How Medication Reconciliation Supports Patient Safety 15 September 2007 Jane Richardson, BSP, PhD, FCSHP Coordinator, Clinical Pharmacy Services Team Lead, SCH Med Rec Pilot Site

Objectives To define Medication Reconciliation & describe why it’s important. To outline our initial experience with admission Medication Reconciliation within the Saskatoon Health Region (SHR). To describe early use of the Pharmaceutical Information Program (PIP) auto-populated Medication Reconciliation form in SHR Emergency Departments.

Medication Reconciliation – what is it? A formal process of: Obtaining a complete and accurate list of each patient’s current home medications (name, dosage, frequency, route) Comparing the physician’s admission, transfer, and/or discharge orders to that list Bringing discrepancies to the attention of the prescriber and ensuring changes are made to the orders, when appropriate Reference: IHI, Getting Started Kit: Prevent Adverse Drug Events (Medication Reconciliation)

Institute for Healthcare Improvement The Institute for Healthcare Improvement introduced the 100K Lives campaign, December 2004, to challenge health care providers to join a national effort to make health care safer & more effective & ensure hospitals achieve the best possible outcomes for all patients How? Implement six targeted strategies proven to prevent adverse events The initiative captured the attention of Canadian care providers, hospital administrators & others committed to improving patient safety. On April 12, 2005, the Canadian campaign, Safer Healthcare Now! was created.

IHI / Safer Healthcare Now! Initiatives Improved care for AMI Prevent surgical site infections Prevent central line infections Prevent ventilator associated pneumonia Deploy rapid response teams Prevent adverse drug events: Medication reconciliation

Why Medication Reconciliation? 2.9-16.6% of patients, in acute care hospitals, have experienced one or more adverse events Adverse drug events are a leading cause of injury to hospitalized patients Greater than 50% of all hospital medication errors occur at the interfaces of care Admission to hospital Transfer from one nursing unit to another Transfer to step-down care Discharge from hospital Transition points are areas of great vulnerability for our patients Greater than 50% of all hospital medication errors occur at the interfaces of care. Admission to hospital, Transfer from 1 nursing unit to another, Transfer to step-down care, Discharge from hospital [Rozich JD. Medication safety: One organization’s approach to the challenge. JCOM. 2001;8(10):27-34.]

Why Medication Reconciliation? Frequency of medication discrepancies on a general medicine clinical teaching unit 53.6% of patients had at least one unintended discrepancy 38.6% of the discrepancies were judged to have the potential to cause moderate – severe discomfort or clinical deterioration Most common error was an omission of a regularly used medication (46.4%) Arch Intern Med, 2005 Patients were on at least 4 regular prescription medications Patients could not be admitted from an extended care facility A recent Canadian study examined the frequency of medication discrepancies on a general medicine clinical teaching unit. 53.6% of patients had at least 1 unintended discrepancy 38.6% of these discrepancies were judged to have the potential to cause moderate – severe discomfort or clinical deterioration Most common error was an omission of a regularly used medication (46.4%) [Cornish PL. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med 2005;165:424-429.]

SCH Patient: MP 76 y.o. woman attending GDH admitted to CCU with bradycardia, then returned to GDH after receiving a pacemaker CCU admission medication orders based on faxed hand-written list from community pharmacy Errors: Lescol 20mg written as Losec 20mg (Rx error) Tramacet recorded as Tagamet (MD error) On warfarin for AF: not ordered on admission or restarted on discharge Sertraline & metformin put on hold in hospital but not reordered on discharge Community pharmacist had no idea what this woman should or shouldn’t have in her blister pack

Medication Reconciliation – the solution? Medication Reconciliation can: Prevent omission of an at-home medication Match in-house dose, frequency, and route with at-home usage Ensure medications follow the patient from one care site to another Key point: creating the most complete and accurate list possible of all home medication for each patient.

Why Now? It’s the right thing to do…….. Culture of safety: reduce medication errors & potential for patient harm Key component of seamless care strategies Saves time for physicians, nurses, and pharmacists in the long-term Medication Reconciliation is a Canadian Council on Health Services Accreditation Standard (ROP) In the SHR, Senior Leadership has endorsed Medication Reconciliation as a Regional Project of high priority Saves time for physicians, nurses, and pharmacists in the long-term [Rozich JD, Resar RK. Medication safety: One organization’s approach to the challenge. JCOM 2001;8(10):27-34]. A Required Organizational Practices (ROP) is an essential practice that Canadian Council on Health Services Accreditation (CCHSA) has determined, based on evidence, what an organization must have in place to enhance patient/client safety and minimize risk. These goals and practices were first approved by the CCHSA Board in 2004, and came into effect in January 2005.

SHR Form and Process A formal process of: Obtaining ONE complete and accurate list of each patient’s current home medications (name, dosage, frequency, route) Using the information obtained to write the admission orders Referring back to the information obtained to write transfer and discharge orders Our approach incorporates the two primary concepts of obtaining accurate medication lists and preventing discrepancies by using a process that combines medication histories & physician orders on one form. The reason for this is that the Preadmission Medication List Physician Order Form serves a dual purpose: (1) area to document the patient’s medications they were taking prior to admission (not to be duplicated in the RN database) (2) serves as the admission orders for that patient. This should eliminate any transcription errors and save health care professionals time by documenting in 1 section.

Medication Reconciliation SHR Manual Medication Reconciliation Form and Process

Medication Reconciliation Form, page 2

Measuring Progress: Discrepancies Undocumented intentional discrepancy: physician made an intentional choice to add, change or discontinue a medication but this choice is not clearly documented Unintentional discrepancy: physician unintentionally changed, added or omitted a medication the patient was taking prior to admission Goal: reduce number of discrepancies by 75%

SHR Baseline Data (5 Pilot Sites) Undocumented Intentional Discrepancies: 1.32 / patient Goal: 0.33 / patient Unintentional Discrepancies: 1.28 / patient Goal: 0.32 / patient Baseline data was collected on each of the five pilot sites and the collated results are reported on the slide. Undocumented intentional discrepancies: 1.32 / patient An undocumented intentional discrepancy is one in which the physician has made an intentional choice to add, change or discontinue a medication but this choice is not clearly documented. SHR goal: reduce by 75% in 12 months on pilot sites = # undocumented intentional discrepancies / # patients Unintentional discrepancies: 1.28 / patient An unintentional discrepancy is one in which the physician unintentionally changed, added, or omitted a medication the patient was taking prior to admission. SHR goal: reduce by 75% in 12 months on pilot sites = # unintentional discrepancies / # patients

Are we making a difference? Baseline National: 1.1 Revise form PDSA 2 National: 0.6 PDSA 3 March 2007 SHR Data = 0.25 1 yr data check PDSA 4 Education PDSA 1 survey

Are we making a difference? Revise form PDSA 2 National: 1.2 PDSA 3 Baseline PDSA 4 1 yr data check Education March 2007 SHR = 0.75 National: 0.65 PDSA 1 survey

Comments on the Manual Form It’s a blank form! All medication information will have to be written in: Will need to get the information from someone or somewhere. How accurate is that information? Potential for transcription errors when recording the medication history. We need to get the medication history right for the rest of the process to work

Medication Reconciliation Form The Next Step Using PIP to Generate an Admission Medication Reconciliation Form

PIP Auto-populated Medication Reconciliation Form

Has it made a difference? SCH Emergency Admissions to General Medicine: Undocumented Intentional Discrepancies SHR Goal: 0.33 / patient April 2007 (Manual Form): 0.1 September 2007 (PIP Form): 0.2 Unintentional Discrepancies SHR Goal: 0.32 / patient April 2007 (Manual Form): 3.1 September 2007 (PIP Form): 1.3

Comments on the PIP Auto-populated Form Gives medication name, strength, most recent fill date & prescriber’s name A better starting point than a blank page, especially if a patient or caregiver cannot provide information. Dose & interval still need to be clarified (& may be different than what was on the original prescription) Still need to ask about medications not recorded on PIP Avoids name & strength transcription errors for auto-populated medications

Conclusions Medication Reconciliation does decrease medication errors The Pharmaceutical Information Program auto-populated history and admission order form is a valuable tool for this initiative Through collaboration we are advancing patient safety in Saskatchewan