Medication Reconciliation Insert your hospital’s name here

Agenda  Define the problem  What is medication reconciliation?  CheckPoint measure  Things to consider when developing a process  Keys to success

What is the problem?  Hospitalized patients who experience an adverse drug event (ADE) are twice as likely to die as those without an ADE (JAMA 1997; 277: )  The Institute of Medicine has estimated that medication errors account for 7,000 deaths annually (To Error Is Human: building a safer health system, 1997, IOM)  ADEs account for 6.3% of malpractice claims (Arch Intern Med. 2002; 162: )

Where is the problem?  Chart reviews revealed that 50% of all medication errors and 20% of adverse drug events are due to poor communication at the interfaces of care (Institute for Healthcare Improvement 2005)  Patient admission to the hospital  Patient transfer out of specialty units to other nursing units  Patient discharge from the hospital

Why?  Interfaces lack a process for comparing the patient’s most current list of medications against physician orders for admission, transfer, and discharge

Examples of interface problems  Physician admission orders read “continue home meds”  Patients transferring from a critical care setting to a nursing unit would still have lidocaine drip listed on their medication record  Patients’ discharge orders read “discharge on home meds”

What is Medication Reconciliation?  A process of identifying the most accurate list of medications a patient is taking and using this list to provide correct medications for the patient anywhere within the health care system

How Are Medications Reconciled? 1.Verify: Collect an accurate medication history 2.Clarify: Compare the patients list of current medications – including name, dosage, frequency, and route – against the physician’s orders. Any medication that does not match must be “reconciled” by bringing the discrepancies to the attention of the physician 3.Reconcile: Document the change or why the medication was not ordered to communicate to the healthcare team

When are Medications Reconciled?  Admission  The patient’s home medications are compared to the physician’s admission medication orders  Transfer One Unit to Another Unit  The patient’s most current medication record is compared against the physician's transfer orders  Discharge  The patient’s reconciled list of admission medications is compared against the physician’s discharge orders

Sample High Level Medication Reconciliation Process Patient Profile H&P/Clinic Note/Outpt Pharmacy Reconciled Admission Med List Reconciled Discharge Med List Admission Orders Latest MAR Discharge Orders

Medication Reconciliation is Viewed as a Quality Measure  JCAHO 2005 safety goal  IHI 100K Lives Campaign  WI Node 100K Lives Web site  Statewide improvement team (PSW/WHA)  CheckPoint Error Prevention Measure  It is the right thing to do, but very challenging to implement

WI Hospital Medication Reconciliation Survey – June 30, 2005 N=57 Wisconsin Hospitals

CheckPoint Scoring  Each hospital that volunteers to publicly report on the medication reconciliation measure will have their score posted to the CheckPoint website with the other Error Prevention measures  The medication reconciliation score will consist of a composite number ranging from points  The points are cumulative based on the hospitals response to 4 components

4 Components of the Score Components Respons e Options Possible Points 1. A written document is developed including all components of the goal Yes or No The requirements of the written document are implemented in all relevant patient care areas Yes or No A compliance monitoring system is in place with the results periodically reviewed by an oversight committee Yes or No Demonstrated Success Rate (DSR): varies by goal Collected Rate 0-50

Goal 6 DSR – Medication Reconciliation Number of cases that have a complete medication reconciliation form in their medical record within 48 hours of admission ____________________________________ X 100 Total number of cases reviewed

What is a “complete” form?  All fields required by your hospital’s policy are complete on the form  Must include medication name, does, frequency, route and reconciliation status  All medications are reconciled with a  Medication order OR  Documentation that the medication was not ordered  All required signature are present  Must have at least 2 signatures from different disciplines

What Medications are Included?  All medications on the patients current home medication record should be reconciled  Prescription  Over-the-counter  Homeopathic  Vitamins  Herbals  Nutritional supplements  If your hospital has a policy that excludes OTC, homeopathics, vitamins, herbals, or nutritional supplements from reconciliation, you may consider these medications reconciled

Reconciliation Definitions  If a medication is on the patient’s current home record, but no order is written, it is reconciled if:  Documentation that it is not being ordered  Contraindicated for the admitting condition  If the patient is NPO on admission and no medications are ordered, the case is reconciled

48 Hours  Use the inpatient admission date and time to determine the 48 hour window  Make sure that the date and time the reconciliation was completed is on your reconciliation form

Case Selection  Minimum number is 75 cases in 6 months  Inclusion criteria  All patients admitted for inpatient services including admits from the ER and direct admits  Exclusion criteria  LOS based on admit date and time of <48 hours  Patient unresponsive on admission and you cannot obtain a medication history from a competent source  Newborn born during that admission

CheckPoint Report  WHA will start reporting the medication reconciliation measure March 15, 2006 as part of the CheckPoint Error Prevention report  The data will be updated every 6 months

Optional Internal Measures  Number of reconciled medications  Number of medication errors after reconciliation  Number of adverse medication events related to non reconciliation  Number of admissions reconciled

Things to Consider  Admission  Sources of information  Patient and family (have patient bring meds?)  Physician’s office  Patients pharmacy  Past medical record  Transfer form  Format?  What medications are included?  Who does it?  Speed and accuracy  Discrepancies  What will the process be?  Who follows up?  Reconciliation  Who does it?

 Transfer Compare medication lists before and after a transfer or procedure Check home meds Who does it?

 Discharge  Review 3 lists  Current meds  Home Meds  Discharge orders  Document format  Who does it?  Patient Education  Address hospital formulary changes  Who gets the discharge medication list?  Encourage patient to maintain a accurate medication list over time

Team effort, but who does what?  Physician  Best knowledge of patient  Decision maker/write the orders  Nurse  Best access to patient and family  Frequently does the admission history  Frequently does the discharge education  Pharmacist  Best knowledge of drugs and formulary  Limited patient and family access  Hosp/community pharmacy interface  Transfer reconciliation

 Patient  Real decision maker  Variable motivation factors that need to be included  Need tools to keep track of medications  Administration  Realize the gravity and challenges of the process  Prioritize clinical resources  Culture of patient safety

Keys to Successful Implementation 1) Teamwork! 2) Commitment to improve by nurses, pharmacists, physicians, and administration 3) Baseline and ongoing data collection to track progress 4) Policies and procedures to govern the process 5) Well designed and communicated processes a) Thorough evaluation of existing processes including a high level flowchart of the existing process to determine where problems exist b) Flowchart new process to assure new problems not created and to use as a communication tool

6) Create/adopt forms to document reconciliation at admission, transfer and discharge a) May have one or many forms b) Forms may be paper, electronic, or a combination of both a)Remember to review computer systems to determine if there are links to existing information that could be utilize 7) Educate staff to assure that everyone understands and can use the new process consistently

It’s effective!