Start to Finish Medication Reconciliation

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Start to FinishMedication Reconciliation

• Raymond Fung MD
• Andrew Liu RPh
• Toronto East General Hospital
• May 27, 2013

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Disclosures

• Raymond Fung none
• Andrew Liu - none

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Outline

• Introduction
• Medication reconciliation setup
• Results
• Success factors and challenges
• Future directions

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• Single site community teaching hospital
  serving southeast Toronto
• TEGH has over 2,500 employees and 400 physicians

Inpatient Care Beds 510 Patients
admitted 14,673 Cerner - CPOE (2009)
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Medication Reconciliation

• Systematic way to prevent medication errors at
  transition points
• Best possible medication history (BPMH)
• Examine/update list at admission, transfer, and
  discharge
• Effective communication of list to patient and
  next care provider at points of
  transfer/discharge

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Why Medication Reconciliation

• Medication Errors are common!
• ISMP Canada
• Voluntary medication incident reports
• 30612 (2000-2008), 1169 caused harm or death
• 67 prescription medication histories have errors
• 46 medication errors occur on admission or
  discharge

Dialogue, December 2008
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Medication Reconciliation

• 3 hospitals in Massachusetts
• 85 reduction in medication errors over 10
  months
• Provides opportunity to reconsider
  appropriateness of patients medications and
  reduce polypharmacy
• Required Organizational Practice (ROP)
  Accreditation Canada
• Safer Healthcare Now priority

Dialogue, December 2008
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Admission Med Reconciliation Process
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Med Rec Process 1.Document BPMH
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(No Transcript)
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Completed Medication History
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(No Transcript)
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2. Add Admission PowerPlan
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3. Admission Reconciliation
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Admission Reconciliation Screen
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Discharge Reconciliation Screen
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Completed D/C Reconciliation
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Prescriptions and Med Discharge Report

• Print out prescriptions
• Signature
• Included CPSO No.
• Limited use code
• Medication Discharge Report
• Instructions for patient to know which
  medications to continue at home/stop, etc
• Can take it to their family physicians, pharmacy

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Prescription
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Custom Report Medication Discharge Report
Medication Discharge Report
Toronto East General Hospital 825
Coxwell Ave Toronto, ON M4C
3E7 Tel[phone]
-MAY-2011 Re Taking, Meds D.O.B
05-NOV-1944 Health Card Number
Address
Family MD

Family MD Phone

Inpatient
Attending MD FUNG MD, RAYMOND
Prescriptions 1. predniSONE 35 mg, Tablet,
Oral/Enteral Tube every morning taper by 5mg
until finished 2. ramipril 10 mg, Capsule,
by mouth once daily 3. rosuvastatin
(Crestor) 20 mg, Tablet, by mouth every night at
bedtime 4. tiotropium (Spiriva) 18 mcg,
Capsule, Inhalation once daily
Continue taking 1. Lantus 20 unit,
Injection, Subcutaneous every night at bedtime
2. Novorapid 8 unit, Injection, Subcutaneous
three times a day with meals 3. metFORMIN
1,000 mg, Tablet, by mouth twice daily with
meals Stop taking 1. acetylsalicylic
acid (Aspirin) 81 mg, Enteric Coated Tablet, by
mouth once daily 2. ramipril 5 mg, Capsule,
by mouth once daily Please take this list
to your Family Physician. If you have any
questions about your medications, check with your
Family Physician.
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Challenges

• Build challenges
• Preferences not honored
• Discontd, compld meds still showed
• Orders package broke PowerPlan build tools
• Accuracy of Discharge Medication Report
• Prescription printing
• Resend
• End user adoption
• Ease of use a barrier dispense quantity,
  updating BPMH
• End user expectations have increased
• Use was not mandated

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Dispense Quantity

• Necessary detail when writing prescriptions
• On paper, MDs often put one quantity for multiple
  meds
• Electronically, need to fill in detail for each
  med slow
• Mandatory field Yes vs. No
• Compromise fill in quantity on paper

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Medication Discharge Report

• When dispense quantity entered, medication showed
  in the Medications to Continue Taking That have
  Changed
• Had to abandon this report and create own custom
  report
• Custom report made into clinical note so that it
  can be saved, easy to look back

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(No Transcript)
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Medication Discharge Report
Medication Discharge Report
Toronto East General Hospital 825
Coxwell Ave Toronto, ON M4C
3E7 Tel[phone]
-MAY-2011 Re Taking, Meds D.O.B
05-NOV-1944 Health Card Number
Address
Family MD

Family MD Phone

Inpatient
Attending MD FUNG MD, RAYMOND
Prescriptions 1. predniSONE 35 mg, Tablet,
Oral/Enteral Tube every morning taper by 5mg
until finished 2. ramipril 10 mg, Capsule,
by mouth once daily 3. rosuvastatin
(Crestor) 20 mg, Tablet, by mouth every night at
bedtime 4. tiotropium (Spiriva) 18 mcg,
Capsule, Inhalation once daily
Continue taking 1. Lantus 20 unit,
Injection, Subcutaneous every night at bedtime
2. Novorapid 8 unit, Injection, Subcutaneous
three times a day with meals 3. metFORMIN
1,000 mg, Tablet, by mouth twice daily with
meals Stop taking 1. acetylsalicylic
acid (Aspirin) 81 mg, Enteric Coated Tablet, by
mouth once daily 2. ramipril 5 mg, Capsule,
by mouth once daily Please take this list
to your Family Physician. If you have any
questions about your medications, check with your
Family Physician.

• Saves as clinical note look back
• Once Cerner report printed once, dithered, cannot
  print again
• Can modify type specific instructions within
  clinical note
• Disadvantage need to go to another section of
  e-chart

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How are we doing?
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Medication History Completion
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Medication History Frontline Report
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Discharge Reconciliation -Trends
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D/C Med Rates by Dept Mar 2013
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Success Factors

• Multidisciplinary team
• Pharmacists
• Physician assistants
• Physician champions -specific
• Integrated electronic process and reports
• Reporting rates at departmental meetings
• Timely reporting of real-time metric and goal to
  frontline staff
• Competition participation in CHI ImagiNation
  Challenge

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Challenges

• Residents
• Engaging different physician groups
• Sustain enthusiasm
• Technical
• Outpatient/inpatient/conversion
• Dispense quantity
• Customizing to provincial formulary (LU)

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Future Directions

• Expanded ambulatory clinic areas
• Expand into other inpatient areas
• Incorporation into depart process/ discharge
  summary
• Relook at technical challenges
• Optimization of admission BPMH/reconciliation
  workflow
• Prioritize and measure med rec in high risk
  populations

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Acknowledgements

• eChart team
• Karen Hunter
• Owen Osmond
• Tina Price
• Pegi Rappaport
• Pharmacy
• Valerie Leung
• Jessica Ma
• Kieu Mach
• Carmine Stumpo

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Questions
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For more information Toronto East General
Hospital 825 Coxwell Ave. Toronto, Ontario M4C
3E7 Tel [phone] Fax (416)
469-6106 www.tegh.on.ca
Above all, we care.