hospital medication errors occurred at the
  interfaces of care
• Rozich, Resar 2001

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Medication errors based on chart review
Source Luther Midelfort Hospital -- Mayo Health
System chart review
We found that the list of medications that
details current drug use was either nonexistent
or wrong more than 85 of the time
Rozich/Resar 2004, p.8
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Examples of errors

• No orders for needed home meds
• Missed or duplicate doses from inadequate records
  of frequency/last administration time
• Surgeon inadequately addressing meds for chronic
  conditions
• Failure to restart meds at transfers
• Doubling up (brand/generic combinations,
  formulary substitutions)

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Unintended medication discrepancies at admission

• Studies show over half of patients have
  discrepancies between home medications and
  medications ordered at admission, many with
  potentially serious results
• 54 of patients 39 potentially serious
  Cornish Arch Intern Med 2005
• More than half 59 could have caused harm if
  the error continued after discharge Gleason Am
  Jnrl H-Sys Pharm 2004 

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More evidence on impactJohns Hopkins Surgical
ICU

• Dramatic reduction in medication errors resulted
  from reconciling
• Baseline 31 of 33 (94) of patients with MD
  changing orders when discrepancies brought to
  their attention
• By week 24, nearly all medication errors in
  discharge orders eliminated
• As a result of routine reconciling, average of 10
  orders per week are changed

Pronovost, 2003
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• The
• Reconciling Process

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THE PROPOSED SOLUTION

• A process to obtain the best home medication list
  possible through a defined resource list and
  active review of the patients medical history.

• Patient
• Pharmacy
• Family
• Patients Med List
• PCP
• VNA
• Utilize strategic interviewing practices.
• Ask open ended questions to obtain info on OTC
  meds herbals.

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Reconciling process admission

• Getting the home med list (at intake)
• Interviewing strategies to promote accuracy
• Input from patient/family/alternative sources
• Outreach patients arrive with accurate list
• Writing medication orders
• Goal work from accurate home med list
• Identify and reconcile discrepancies
• ?Order (no omissions, no duplicates, right
  med/dose/
• frequency/route)
• ? Communicate (to next level of service)

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BECOMING A STATEWIDE INITIATIVE

• The Massachusetts Hospital Association in
  collaboration with the Massachusetts Coalition
  for the Prevention of Medical Errors reviewed
  evidence of medication reconciliation to
  determine
• Importance How much can we impact safety?
• Feasibility Is this a doable process?
• Measurability Can we monitor our progress?
• Statewide advisory board voted to accept this
  initiative!

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Getting started

1. Initiate leadership dialog resource commitment,
   regular reporting channels
2. Form a multidisciplinary team
3. Risk assessment/baseline measurement
4. Aim statement, timeline
5. Pick pilot unit
6. Begin testing

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Define Aim / Obtain Baseline Measure

• Aim
• To reduce the rate of unreconciled medications at
  admission by 50 within 9 months.
• Measure
• Baseline measurement of 20 charts, subsequent
  measures performed on 30 charts per month for the
  first 3 months after implementation of form.
  Evaluate the frequency of the measure after the
  first three months.

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1. Getting the home med list

• What have we learned?
• Adopt standardized form
• Share responsibilities, ordering prescriber
  accountable... crew resource management
  principles
• Validate with the patient
• Dont let perfection be the enemy of the good

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1. Getting the home med list

• Who? Shared responsibilities, always someone
  with sufficient expertise
• RN who completes the initial admission history
• Pharmacist/pharmacist technician
• Michels/Meisel 2003 Gleason/Groszek 2004
• MD if reconciling form not complete when ready to
  write orders

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1. Getting the home med list

• What?
• Current home meds
• Include OTCs herbals
• Dose, frequency, time of last dose
• Optional route, source of information,
  compliance, purpose
• Many building collection of patient allergies
  into the process

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2. Using home list when writing orders

• What have we learned?
• Make highly visible
• Provide access at point when orders are written
• Have reconciling form serve as an order sheet.
  benefits and issues...

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Project phasing

• Pilot testing identify changes, measure to know
  if the changes are an improvement
• Implementation take a successful change and
  build it into the way the entire pilot
  population/pilot unit does their work
• Spread replicating a change/package of changes
  beyond the pilot unit into other parts of the
  organization
• Maintain the gains

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3. Identifying, reconciling discrepancies

• Who?
• Generally nursing assigned responsibility of
  comparing the home list to the admit orders,
  identifying variances, and reconciling all
  differences
• Pharmacist involvement can be productive,
  especially for organizations with decentralized
  pharmacy
• Need strategy for handing off any unresolved
  differences at shift change

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• Implementation Strategies

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Resource requirements

• During testing/implementation phase
• Make explicit allocation for those with patient
  care responsibilities
• Managers need to pay attention to workloads
  dont assign tests to someone overloaded
• Ongoing
• Build into regular workflows
• Collecting home history IS time consuming some
  have added resources to support that (e.g.
  pharmacy techs)

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Post Team Members- Encourage Input

• Contact any of the following Medication
  Reconciliation PI Team members to answer any of
  your questions
• Melissa Bartick, MD - X9335
• Jennifer Fexis, Quality - X9406
• Darlene Civita, RN ICU- X9350
• Vicky Casto, RN ACU - X9335
• Deb Wilkinson, RPh - X9363

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Tips for engaging MDs

• Personal appeals from VP of Medical Affairs
  and/or Chiefs of services
• Trial with key leaders on each unit get their
  input via hallway consultations not meetings
• Identified Ambassadors from engaged
  hospitalists they then educated others
• Developed into CME risk program
• MDs from key committees (PT, Medical Records)
• Chief Medical Resident on the team, with
  responsibility to report back to other residents

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Baseline risk assessment

• Chart review
• Institution-wide
• Mini-FMEA, flow charting existing processes
• Do in conjunction with initial tests of change
• Just-enough measurement/analysis
• Dont get bogged down here!!

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Mission

• Every patient will receive all medications they
  have been taking at home unless they are
  held/discontinued by their caregiver(s) and all
  new medications as ordered -- correct drug, dose,
  route, and schedule.

• The goal of reconciling is to design a process
  that will ensure the most accurate patient home
  medication list available, thus reducing the
  number of medication events upon admission,
  transfer and discharge

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Choosing where to start

• Use risk assessment process
• Willing volunteers
• At admission logical place
• Pros cons Med vs Surg units
• Some success starting _at_ transfer ICU, CCU,
  telemetry units
• Probably not ED

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Start small, focus on one unit

• Small tests... 1 unit, 1 RN, 1 MD, 1 patient
• Add more staff, more shifts, refining process and
  form
• Keep testing on that one unit until you refine
  the process and can show that it works (test on
  all shifts, patients coming in as direct admits,
  from ED, transfers, etc)

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Pilot unit

1. Mini-team including nurse managers, front-line
   nurses, MD champion
2. Project introduction, staff education
3. Baseline measurement for the unit
4. Pick reconciling form to test (steal
   shamelessly...)
5. Begin testing

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Piloting a reconciling form

• Testing avoid forms committees...
• Simple vs complex
• Reconciling status
• Orders continue, change, d/c, hold
• Optional data sources, purpose/indication,
  date/time of last dose, amt of non-compliance
• Columns for reconciling at discharge?
• Signature lines

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Fundamental ingredients...

• Get support of your CEO cannot do it without
  leadership at the top
• Use data (to motivate, to know if changes are
  leading to improvement)
• Strong representation from leadership of the 3
  key stakeholder groups MD, RN, pharmacy
• Start small

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Culture...

• Core issues of teamwork and communi-cation...
  organizational culture matters
• Changing the way people do work every time you
  try to change behavior, its only natural to be
  met with resistance
• Recognize that this is HARD
• Difficult task but not impossible
• Unit briefings/pharmacy rounding

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Challenges and barriers

• Time and resources
• How can we find the time to do this?
• Roles and responsibilities
• Its not my job
• Im not going to sign that form
• Data collection
• Need data... but dont let data collection delay
  testing, overwhelm

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Medication ChecklistHeres how patients can help
the medication reconciliation process
? Keep an updated list of all medications
including herbals, vitamins and OTC. Including
dosage and reason for taking the drug ? Include
all allergies and describe reaction ? Include
immunization history ? Take the list to all
doctor visits and medical testing labs, as well
as pre-assessment visit for admission or surgery
and all hospital visits including ER ? When you
leave the hospital, be sure to update your list
with new medications and ask if any medications
are duplicated ? Keep this list in with you at
all times
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Staff education

• Include staff ed rep on your team
• Create simple template clarifying the steps to be
  taken to complete reconciling
• Lead off with examples of errors from your own
  hospital
• Use front line staff from pilot unit to educate
  staff on subsequent units
• Build into orientation, ongoing staff ed
• Publish your data and progress in your
  organizations newsletter

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• Measurement

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Just-enough measurement

• Core measure
• Percent Medications Unreconciled
• Orders changed, great catches, stories
• Measures linked to each test, for example
• patients with reconciling form in chart
• RN/MD assessments of process
• Spread patients on units w/ reconciling
• Context of institution-wide ADE reduction

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Medications Unreconciled(per 100 Admissions)
Luther Midelfort Implementation Impact
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Baseline data collection

• GOAL Identify current safety risks
• How complete is info on patients pre-admission
  meds? How hard to find? In multiple places?
• How often are home meds omitted from admit
  orders? not re-started after transfer, at
  discharge? duplicate therapies at discharge?

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Example Why is it Needed?

• In a chart review of our admit orders, we found
  an average of over 4 discrepancies per patient,
  with omitted medications the most significant
  error.
• Source University of Kansas Hospital
• Terry Rusconi 2003

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Collecting your data
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Baseline practical process

• Multidisiplinary team of reviewers
• RN, MD, Pharm... QI rep to combine
• Minimum 20 charts
• Institution-wide, random or stratify to ensure
  all units represented
• Minimum stay of 3 days
• Can be fruitful to include re-admits
• Find home meds and list on form
• Compare to admit orders
• Identify unreconciled medications

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Ongoing data collection

• Need frequent measurement on every unit where you
  are testing monthly charts to display on unit
• Process easy for patients where the reconciling
  form has been completed follow process used in
  baseline data collection when no reconciling form
• DONT CHEAT
• Dont skip patients without a reconciling form
• Dont just look for home med list the question
  is, have the home meds been RECONCILED?

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TIPS on collecting your data...

• Share responsibilities, engaging implementers
• Limit sample 20 charts
• Real-time review patients on unit for 24 hours
• Establish rules for consistent treatment where
  judgment required (omission or obvious hold or
  d/c based on patient condition but strategy
  should encourage increased documentation by
  prescriber)
• Set time limit (when unable to find home meds,
  use list from admit orders and indicate that all
  are unreconciled)
• Share Great Catches examples of orders
  changed, errors prevented

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• Beyond Admission
• and
• Longer-term Considerations

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Reconciling at Transfer

• Compare most recent med record (MAR) and home med
  list against transfer orders. Issues
• Access to reconciling form with home med history
  at point when new orders written
• Need to modify reconciling form to add columns
  for reconciling at transfer?
• Identifying responsibilities of both the
  transferring and the receiving unit
• Embedding into workflow Who writes transfer
  orders? When? Where?

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Reconciling at Discharge

• Patients especially vulnerable immediately
  post-discharge
• Over 12 of patients with an ADE within 2 weeks
  of discharge Forster 2003
• Address potential for doubling up based on
  formulary substitutions or other brand/generic
  name confusions
• Prohibit resume home meds!!!
• Verification of dosing instructions

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Outpatient Settings

• Applies to settings where the outpatient
• may receive medication
• where patient's response to treatment might be
  affected by medications they are on
• where a practitioner who can review and modify
  the patient's medications is a part of the
  outpatient service
• Examples include outpatient oncology services, GI
  laboratories, emergency department, urgent care
  clinics, certain imaging procedures.

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Using as an order sheet

• Proceed with caution, but efficiency gains
• Most MDs find it very helpful makes their life
  easier, decreases duplication
• Timing 6-10 months into the process?
• Modifications to reconciling form
• Add MD signature line(s)
• Columns to indicate continue or discontinue
• Amendment form

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Automation

• If you cant do it on paper,
• dont even try it in vapor
• First must have a stable process adequate
  testing of the form, implementation on multiple
  units
• Careful design required who enters info, who can
  update/change, may introduce new errors

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Automation John Hopkins ICU project

• Revised form to strike balance between burden of
  data collection and comprehensiveness of
  medication information
• Automated process after 48 weeks, paper forms
  converted to electronic form
• Intervention now takes 20 minutes on admission
  and 20 minutes at discharge with minimal marginal
  costs

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Better access to medication histories

• Promote patients maintaining medication cards
• Provide in ED, at discharge
• Disease specific support groups
• Pharmacy medication review
• Senior center (file of life)
• Partner with PCPs, nursing homes, VNA, health
  plans

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Better access to medication histories

• Interview strategies including increased use of
  open ended questions
• Link medications to conditions, prescribing
  physicians
• Checklists of OTCs/herbals and commonly missed
  meds
• Leverage expertise of VNAS
• Shared databases