Medication Reconciliation in Continuing Care Getting It Right Together Creating a Culture of Safety September 8, 2008 Dr. Paula Creighton MD, FRCP(C) Geriatric Medicine Specialist Cape Breton District Health Authority

Outline Understand why Medication Reconciliation is getting so much attention through: Understanding how adverse drug events (ADEs) commonly occur Identify practical steps that can reduce the risk of ADEs in practice Identify key features of a safer system September 2008 Dr. Paula Creighton

September 2008 Dr. Paula Creighton

September 2008 Dr. Paula Creighton

Definition Adverse Event UNINTENDED act or event during care May result in potential harm Harm = increase length of stay = temporary/permanent disability = death September 2008 Dr. Paula Creighton

September 2008 Dr. Paula Creighton

How ADEs occur? Increase range of medicines to treat or prevent disease Multiple co-morbid conditions Age-related changes physiology Tsilimingras, Rosen, &. Berlowitz 2003. Canadian Patient Safety (CPSI) Institute 2006 September 2008 Dr. Paula Creighton

How ADEs occur? Multiple health care practitioners Frequent visit to hospital setting (hospitalization, procedures, tests) Adherence problems Tsilimingras, Rosen, &. Berlowitz 2003. Canadian Patient Safety (CPSI) Institute 2006 September 2008 Dr. Paula Creighton

How ADEs occur? OTC medication use Impaired vision, dexterity, literacy Tsilimingras, Rosen, &. Berlowitz 2003. Canadian Patient Safety (CPSI) Institute 2006 September 2008 Dr. Paula Creighton

When ADEs occur? Entry and exit points of clinical encounters Cornish P. et al Arch Intern Med 2005:165; 424-429 September 2008 Dr. Paula Creighton

Traditional Medication History Labels Lists Verbal (open ended inquiry) Someone else has/will complete September 2008 Dr. Paula Creighton

Limitations to Traditional Medication History Discrepancies: Unintentional Undocumented Intentional September 2008 Dr. Paula Creighton

Unintentional Discrepancies Over-the-counter medications Shared prescriptions Labels “as directed” Prescription change without script Samples September 2008 Dr. Paula Creighton

Undocumented Intentional Discrepancies What changed and why? Convey a clear understanding of desired outcomes to therapy. Written communication with patient/family and pharmacist September 2008 Dr. Paula Creighton

Get Involved safer healthcare Now! September 2008 Dr. Paula Creighton

Key Features toward a Safer System Change September 2008 Dr. Paula Creighton

Key for a Safer System …If you always do what you have always done; Doing our jobs differently… …If you always do what you have always done; You always will get what you always got September 2008 Dr. Paula Creighton

Practical steps to reduce risk of ADEs “To prescribe according to best evidence from scientific research and to be mindful of the precepts of patient autonomy” Holland R, Wright D. Medication Review for Older Adults. Geriatrics and Aging March 2006, Vol 9. No.3. September 2008 Dr. Paula Creighton

Practical steps to reduce risk of ADEs When might it be best to withhold or discontinue medications that are otherwise appropriate on the basis of guidelines? September 2008 Dr. Paula Creighton

Practical steps to reduce risk of ADEs Consider life expectancy Goals of care and quality of life defined by patient/family Potential benefit & risk of medications September 2008 Dr. Paula Creighton

Practical steps to reduce risk of ADEs Start low, Go slow, Or don’t start at all! September 2008 Dr. Paula Creighton

Practical steps to reduce risk of ADEs Partnering with Patients “Nothing about me, without me” (author unknown) September 2008 Dr. Paula Creighton

Medication Reconciliation Partnering with Patients patient/family interview September 2008 Dr. Paula Creighton

Practical steps to reduce risk of ADEs Humans require formal cues/processes to stay on track reliably Reliable work processes account for the known imperfections of humans Adapted from PSO Training Course (IHI) 2004 September 2008 Dr. Paula Creighton

Medication Reconciliation MEDICATION RECONCILIATION: include on list below Over the counter products, Samples, Shared pills Drug Name Drug Strength When Taken Indicate if: -New -Change from label -Effects from new and change Morning Noon Evening Bedtime 1   2 3 4 5 6 September 2008 Dr. Paula Creighton

Threats for Change toward a Safer System Power Gradient Fear (Mis)-Perception “touchy, feely” initiatives September 2008 Dr. Paula Creighton

Key for Change toward a Safer System Self audit: More mirrors and fewer windows September 2008 Dr. Paula Creighton

Self Audit "One of the major impediments to convincing people of the prevalence and seriousness of cognitive error is the faith they have in their own thinking abilities" Croskerry, P. The Science of Human Factors in Healthcare, QHN, October 2003 September 2008 Dr. Paula Creighton

Key for Change toward a Safer System “ Many little people Doing many little things In many little places Can change the world.” (Chinese Proverb; author unknown) Susan Sheridan, Chair, Patients for Patient Safety Strand, WHO World Alliance for Patient Safety; Co-Founder, Consumers Advancing Patient Safety, Eagle, Idaho September 2008 Dr. Paula Creighton

Get Involved safer healthcare Now! September 2008 Dr. Paula Creighton