Emergency Department Implementation Medication List Tool Emergency Department Implementation

Medication List Tool Changes Objectives: State the rationale for replacing PAML/Med List with the new Medication List Tool (MLT) in the ED Triage Form and Inpatient Nursing Admission History (Peds & Adult) Describe features of the Medication List Tool (MLT) and associated workflow Understand implementation and support plans for VUH and VCH

Medication List Tool Implementation June 10 MCJCHV ( except NICU/ NBN) June 17 VUH Inpatient Nursing Medication List Tool (MLT) embedded in Adult & Peds Nursing Admission History Starform (replacing PAML) June 24 VUH & VCH ED Emergency Department Medication List Tool (MLT) Embedded in Nurse Triage MLT embedded in provider workflow (tentative)

Why Change? Patient Dissatisfaction Wasted Time Patients are asked multiple times to supply the same information about medications taken at home Wasted Time Redundant work being done due to lack of integration of current tools

Why Change? SAFETY - There is not one source of truth for home medications Numerous members of the team collect medication lists yet these lists are not shared and there is lack of confidence in the list. For example, RN collects medication list in triage form yet this information doesn’t display in the provider workflow when completing the H&P. The provider collects yet another list. Failure to reconcile medications during transitions (home to hospital, hospital to home) results in medication errors

IMPLICATIONS Adverse drug events, ED visits, hospital admissions and readmissions, prolonged length of stay, patient and provider dissatisfaction Up to 67% inpatients have at least 1 discrepancy between the prescription medication list obtained by the admitting provider and the patient’s actual pre-admission medication regimen (Tam) On average, each patient on a general medicine service has more than 1 discrepancy with potential for harm in the admission or discharge orders (Pippins) 59% of admission medication discrepancies could result in patient harm if they persist beyond discharge (Gleason)

Medication Errors at Vanderbilt In a randomized study of cardiac patients: ~50% of patients experienced a clinically important medication error within 30 days post-discharge (Kripalani) ~42% of patients had at least 1 error in pre-admission medication list (Salanitro) ~39% had at least 1 error in discharge medication list (Salanitro) In a quality improvement study of general medicine patients: ~90% of patients had an error in their MD-obtained admission med list during night shift

Background Replacing PAML and other medication list tools with the new Medication List Tool (MLT) in the Nursing Admission History and ED Triage form is phase 1 of the One Medication List project Goals of the One Medication List project: One source of truth for medications All members of the team access and edit the same list Processes, tools and expectations for the medication list management are standardized across VUMC

One Medication List Project Implementation VPH completed a successful pilot in March Medication List Tool (MLT) in VPH Nursing Admission History (replace PAML) MLT embedded in the VPH provider H&P Perioperative workflow analysis and adoption of MLT is in progress OB is on hold until system updates occur later this year

One Medication List Project Embed MLT in the Adult and Pediatric ED Triage form and Nursing Admission History Replace PAML with MLT Provider workflow will be part of future phases Embedded in provider admission process, i.e., documenting H&P Exit check during the discharge process Long term goal is for the providers to have the ability to enter orders for medications from the list Implementation – continued

Current Medication Reconciliation Tools New Medication List Tool PAML The Med List Tool New Medication List Tool MLT NEW

The MLT Summary page display in the Admission History & Triage Note Last completed list visible with date, time and collector included Click Edit or Pencil icon to open the tool and make changes Embedded in Admission History Embedded in Triage Note

The Med List Tool MLT will open a new window when clicked from the triage screen Left column pulls previous VUMC medication list from Patient Summary (PSS)– such as from clinic visit, last hospitalization. NON EDITABLE Right column is “SCRATCH PAD” which is an EDITABLE version of the previous VUMC medication list. EDIT list to reflect medications patient is currently taking prior to admission

How to DELETE a medication DELETE icon Click “X” to delete a med that is no longer being taken Med appears with strikethrough Make a mistake? Use the UNDO icon

How to EDIT a medication Click EDIT icon to edit medication information Edit Icon -> Denote edits to dose, route, frequency, indication, start date (OPTIONAL), comments. Specify date/time last dose taken if appropriate. Click SAVE when revisions completed Changes are highlighted for easy review

How to ADD a medication Click Add Medication Type Medication Name. Select from list if appropriate Denote dose, route, frequency, start date, indication, comments. Specify date/time last dose taken if appropriate Click Save New Med highlighted for easy review

Incomplete medication information Type medication information that is known, i.e. “little blue pill for BP” Select “Unable to Obtain” and denote reason, if obtaining medication history is not possible. Select “Submit” and then “No Current Medications” if the patient does not have any home medications. This button will only be available when the scratch pad has no meds listed or all meds have been deleted.

How to Save MLT Preview- Displays the list without the strikethroughs and highlights. Click a second time return to display with strikethroughs and highlights Submit for Review- saves the list and prompts the provider that the medication list collection by nursing is complete and ready for the provider to review/edit/ send to Patient Summary

Click to display all comments. Click again to hide comments Icons & Displays Delete Edit View Click to display icons to print, show/hide comments or display list of edits by visit Click to display all comments. Click again to hide comments The View icon displays detailed medication information including; history, creation date, and editor

Click Med List Tool to open Accessing the Med List Tool (MLT) in Star Panel Click Actions to open Click Med List Tool to open May have to customize menu to have Med List Tool available as an option Click Actions to open Click Med List Tool to open

MLT and the Provider Integration of MLT into ED provider workflow is tentatively planned for June 24 A column will be added to the ED Whiteboard “M” that will link to the MLT and will flash if not completed by the provider within an hour of the patient being placed in a room MLT will be embedded in the ED H&Ps Medication lists from the MLT will be presented in the ED Discharge Med Reconciliation process Once the Nurse Submits for Review, the Provider will review the list obtained in the Triage Form and will have the option to: Edit the list and/or to Save to Pt. Summary if there is a high confidence that the list is accurate OR Document that the list has been Reviewed but Don’t Save to Pt. Summary if the confidence level in the accuracy of the list is low (i.e. patient is poor historian or unable to give a complete home medication list). A reason will be required. Document Unable to Obtain a medication list

Implementation & Support IMPACT TO PATIENTS IN THE ED WHO ARE ADMITTED AND AWAITING BEDS June 10: VCH PAML link in the Peds Nursing Admission History will be replaced with MLT June 17: VUH PAML link in the Adult Nursing Admission History will be replaced with MLT Support: System Support Services staff will be rounding in the ED. Contact the help desk (343-4357) for assistance. IMPACT TO ALL ED PATIENTS (VCH & VUH) June 24: Medication List Tool will be embedded into the Triage form Support: System Support Services will provide 24h support onsite in the ED X 4 days then via call to help desk (343-4357).