© Institute for Safe Medication Practices Canada 2008® Medication Reconciliation in Long Term Care Atlantic Node Collaborative Margaret Colquhoun SHN Intervention Lead Sept. 2008

© Institute for Safe Medication Practices Canada 2008® ISMP Canada Mission: To identify risks in medication use systems, recommend optimal system safeguards and advance safe medication practices.

© Institute for Safe Medication Practices Canada 2008® Medication Reconciliation in LTC Goal: Reduce the potential for adverse drugs events (ADEs) by identifying and resolving discrepancies and improving documentation in drug regimens at LTC care transitions

© Institute for Safe Medication Practices Canada 2008® Background Incomplete/inaccurate medication information is reflected in growing number of LTC studies. Alberta 2007: 75% medication information was NOT legible/complete 90% information was NOT available to tell prescribed medications appropriate for diagnoses. 40% medication information DID NOT arrive the same day as the resident’s admission.(1) [1] Earnshaw, K et. al. Perspectives of Alberta Nurses and Pharmacists on Medication Information Received. July 29, 2007[1]

© Institute for Safe Medication Practices Canada 2008® Background 2004 study “incidence of ADEs caused by medication changes at transfer between facilities was 20%. Most on transfer from acute to LTC Incomplete/inaccurate communication a factor Broockvar K, et al. Adverse events due to discontinuations in drug use and dose changes in patients transferred between acute and Long-term care facilities. Arch Intern Med. 2004;164:

© Institute for Safe Medication Practices Canada 2008® True Story… Patient admitted for investigation of recent onset of jaundice Levothyroxine daily not ordered – missed for 3 weeks Returned to LTC with symptoms of hypothyroidism

© Institute for Safe Medication Practices Canada 2008® Another… Admission from LTC with urosepsis successfully treated Three chronic medications not continued during acute care stay On transfer back to LTC experienced acute attack of gout secondary to furosemide use/not receiving allopurinol

© Institute for Safe Medication Practices Canada 2008® Medication reconciliation in LTC A formal process of: At admission, creating a complete list of resident’s current and pre-admission medications – including name, dosage, frequency and route (BPMH). Using the BPMH to create admission orders or comparing the list against the resident’s admission orders, identifying and bringing any discrepancies to the attention of the prescriber for resolution. Documenting any resulting changes and communicating to relevant providers

© Institute for Safe Medication Practices Canada 2008® Sounds Easy Right? Complex interplay of documentation and cognitive tasks

© Institute for Safe Medication Practices Canada 2008® What’s so Different? L engthy stays T reatment includes many medications Average 9.8 meds, up to 12.7 meds including prn C are by fewer professional staff Limited on-site pharmacist time Variable availability of physicians

© Institute for Safe Medication Practices Canada 2008® Terminology Best Possible Medication History (BPMH) - A current medication history includes all regular medication use Training Multiple sources of info BPMH compared to admission orders to identify discrepancies

© Institute for Safe Medication Practices Canada 2008® Terminology Undocumented Intentional discrepancy is one in which the prescriber has made an intentional choice to add, change or discontinue a medication but this choice is not clearly documented. Unintentional discrepancy is one in which the prescriber unintentionally changed, added or omitted a medication the resident was taking prior to admission.

© Institute for Safe Medication Practices Canada 2008® Terminology Most Current Medication List – The most recent list of medications (name of medication, dose, route and frequency) currently taken by the resident – Used for medication reconciliation at discharge

© Institute for Safe Medication Practices Canada 2008® Core Measures Mean number of UNDOCUMENTED INTENTIONAL Discrepancies (Documentation Accuracy) Target: Reduce baseline by 75%. Mean number of UNINTENTIONAL Discrepancies (Medication Error) Target: Reduce baseline by 75%. Percentage of Residents Reconciled upon admission Target: 100% of residents at admission.

© Institute for Safe Medication Practices Canada 2008®

Keys to Implementation Secure leadership commitment/involvement Project plan (map current process) Educate staff: Why medication reconciliation? How to reconcile BPMH training Develop and test new process Embed process so that it becomes “the way you do things” Measure & sustain the improvements you have made Spread to other areas / populations

© Institute for Safe Medication Practices Canada 2008® Considerations Proactive vs reactive Admission, transfer, discharge Different disciplines Institution specific NOT about a form Engage patient & family

© Institute for Safe Medication Practices Canada 2008® Supports GSK Atlantic node collaborative National calls Community of Practice – LTC section National Learning Series

© Institute for Safe Medication Practices Canada 2008® Getting Started Kit Medication Reconciliation in Long-Term Care Step-by-step guide to the process Model for Improvement Tools and Tips Samples

© Institute for Safe Medication Practices Canada 2008® Communities of Practice

SHN Website – Critical Success Factors: Education Standardize material Make use of “teaching” moments

COP – Critical Success Factor: Communication Speak language of audience Preparation and follow-up are critical Show-off your results Use your stories!!!!

© Institute for Safe Medication Practices Canada 2008® Acute Care Learning Data, results, stories Training Leadership One size does not fit all Is a clinical function Requires resident/family participation Use different health disciplines appropriately Commitment!!

© Institute for Safe Medication Practices Canada 2008®