continuity of medication management medication reconciliation: beyond admission hospital presenter...
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Continuity of Medication Management
Medication Reconciliation: Beyond Admission
HospitalPresenterMonth YYYY
Continuity is an Issue in Health Care
• 10-67% of medication histories contain at least one error1
• Incomplete medication histories at the time of admission have been cited as the cause of at least 27% of prescribing errors in hospital2
• The most common error is the omission of a regularly used medicine3
• Around half of the medication errors that happen in hospital occur on admission or discharge4
• 30% of these errors have the potential to cause harm3,5
NSW Examples - Medication Errors
Aspirin and clopidogrel ceased in ICU and not recommenced when patient transferred to
ward
Patient suffered sudden cardiac
arrest resulting in death
May have contributed to
patient’s death
Patient prescribed ramipril 1.25mg daily, medication chart was rewritten as ramipril
12.5mg daily
Patient suffered pre-syncopal episode, was transferred to HDU and required
noradrenaline
Caused temporary harm and required
intervention
Patient initiated on new cardiac medication,
discharged with no summary or medicine
Patient became acutely unwell and
was re-admitted
Caused temporary harm and required
intervention
Medication Reconciliation
• A process to reduce adverse medication events by:- Ensuring patients receive all intended
medicines- Mitigating common errors of transcription,
omission, commission and duplication - Ensuring accurate, current and comprehensive
medication information follows patients on transfer and discharge
Complete Step 3 and Step 4 at transfers between:- ICU to ward- ED to ward- Ward to ward- Hospital to hospital- Hospital to home or
aged care facilityand
- When re-writing or reviewing medication charts
NSW Medication Management Plan (MMP)Facilitates Medication Reconciliation at Transfers
Area to record medicines taken
prior to presentation
Contains a list of the patient’s pre-admission medications for comparison.
It is available at the point of care.
Know where to find the most accurate list of your patient’s pre-admission medications, commonly referred to as the
Best Possible Medication History (BPMH)
Re-Writing or Reviewing Medication Charts
• Consider re-writing an opportunity to review a patient’s medications:- Pre-admission medications with - Prescribed medications
• Consider:- Medications to be re-started- Medications no longer required- Medications to be adjusted or commenced
• Check:- New chart with previous chart- Any changes made have been documented
Change in Clinical Setting / Ward• Compare:
- Pre-admission medications with - Prescribed medications
• Consider: - Medications to be re-started- Medications no longer required- Medications to be adjusted or commenced
• Communicate:- Medications that are to be continued- Any changes that have been made- Any ongoing plan
ED
ICU Ward 1
Ward 2
Hospital to Hospital• Referring hospital to:
- Communicate- Medications that are to be continued- Any changes that have been made- Any ongoing plan
- Provide a copy of - Pre-admission medications (to facilitate identification
of changes)- Prescribed medications (as a reference for the new
treating team)
Hospital to Hospital
• Accepting hospital to:- Compare
- Medications that are to be continued with previously prescribed medications and pre-admission medications
- Identify and clarify- Any changes that have been made- Any ongoing plan
Hospital to Home or Aged Care FacilityMMP
Medication Chart
Compare:
- Pre-admission medications with
- Prescribed medications
Consider:
- Pre-admission medications to be re-started
- Prescribed medications no longer required
- Medications to be adjusted or commenced
Hospital to Home or Aged Care Facility• Communicate to the next care provider and patient:
- Medications that are to be continued- Any changes that have been made- Any ongoing plan
Example of a medication list for the patient
A Final Check
• Ensure the same medicines information is provided on the:- Discharge summary- Discharge order/prescription- Discharge medicine labels- Patient medication list
• Ensure the patient understands the changes that have been made
Key Points• Medication errors and patient harm can be reduced by
reconciling medicines when re-writing medication charts and at transfers between:- ICU and ward- ED to ward- Ward to ward- Hospital to hospital- Hospital to home or aged care facility
• Providing accurate information at transfers/discharge results in safer ongoing care
References1. Lee JY, Leblanc K, Fernandes OA, et al. Medication reconciliation
during internal hospital transfer and impact of computerized prescriber order entry. Ann Pharmacother. 2010;44:1887-1895.
2. Santell JP, Reconciliation failures lead to medication errors. Jt Comm J Qual Patient Saf. 2006;32:225-229.
3. Elliott RA, Tran T, Taylor SE, et al. Impact of a pharmacist-prepared interim residential care administration chart on gaps in continuity of medication management after discharge from hospital to residential care: a prospective pre- and post-intervention study (MedGap Study). BMJ Open 2012; 2:e000918.
4. Stowasser DA, Collins DM, Stowasser M. A randomised controlled trial of medication liaison services – patient outcomes. J Pharm Pract Res 2002; 32:133-40.