medication reconciliation july 12, 2005 glenn billman, m.d., medical safety officer, children’s...
TRANSCRIPT
Medication Reconciliation
July 12, 2005 Glenn Billman, M.D.,
Medical Safety Officer, Children’s Hospitals and Clinics of Minnesota
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First, do no harm….
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“Medicine used to be simple, ineffective and relatively safe.
“Now it is complex, effective, and potentially dangerous.”
Sir Cyril Chantler
The Issue:
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Optimal care for patients requires totally effective communication regarding medication use among numerous people of varying disciplines in multiple locations over time including the families themselves.
Our Challenge :
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Implement a Process that will ensure that patients and their caregivers
possess the most accurate, and up to date medication list possible
Our Aim: Implement Medication Reconciliation
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Definition 1:
Medication ReconciliationMedication Reconciliation Reconciliation is the process of
comparing what medication the patient is taking at the time of admission or entry to a new setting or level of care, with what the organization is providing (admission or new medication orders) to avoid errors such as conflicts or unintentional omissions.
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Definition 2:
Medication ReconciliationMedication Reconciliation All medications appropriately and
consciously continued, discontinued, or modified at all transitions of care.
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Why Should We Do This?
140 discrepancies in 81 patients (1.7/pt) 65 omissions 59 wrong dose/frequency 16 wrong drug
32.9% discrepancies rates as potentially moderate harm; 5.7% severe harm
Arch Intern Med, Feb 2005
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Why Should We Do This?
Ineffective medication reconciliation upon hospital admission up to 50% of medication errors up to 20% of future ADEs
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1) Increased Percent of Patients That Completed Medication Coordination
Per
cen
t
Bas
elin
e
Time
Why Should We Do This?Because It’s Doable !
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Pe
rce
nt
Discrepancies, All Types And Sources
Discrepancies, Patient Related
Baseline
BaselineCycle 1
Cycle 2 Cycle 1 Cycle 2
Why Should We Do This?Because It Works !
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Number Of Days Between ED Visits By Hem/Onc Patients Related To ADE's
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11/5/01 11/25/01 12/15/01 1/4/02 1/24/02 2/13/02 3/5/02 3/25/02 4/14/02 5/4/02
Date
Nu
mb
er
of
Days B
etw
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AD
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Potentially Preventable ADE
Non-Preventable ADE
Medication CoordinationParent EducationADE Monitoring
4) An Increase In The Number Of Days Between ED Visits Related To ADE’s
Why Should We Do This?Because It Works !
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Improve
AmbulatoryMedication
List
Improve AdmissionMedication
List
Improve Discharge
Medication List
Improved Accuracy of Medication
List
Why Should We Do This?Efficiency !
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Impact on ADE
Low HighLow
HighCPOE
Automated ADE Monitoring
Bar Code Reconciliation
Pocket Formulary
Preprinted Order Forms
Zero ToleranceOrdering Standards
MedicationCompetency Testing
InterventionDatabase
Diagnosis SpecificOrder Sets
Dedicated Unit Pharmacist
Pharmacist Order Entry
PharmacyManaged Protocols
MedicationReconciliation
Pharmacist Patient Interview
Cost To Implement
Do First
Don’t Bother
Investing In Safety
Why Should We Do This?It’s Cost Effective !
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2005 NPSG Goal 8: Medication Reconciliation
Accurately and completely reconciles medications across the continuum of care 8a: During 2005, for full implementation by
January 2006, develop a process for obtaining and documenting a complete list of the patient’s current medications upon the patient’s admission to the organization and with the involvement of the patient. This process includes a comparison of the medications the organization provides to those on the list.
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2005 NPSG Goal 8: Medication Reconciliation
Accurately and completely reconciles medications across the continuum of care 8b: A complete list of the patient’s
medications is communicated to the next provider of service when it refers or transfers the patient to another setting, service, practitioner, or level of care within and outside the organization.
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Medication Reconciliation Is A Tool To Help Bridge Gaps That Occur At Transitions and Transfers of Care
Process steps: The medication history is completed The physician reviews and acts upon
each medication The medication orders are written A 2nd person reviews medication
history That 2nd person resolves
discrepancies
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Reconciliation
Virtually all hospitals who have successfully addressed admission reconciliation have created a special form as part of the solution. These forms pretty much look alike.
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Children's Hospital San Diego
Admit Date:
Time:
Initials
Signature of RN(s) reconciling medications: _________________________ Initials___________
___________________ _____ Initials___________
___________________ _____ Initials___________Administrative Data Screen Completed by : Date:_____________Time:________________
Date:_____________Time:________________
Did you identify and correct a discrepancy? Yes No Patient Related? Yes No Order Related? Yes No
Last Dose Drug
If "No", which elements require
review?
Medication Coordination Form
Please Explain How The Discrepancy Was Resolved
M.D. Reviewer
Instructions: Please Complete Items 1 - 10
Date:_____________Time:________________
RouteFreq
Addressograph Stamp
Drug……….Dose…Freq….Route…... YES NO
Do All Medication Elements Match?
Dose
List All Medications Identified by Patient, Family, Prescription bottle,or M.D. order.
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What is included? Current home meds / OTC / Herbals,
including dose, route & frequency Time of last dose Source of the information The medications ordered at
admission An Assessment of patient
compliance
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There is no perfect medication list.
Quit thinking there is.
Do not be paralyzed by trying to perfect the list.
Steve Meisel, PharmD
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Who uses the form?
The nursing staff or pharmacist use the form to collect information at admission.
The physician uses the form as a reference and/or order when writing initial orders for medications. In some cases the form itself serves as the order form, thereby obviating the need to rewrite orders.
Both physicians and nurses use the form throughout the patient’s stay as a reference.
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Source of the information
The patient/family The patient’s pharmacy Previous medical records The patient’s medication bottles The physician’s office
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A completed Medication List is only the Half Way Point.
Reconciliation is real work!
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A Big Problem Is Often Just Getting An Accurate Medication
List Patient brings in incorrect list. Patient does not take what is marked on
bottle. Patient does not know what is on and family,
pharmacy not available. Wrong name of med on ED sheet. Med bottles don’t jive with what the patient
says. Patient is unable to tell you. No family
available. MD on call does not know either. Can’t call the pharmacy “after hours”.
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Pt. Admitted Is time of last dose in question Yes Is this a 24 hour Med? Can clinic chart or Does clinic chart other sources be or other external obtained in 24 hours source reconcile? Is the medication list from an external source No available? Does this confirm Can Pharmacy reconcile drug and dose? drug and dose? Can patient or family give accurate, confirming data? Is time of last dose in question
Nurse completes Med Coordination Data Sheet
Physician orders with drugs, dosages, and times are assembled
Stop. Use this information
Yes
Call M.D.
Reconciled
Yes
No
No
Yes
Call M.D.
No
Yes
No
No Yes
No
Reconciled
No Call M.D.
Yes No
Reconciled Yes
No
Medication Coordination Flowsheet (Adapted from the work of Roger Resar, M.D.)
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The Intent and Value of Medication Reconciliation Is In Having An Accurate
Medication List.
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Transfer Reconciliation
Critical especially upon transfer in and out of intensive care and other specialty units
As much as 60% of the care plan after transfer may be different than what the physician expects
Can utilize internal computer systems to facilitate, but there must be an active decision to continue, discontinue, or modify each line item
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Transfer Reconciliation
Automatic stops of certain critical-care-specific drugs (e.g. dopamine) are acceptable provided those stop orders appear in the medical record. ? Benzodiazepines
Requirement to re-write all orders upon transfer introduces new opportunities for error
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Discharge Reconciliation
The patient’s reconciled list of admission medications is compared against the physician’s discharge orders along with the last day’s MAR.
The lists can either come from the computer system or be integrated with the original admissions list.
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To Be Successful:
Put the patient first (this isn't someone else's job)
You need to have some good change methodology to be able to develop a good product
You need to use this to replace something else i.e. medication history in nursing data base
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Understand Your Processes Process flow Data flow Roles and responsibilities Procedures
Build Incrementally – Start SmallLeadership Support is Critical
Project champions
To Be Successful:
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You must have organization alignment (physician, nursing, pharmacy, administration) Process Owner and Sub-Process Owners A champion for the entire process
Have a good education program when rolling it out
Appropriately Resource the project
You Need To Start!
To Be Successful:
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Questions / Comments/ Discussion
