Admission to hospitalAdmission to hospital

Tania WateneTania Watene

Measuring the value of Measuring the value of medication reconciliationmedication reconciliation

SHPA Standards of Practice for Clinical Pharmacy Services 2013

Hospital pharmacy services that support the medicines management pathway.

• High 5s project commenced 2010

• Medication reconciliation had already been in place for many years at MPS

• Thought we were doing very well

• Detecting and fixing many and significant discrepancies/errors before patient harm

• High 5s was a way of measuring

Starting outStarting out

Eligible patientsEligible patients

• Target group at highest risk of medicines-related problem (SHPA criteria)

• Patients 65 years of age and over

• Admitted to inpatient units

• Entering through emergency department

BPMHBPMH

• Best Possible Medication History• Medication Reconciliation obtained by a clinician• Includes a thorough assessment of all regular

medication use (prescribed and non-prescribed)• Involves a systematic patient interview• Verification of information with more than one source• Complete and accurate information - drug name, dose, frequency & route - represents what the patient is currently taking even

though this may be different from what was actually prescribed

Measures – MR1Measures – MR1

• Percentage of eligible patients who have received formal medication reconciliation within 24 hours of the decision to admit to an inpatient unit.

• Denominator is the number of eligible patients admitted

• Allows teams to gauge their capacity to reach as many eligible patients as possible

MR1MR1

• Mater Health Services MR1 (red line)

• Pretty good

Measuring what exactly?Measuring what exactly?• “Not previously found (or documented) by the medication

reconciliation team”• Not measuring the difference between an ad hoc

medication history and formal medication reconciliation• How many discrepancies do we detect by doing medication reconciliation

• Measuring the accuracy of the end-result formal, structured medication reconciliation

• How accurate are we at detecting and documenting discrepancies?• Could we be better?

• Decided to collect both (MR0 = Total number of discrepancies on admission)

• Clinical pharmacy indicator• No extra work

Measures – MR2Measures – MR2• Mean number of outstanding

undocumented intentional medication discrepancies per patient

• Measure of the clarity of prescriber communication and documentation

• Outstanding discrepancies identified by the independent observer not previously found (or documented) by the medication reconciliation team

MR2MR2

• Mater Health Services MR2 (red line)

• Not so flash!

Measures – MR3Measures – MR3• Mean number of outstanding (undocumented)

unintentional medication discrepancies per patient• Measure of non-purposeful discrepancies that

include errors of omission, commission and description

• Can lead to actual adverse drug events• Outstanding discrepancies identified by the

independent observer not previously found or documented by the medication

reconciliation team

MR3MR3

• Mater Health Services MR3 (red line)

• Huge improvement!

Measures – MR4Measures – MR4

• Percentage of patients with at least one outstanding unintentional discrepancy

• Patient-focussed measure

• Measure of the magnitude of patients who experience a discrepancy

MR4MR4

• Mater Health Services MR4 (red line)

• Huge Improvement

What MR0 tells usWhat MR0 tells us• For MR3 we were achieving significant

differences even before we met the MR3 target of 0.3

• Unintentional errors of omission, commission and can lead to actual adverse drug events

• “Obvious” problems• Highest priority in the short term• Maintained our ability to detect and document

unintentional discrepancies

What MR0 tells usWhat MR0 tells usBlue line = intentional undocumented discrepancies at admission

Red line = intentional undocumented discrepancies after BPMH & medication reconciliation

Green line = unintentional discrepancies at admission

Purple line = unintentional discrepancies after BPMH & medication reconciliation

What MR0 tells usWhat MR0 tells usBPMH and Medication Reconciliation makes a significant difference to accuracy of information about medication use at admission to hospital.

Proportionally much bigger difference between detection, documentation and follow up of

unintentional discrepancies (MR0u vs MR3 p=0.000809)

than of intentional discrepancies (MR0i vs MR2 p=6.04x10-7).

What MR0 tells usWhat MR0 tells us• For MR2 we are not very good at clarifying (documenting)

reasons for intentional changes to medications• Everyone else knows what I know?• Longer term, this can still be the cause of medication errors if

not clarified• Not so obviously problematic• Patient or GP revert to pre-hospital medication schedule• You come into the hospital wearing size 12 grey pants, a red

shirt, blue shoes, and a black belt….You leave the hospital wearing a red dress, a blue shirt, no belt and a size 12 grey thong

• Changing back to what’s comfortable?

Changes for MR3 improvementChanges for MR3 improvement• Recognising that we weren’t meeting target• Previously we had no measure or comparison• Comparing our interpretation of the significance of

CAMs and PRNs with national interpretation• Considering the culture of minimal documentation

of decision-making process (intentional vs unintentional)

• Recognising that Pharmacists had inconsistent documentation about intervention

when discrepancies were detected

Changes for MR3 improvementChanges for MR3 improvement• Discussion with pharmacists about the

importance of documentation of discrepancies

• Ongoing reinforcement of this• Education of medical interns about BPMH

process at orientation• Expanded medical intern education a few

months later• Definite improvement maintained

Case studyCase study• Daniel – 60y.o man presents for day

procedure (not eligible for High 5s)• Private hospital – minimal information from

VMO or GP• Patient didn’t bring own medications• Patient only knows names of medications, not

doses• Patient asked to give “best guess” of dose• No second source used

Case study cont.Case study cont.• Patient complained of palpitations during

procedure – HR 150 bpm

• Admitted to CCU at 1730h

• Surgeon contacted for telephone order for night/evening medications

• Medications charted by cardiologist from patient information

• Still only one source: patient recall

Case study cont.Case study cont.• Medications charted:

• Dexamphetamine 10mg po tds - withheld• Allegron® (nortriptyline) 80mg nocte - administered• Paxam® (clonazepam) 20mg nocte

• Nurse noted only 2mg clonazepam tablets in safe

• Patient unable to recall dose – might be 20mg, might be 10mg

• Nurse called VMO – reduce to 10mg

Case study cont.Case study cont.• Pharmacist conducts BPMH & medication

reconciliation next morning (within 24h)• Uses more than one source of information• Community pharmacy & patient’s

psychiatrist• Dexamphetamine 10mg tds – correct (but may have

contributed to tachycardia)

• Nortriptyline 100mg nocte – vs 80mg

• Clonazepam 0.5mg nocte – vs 20mg prescribed, 10mg administered

Case study cont.Case study cont.

• From cardiac perspective, patient deemed ok for discharge in the afternoon.

• However• Patient very weak on his legs, unsteady• Almost fell multiple times on mobilisation to toilet• Denied feeling dizzy, but drowsy ++• SBP 96, HR 60-80

Case study cont.Case study cont.• Pharmacist recognised significance of clonazepam

overdose• Clonazepam 30-40h half-life• 20x overdose (40x overdose prescribed)• Unlikely to be safe for discharge by the afternoon

• Pharmacist discussed with NUM and both contacted cardiologist

• Patient required another night in hospital (first tachycardia, second drowsiness, unsteadiness)

• Discharged following day• Multidisciplinary CISA

ConclusionConclusion• Structured medication reconciliation soon

after or at the time of admission• Regardless of entry point for admission• Reduces number of unintentional errors• Reduces potential errors by clarifying

intentional changes• More effective than ad hoc process• Still room for improvement - documentation