NQF-Endorsed

1
NQF-Endorsed Safe Practices for Better
Healthcare
Safe Practice 17 Medication Reconciliation
Chapter 6 Improving Patient Safety Through
Medication Management
2
Slide Deck Overview

• Slide Set Includes
• Section 1 NQF-Endorsed Safe Practices for
  Better Healthcare Overview
• Section 2 Harmonization Partners
• Section 3 The Problem
• Section 4 Practice Specifications
• Section 5 Example Implementation Approaches
• Section 6 Front-line Resources

3
NQF-Endorsed Safe Practices for Better
Healthcare Overview
Safe Practice 17 Medication Reconciliation
Chapter 6 Improving Patient Safety Through
Medication Management
4
2010 NQF Safe Practices for Better Healthcare A
Consensus Report

• 34 Safe Practices
• Criteria for Inclusion
• Specificity
• Benefit
• Evidence of Effectiveness
• Generalization
• Readiness

5
Culture SP 1
2010 NQF Report
6
Culture

• CHAPTER 2 Creating and Sustaining a Culture of
  Safety (Separated into Practices
• Culture of Safety Leadership Structures and
  Systems
• Culture Measurement, Feedback, and Intervention
• Teamwork Training and Skill Building
• Risks and Hazards

Culture Meas., FB., and Interv.
Structures and Systems
Risk and Hazards
Team Training and Skill Bldg.
Consent Disclosure

Consent and Disclosure

• CHAPTER 3 Consent and Disclosure
• Informed Consent
• Life-Sustaining Treatment
• Disclosure
• Care of the Caregiver

Informed Consent
Life-Sustaining Treatment
Disclosure
Care of Caregiver
Workforce

• CHAPTER 4 Workforce
• Nursing Workforce
• Direct Caregivers
• ICU Care

Nursing Workforce
ICU Care
Direct Caregivers

• CHAPTER 5 Information Management and Continuity
  of Care
• Patient Care Information
• Order Read-Back and Abbreviations
• Labeling Diagnostic Studies
• Discharge Systems
• Safe Adoption of Computerized Prescriber Order
  Entry

Information Management and Continuity of Care
Read-Back Abbrev.
Patient Care Info.
CPOE
Discharge Systems
Labeling Diag. Studies
Medication Management

• CHAPTER 6 Medication Management
• Medication Reconciliation
• Pharmacist Leadership Structures and Systems

Med. Recon.
Pharmacist Leadership Structures and Systems

• CHAPTER 7 Healthcare-Associated Infections
• Hand Hygiene
• Influenza Prevention
• Central Line-Associated Blood Stream Infection
  Prevention
• Surgical-Site Infection Prevention
• Daily Care of the Ventilated Patient
• MDRO Prevention
• Catheter-Associated UTI Prevention

Healthcare-Associated Infections
Central Line-Assoc. BSI Prevention
Hand Hygiene
Influenza Prevention
VAP Prevention
Sx-Site Inf. Prevention
MDRO Prevention
UTI Prevention

• CHAPTER 8 Condition- and Site-Specific Practices
• Wrong-Site, Wrong-Procedure, Wrong-Person Surgery
  Prevention
• Pressure Ulcer Prevention
• VTE Prevention
• Anticoagulation Therapy
• Contrast Media-Induced Renal Failure Prevention
• Organ Donation
• Glycemic Control
• Falls Prevention
• Pediatric Imaging

Condition- and Site-Specific Practices
Wrong-site Sx Prevention
Press. Ulcer Prevention
VTE Prevention
Anticoag. Therapy
Contrast Media Use
Falls Prevention
Organ Donation
Glycemic Control
Pediatric Imaging
7
Harmonization Partners
Safe Practice 17 Medication Reconciliation
Chapter 6 Improving Patient Safety Through
Medication Management
8
Harmonization The Quality Choir
9
The Patient Our Conductor
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The Objective

• Medication Reconciliation
• The healthcare organization must develop,
  reconcile, and communicate an accurate medication
  list throughout the continuum of care

11
The Problem
Safe Practice 17 Medication Reconciliation
Chapter 6 Improving Patient Safety Through
Medication Management
12
The Problem
13
http//www.medscape.com/viewarticle/586617
14
http//content.nejm.org/cgi/content/full/362/5/38
0
15
http//www.myfoxny.com/dpp/health/091226_near_mis
s_registry
16
http//www.ashp.org/import/news/HealthSystemPharm
acyNews/newsarticle.aspx?id3023
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The Problem

• Frequency
• Medication reconciliation errors are estimated to
  be 20 of adverse drug events (ADEs)
• A study found that ADEs occur in approximately
  12 of patients

Rozich, J Clin Outcomes Manage 2001
Oct8(10)27-34 Forster, Ann Intern Med 2003 Feb
4138(4)161-7
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The Problem

• Severity
• ADE statistics
• 41 of medication reconciliation errors were
  clinically important
• 22 would have resulted in serious harm had the
  pharmacist not intervened
• 75 of potential ADEs occurred at discharge and
  60 were due to omissions of medications

Gleason, Am J Health Syst Pharm 2004 Aug
1561(16)1689-95 Akwagyriam, J Accid Emerg Med
1996 May13(3)166-8 Pippins, J Gen Intern Med
2008 Sep23(9)1414-22
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The Problem

• Preventability
• A multicenter study of 50 hospitals found that
  reduction of errors and ADEs is most strongly
  correlated with active physician and nurse
  involvement
• having an effective improvement team
• using small tests of change
• having an actively engaged senior administrator
• sending teams to multiple collaborative sessions

Rogers, Jt Comm J Qual Patient Saf 2006
Jan32(1)37-50
20
The Problem

• Cost Impact
• Costs associated with all ADEs are estimated to
  be about 3.8 million annually per hospital, of
  which 1 million is preventable
• One study found that ADEs increased patients
  length of stay by 2.2 days, increasing costs by
  3.2K
• Preventable ADEs caused an increased length of
  stay of 4.6 days, increasing costs by 5.8K per
  patient

Classen, JAMA 1997 Jan 22-29277(4)301-6
Bates, JAMA 1997 Jan 22-29277(4)307-11
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Practice Specifications
Safe Practice 17 Medication Reconciliation
Chapter 6 Improving Patient Safety Through
Medication Management
22
Additional Specifications
23
Safe Practice Statement

• Medication Reconciliation
• The healthcare organization must develop,
  reconcile, and communicate an accurate patient
  medication list throughout the continuum of care

Institute for Healthcare Improvement, Luther
Midelfort Mayo Health System. Medication
Reconciliation Review, 2004 Society of Hospital
Medicine, BOOSTing Care Transitions Resource
Room. BOOSTing Care Transitions Resource Room
Project Team, 2008 American Society of
Health-System Pharmacists, ASHP Medication
Reconciliation (Med Rec) Toolkit, 2009 Institute
for Healthcare Improvement, Medical
Reconciliation at all Transitions. IHI
Improvement Map, 2009 Joint Commission
Resources, 2010 Comprehensive Accreditation
Manual CAMH for Hospitals The Official
Handbook. National Patient Safety Goals, 2010
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Additional Specifications

• Educate clinicians upon hire about the importance
  of medication reconciliation
• Providers receiving a patient in transition of
  care should check the medication reconciliation
  list to ensure accuracy
• Include the full range of medications in the list
  as defined by accrediting organizations
• At the time the patient is admitted, create and
  document a complete list of medications the
  patient is taking at home

Joint Commission Resources, 2010 Comprehensive
Accreditation Manual CAMH for Hospitals The
Official Handbook. National Patient Safety Goals,
2010
25
Additional Specifications

• Medications ordered for the patient while under
  the care of the organization are compared to
  those on the list created at the time of
  admission
• Any discrepancies are reconciled and documented
  while the patient is under the care of the
  organization
• When the patients care is transferred within the
  organization, the current provider(s) inform(s)
  the receiving provider(s) about the up-to-date
  reconciled medication list and documents the
  communication

Joint Commission Resources, 2010 Comprehensive
Accreditation Manual CAMH for Hospitals The
Official Handbook. National Patient Safety Goals.
2010
26
Additional Specifications

• The patients most current reconciled medication
  list is communicated and documented to the next
  provider
• At time of transfer, the new provider is informed
  about how to obtain clarification list of
  reconciled medications
• When the patient leaves the organizations care,
  the current list of reconciled medications is
  provided to the patient, explained, and the
  interaction is documented
• In settings where medications are used minimally,
  modified medication reconciliation processes are
  performed

Jack, Ann Intern Med 2009 Feb 3150(3)178-87
27
Example Implementation Approaches
Safe Practice 17 Medication Reconciliation
Chapter 6 Improving Patient Safety Through
Medication Management
28
Example Implementation Approaches
29
Example Implementation Approaches

• Develop and use a template medication
  reconciliation form to gather information about
  current medications and medication allergies, to
  standardize care, and to prevent errors
• The Medical Executive Committee should aid in the
  creation and reinforcement of medication
  reconciliation
• Identify internal champions to lead
  implementation of the practice
• Educate providers about reviewing the necessity
  of medications upon admission and discharge

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Example Implementation Approaches

• Changes to the home medication list should be
  clearly noted and explained to the patient
• Consider patient needs and barriers when creating
  medication regimens
• Review and utilize sources of fully developed
  implementation solutions
• Provider education should include complementary
  and alternative medication and providers should
  then educate patients about the state of
  scientific knowledge

Jack, Ann Intern Med 2009 Feb 3150(3)178-87
Institute for Healthcare Improvement, Prevent
Adverse Drug Events (Medication Reconciliation),
2008
31
Example Implementation Approaches

• Encourage patients to carry an accurate
  medication list and share with their healthcare
  providers and pharmacist
• Organizations should coordinate with the
  patients home pharmacy in the creation of an
  accurate home medication list
• Use consumer-based kiosk technology to improve
  medication reconciliation and decrease facility
  costs
• Safe medication ordering practices may be
  implemented by pharmacy leaders across the
  organization

Institute for Safe Medication Practices, A Call
to Action Protecting U.S. Citizens from
Inappropriate Medicine Use. A White Paper on
Medication Safety in the U.S. and the Role of
Community Pharmacists, 2007 American Society of
Health-System Pharmacists, Safe Medication My
Medication List, 2008 Lesselroth, Jt Comm J Qual
Patient Saf 2009 May35(5)264-70
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Example Implementation Approaches

• Strategies of Progressive Organizations
• Implementation strategies most strongly
  correlated with success include
• an active interdisciplinary focus
• having an effective improvement team
• using small tests of change
• having an actively engaged senior administrator
• having teams participate in collaborative
  initiatives

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Example Implementation Approaches

• Strategies of Progressive Organizations
• Contd
• Require second check systems by a separate care
  provider to validate patient medication home
  lists
• Include budgetary resources to support the
  medication reconciliation process
• Conduct pharmacist review of medication lists
• Collect accurate medication histories on patients
  identified as high risk for medication errors

Kaboli, Arch Intern Med 2006166955-64
Schnipper, Arch Intern Med 2006 Mar
13166(5)565-71
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Front-line Resources
Safe Practice 17 Medication Reconciliation
Chapter 6 Improving Patient Safety Through
Medication Management
35
http//www.ncbi.nlm.nih.gov/pubmed/18792654
http//archinte.ama-assn.org/cgi/content/abstract/
169/8/771 http//www.ncbi.nlm.nih.gov/pubmed/1469
1892
36
http//www.ihi.org/imap/tool/Process7ce51016-b4
f0-423c-9f8b-5e1ea8d7b810
37
http//www.ashp.org/Import/PRACTICEANDPOLICY/Prac
ticeResourceCenters/PatientSafety/ASHPMedicationRe
conciliationToolkit_1.aspx
38
http//www.jointcommission.org/PatientSafety/Spea
kUp/
Poster available in Spanish
39
http//www.jointcommission.org/PatientSafety/Spea
kUp/
Poster available in Spanish
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TMIT National Webinar Series

• Barcoding End-to-End Solutions
• From Pharmacy to Bedside (SP 16 18)
• Charles R. Denham, MD Topic Safe Practice
  Overview
• David W. Bates, MD, MSc Topic Bar-Coding and
  Medication Safety
• Eric Poon, MD, MPH Topic Barcode Medication
  Verification Technology How Strong Is the
  Evidence?
• Tejal K. Gandhi, MD, MPH Topic Clinical and
  Operational Pearls
• Ulrike Kreysa Topic Harmonization of Supply
  Chain Technology Standards
• Dan Ford, MBA Topic The Role of the Patient
  Advocate
• Go to http//safetyleaders.org/webinars/indexWebi
  nar_June2010.jsp
• (June 17, 2010)

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NQF TMIT National Webinar Series

• Leadership Lessons for Pharmacy, Nursing,
• and Hospital Leaders
• William W. George, MBA Topic 7 Lessons for
  Leading in Crisis
• Charles R. Denham, MD Topic Review of Safe
  Practice 1, Leadership Structures and Systems
• Hayley Burgess, PharmD Topic Review Safe
  Practice 18, Pharmacist Leadership Structures and
  Systems
• Peter B. Angood, MD Topic National Perspective
  on Leadership Issues
• Go to http//www.safetyleaders.org/pages/idPage.j
  sp?ID4945 (August 25, 2009)

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NQF TMIT National Webinar Series

• Medication Safety Complex Issues for All
• (Safe Practices 17-18)
• Peter B. Angood, MD Topic Challenges of Policy
  Development for Medication Management
• Michael R. Cohen, RPh, MS, ScD Topic
  Medication Safety Overview, Evolution, and
  Current Issues
• Mary A. Andrawis, PharmD, MPH Topic
  Perspectives on the Importance of the Pharmacist
  Leadership Safe Practice in the Hospital
  Environment
• Jeffrey Schnipper, MD, MPH Topic Where the
  Rubber meets the Road Implementation of
  Medication Reconciliation at the Practitioner
  Level
• Patti O'Regan, ARNP, ANP, NP-C, PMHNP-BC, LMHC
  Discussion Patient Perspective on Medication
  Management Safe Practices
• Go to http//safetyleaders.org/pages/idPage.jsp?I
  D4935
• (June 18, 2009)

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TMIT National Webinar Series

• Medication Management (Safe Practices 14-18)
• David W. Bates, MD, MSc - Chief of the Division
  of General Medicine, Brigham and Women's Hospital
  
• Hayley Burgess, PharmD - Director, Performance
  Improvement, Measures, Standards, and Practices,
  TMIT
• Mary E. Foley, MS, RN - Associate Director,
  Center for Research and Nursing Innovation,
  University of California, San Francisco (UCSF)
• Go to http//www.safetyleaders.org/pages/idPage.j
  sp?ID4803 (November 8, 2007)