Thunder Bay Regional Health Sciences Centre (TBRHSC) <?xml version="1.0"?><Settings><answerBulletFormat>Numeric</answerBulletFormat><answerNowAutoInsert>No</answerNowAutoInsert><answerNowStyle>Explosion</answerNowStyle><answerNowText>Answer Now</answerNowText><chartColors>Use PowerPoint Color Scheme</chartColors><chartType>Horizontal</chartType><correctAnswerIndicator>Checkmark</correctAnswerIndicator><countdownAutoInsert>No</countdownAutoInsert><countdownSeconds>10</countdownSeconds><countdownSound>TicToc.wav</countdownSound><countdownStyle>Box</countdownStyle><gridAutoInsert>No</gridAutoInsert><gridFillStyle>Answered</gridFillStyle><gridFillColor>0,0,0</gridFillColor><gridOpacity>100%</gridOpacity><gridTextStyle>Keypad #</gridTextStyle><inputSource>Response Devices</inputSource><multipleResponseDivisor># of Responses</multipleResponseDivisor><participantsLeaderBoard>5</participantsLeaderBoard><percentageDecimalPlaces>0</percentageDecimalPlaces><responseCounterAutoInsert>No</responseCounterAutoInsert><responseCounterStyle>Oval</responseCounterStyle><responseCounterDisplayValue># of Votes Received</responseCounterDisplayValue><insertObjectUsingColor>Blue</insertObjectUsingColor><showResults>Yes</showResults><teamColors>User Defined</teamColors><teamIdentificationType>None</teamIdentificationType><teamScoringType>Voting pads only</teamScoringType><teamScoringDecimalPlaces>1</teamScoringDecimalPlaces><teamIdentificationItem></teamIdentificationItem><teamsLeaderBoard>5</teamsLeaderBoard><teamName1></teamName1><teamName2></teamName2><teamName3></teamName3><teamName4></teamName4><teamName5></teamName5><teamName6></teamName6><teamName7></teamName7><teamName8></teamName8><teamName9></teamName9><teamName10></teamName10><showControlBar>Slides with Get Feedback Objects</showControlBar><defaultCorrectPointValue>100</defaultCorrectPointValue><defaultIncorrectPointValue>0</defaultIncorrectPointValue><chartColor1>187,224,227</chartColor1><chartColor2>51,51,153</chartColor2><chartColor3>0,153,153</chartColor3><chartColor4>153,204,0</chartColor4><chartColor5>128,128,128</chartColor5><chartColor6>0,0,0</chartColor6><chartColor7>0,102,204</chartColor7><chartColor8>204,204,255</chartColor8><chartColor9>255,0,0</chartColor9><chartColor10>255,255,0</chartColor10><teamColor1>187,224,227</teamColor1><teamColor2>51,51,153</teamColor2><teamColor3>0,153,153</teamColor3><teamColor4>153,204,0</teamColor4><teamColor5>128,128,128</teamColor5><teamColor6>0,0,0</teamColor6><teamColor7>0,102,204</teamColor7><teamColor8>204,204,255</teamColor8><teamColor9>255,0,0</teamColor9><teamColor10>255,255,0</teamColor10><displayAnswerImagesDuringVote>Yes</displayAnswerImagesDuringVote><displayAnswerImagesWithResponses>Yes</displayAnswerImagesWithResponses><displayAnswerTextDuringVote>Yes</displayAnswerTextDuringVote><displayAnswerTextWithResponses>Yes</displayAnswerTextWithResponses><questionSlideID></questionSlideID><controlBarState>Expanded</controlBarState><isGridColorKnownColor>True</isGridColorKnownColor><gridColorName>Yellow</gridColorName><AutoRec></AutoRec><AutoRecTimeIntrvl></AutoRecTimeIntrvl><chartVotesView>Percentage</chartVotesView><chartLabelsColor>0,0,0</chartLabelsColor><isChartLabelColorKnownColor>True</isChartLabelColorKnownColor><chartLabelColorName>Black</chartLabelColorName><chartXAxisLabelType>Full Text</chartXAxisLabelType></Settings> <?xml version="1.0"?><AllQuestions /> <?xml version="1.0"?><AllAnswers /> Thunder Bay Regional Health Sciences Centre (TBRHSC) Medication Reconciliation

Background Is a 375 bed academic health science centre with a mission to advance world-class Patient and Family Centred Care in an academic, researched-based acute care environment. We provide service to Northwestern Ontario with a population of 250,000 residents scattered over a geographical area the size of France. Rationale – Improve patient safety by developing a consistent approach to obtain BPMH and reconcile medications upon admission and transfer

Aim Educate critical care staff on the medication reconciliation process (in three to four months) Ensure a best possible medication history (BPMH) is obtained and documented for all critical care patients (in 12-months) To reconcile and document all medication discrepancies on admission and transfer from critical care (in 12-months)

Team Members Adam Vinet, Manager – Emergency Department Cece Girard, Critical Care Staff Nurse Chad Johnson, Clinical Nurse Specialist – Critical Care Katrina Niemi, Critical Care Staff Nurse Larry Bertoldo, Pharmacist Lisa Beck, Director – Trauma Program Marios Roussos, Intensivist Wendy Winslow, Manager – Critical Care

Results PDSA #1 Question Result Have you completed the MEDRec course on MEDworxx? 14/14 staff completed the course Do you have any questions or require clarification on current process? 1/14 staff required clarification How many BPMHs have you completed in Medi-Tech with 24-hours of admission? 9/14 staff completed the BPMH in Medi-Tech

Results PDSA #1 (continued) Question Result If you were expected to complete the BPMH but could not complete, please indicate factors/barriers that inhibited completion “No caregiver/family available to assist with BPMH.” (9) “Patient was non-verbal.” (10) “No access to other resources to complete BPMH.” (5) “Workload issues.” (3) “Not familiar with certain medications.” (1) For all the BPMHs that you have completed, list all sources used to complete BPMH Patient (9) Written medication list/medication bottles (9) Caregiver/partner in care/family (9) Local pharmacy (3) Ontario Drug Profile Viewer (1)

Results PDSA #2 Question Result How many admissions occurred in ICU over the trial weekend? 4 days (27 admissions) How many BPMHs were completed in Medi-Tech within 24-hours of admission over the trial weekend? 17 Indicate factors/barriers that inhibited completion Did not know to repeat BPMH on admission Patient unstable (workload) Family did not know medication history Patient condition (unstable, confusion, etc.) In doing follow-up with staff was there common themes to barriers or areas for improvement? Late admissions Patient condition, workload, family not aware of medication history

Changes Tested PDSA #1 Implementation of nurse driven BPMH, a change from the pharmacist lead model Nursing staff completed an e-learning module to learn how to obtain a BPMH and clinical tools were developed to assist nursing staff to obtain the BPMH

Changes Tested PDSA #2 Tested the current weekend process of RNs completing the BPMH while pharmacist is off Nurses are expected to complete BPMH on weekends when pharmacist is off to ensure a 24/7 process that is not fully reliant on one pharmacist Want to ensure that current process is “process driven” and not individual dependant

Lessons Learned PDSA #1 PDSA #2 Need to focus and follow-up individually with nursing staff to asses why BPMH were not completed (identify barriers in completing) PDSA #2 Following up individually provided more details: Why the BPMH was not obtained Exposed ongoing barriers and questioned the expected BPMH time to completion Need to consider having BPMH completion time extended to 48-hours

Next Steps Evaluate quality of BPMH Currently we are focusing on quantity, getting nursing staff in the habit of completing/obtaining a BPMH Medication reconciliation at transfer Develop process Get buy-in from intensivist group